Why pressure matters
Misconceptions about the appropriate direction and pressure for lymphatic massage in lymphoedema abound, and a search of the world wide web would lead us to believe that we should all be doing the same massage with the same pressure in the same direction. If only it were that simple!
The reality is that effective lymphoedema management demands an individualised approach. One that takes into consideration the progressive nature of lymphoedema, and delivers a nuanced application of MLD appropriate to the presentation. A tailored self-care program must also be designed to deliver optimal outcomes for the investment made in time, effort, and family resources that lymphoedema inevitably requires.
What is the right pressure?
In clinical and self-care settings, the question of how much pressure to apply has become a hot topic, with authoritative and influential voices advocating for a one-size-fits-all answer.
This is a seductive notion. The idea that there might be a universal formula we can all follow and achieve instant results is appealing. But years of clinical observation by thousand of Lymphoedema Therapists, and the lived experience of multitudes of individuals around the world, tell another story. One that must consider the unique stage and presentation of the affected skin and tissue in determining the pressure and direction used during MLD.
Stage matters
Lymphoedema is a chronic condition with a predictable course of progression. There is always an initial latent 'Stage 0' which can be brief or last several years. There may be mild subjective symptoms but no visible swelling. Intervention can be effective in preventing the onset of clinical disease and a prospective surveillance model is increasingly implemented after surgery for breast cancer.
Once lymphoedema has become visible the early fluid rich 'Stage 1' is marked by protein-rich fluid accumulation in the soft tissue under the skin presenting as ‘pitting oedema’. The swelling may come and go, especially overnight. Treatment should aim to encourage mobilisation and evacuation of trapped fluid and to reduce the inflammatory load.
Over time, trapped proteins and chronic inflammatory processes drive the tissue changes which feature in the middle 'Stages 2a & 2b' where tissue enlargement is obvious. There is less free fluid and more growth of fibrosis and fatty tissues, but the skin is still in good condition.
Advanced lymphoedema 'Stage 3+' is characterised by chronic skin changes such as hyperkeratosis and papillomatosis. There may be deep skin folds, skin discolouration and nail dystrophies. As the tissues become stiffer and more resistant to movement, MLD pressure and direction must also adjust to continue to both support lymphatic function and soften the skin and underlying tissue.
Using the wrong pressure at the wrong stage may not only be ineffective, but excess pressure could exacerbate swelling and inflammation, particularly in the early stages. A skilled and experienced Therapists will adapt the pressure, pace and depth of action of MLD according to what they can feel of the skin and underlying tissue. Likewise people performing regular lymphoedema self-care at home need a personalise their massage sequence to employ techniques that minimised symptoms and prevent lymphoedema progression.
Insight from Research: A Study on Pressure Variability
A recent study by Xing et al. from the Sichuan Clinical Research Centre for Cancer demonstrated the importance of tailoring MLD pressure by lymphoedema stage.
In a novel collaboration with the Automation Engineering Department, the research team developed pressure sensors to measure the force applied by trained Therapists as they performed MLD. Although not stated by name, the description clearly indicates the Dr Vodder Method was used by 14 certified Lymphoedema Therapists, who treated 42 women with breast cancer-related lymphoedema (BCRL).
The study demonstrated two important aspects of MLD as it is used clinically;
The pressure applied during MLD will vary according to the stage of lymphedema.
The pressure applied during MLD will be consistent between Therapists within a narrow range of variation for each stage of lymphoedema.
Why Pressure varies by stage
In the early stages, lighter pressures are sufficient to encourage fluid movement towards open areas of drainage, while in more advanced stages, where tissues have undergone fibrotic change, therapists will apply firmer pressure for sustained periods to soften the fibrous tissues.
This adaptability underscores the need for a clinical approach rather than a one-size-fits-all protocol, and highlights the common flaw among studies which try to standardise MLD to fit the study design, and thereby fail to reflect real-life clinical settings.
A great strength of the study by Xing and colleagues was that the Therapists were instructed to apply the MLD techniques according to the presentation and response of the skin and tissue.
By assessing and adjusting MLD pressures according to the patient’s condition, therapists were able to tailor their technique to provide more effective treatment and avoid complications, such as lymphatic vessel collapse from excessive pressure.
Since the study design implemented MLD the same way MLD is used clinically, the secondary finding that limb volume reduced significantly (P < 0.05) is also clinically relevant. Forearm circumference in all stages, and upper arm circumference in Stages 1 and 3, all showed significant reductions, attesting to the therapeutic effectiveness of MLD in decreasing limb size across different stages of lymphoedema.
Why Pressure Consistency Matters
The study also found consistency in the pressures applied by therapists, which is not surprising when you consider the rigorous attention to correct technique that is characteristic of the Dr Vodder training program. The Therapists in the study also attended a refresher training session before the study treatments began. Another real-life reflection mirroring the Vodder School Recertification program, a feature that sets Dt Vodder trained Therapists apart from other Lymphoedema Practitioners.
The Role of the Skilled MLD Practitioner
Lymphoedema Therapists understand the importance of adapting their hand pressure and MLD techniques based on individual patient needs and tissue responses. The type of pressure applied in mild stages, where tissue is more pliable, will differ from that used in advanced stages where fibrosis is present.
Skilled therapists tailor their approach to each patient's condition, focusing on maximising lymphatic drainage, and creating change in the subcutaneous tissue using gentle, targeted movements that respond to the underlying skin and tissue texture.
Clinical Implications for Health Professionals
For health professionals, this study emphasised the importance of clinical observation and person-centred treatment in lymphoedema care, something that can't be deduced from randomised controlled trails (RCT) which frequently ignore or control Therapist input. Read more on why RCT's don't offer much of value in lymphedema therapy here.
Many Therapists are swayed by apparent new revelations suggesting there is something they could do better, or more efficiently for their lymphoedema clients.
Mostly this comes about through the unchallenged acceptance of the results from Level 1 research, such as RCTs which, in reality, give us little if any of use to guide our clinical practice.
The very nature of the RCT study design limits the role and autonomy of the Therapist and excludes synergistic factors which may imapct treatment outcomes. Statistic can't tell you where the open pathways are for the client on your table right now, and the nuances of how we practice MLD on an individual basis can't be measured in an RCT.
The findings by Xing and colleagues support the fundamental principles of lymphatic drainage as it has been applied for the last several decades, adjusting MLD pressure according to tissue composition and response. By tailoring pressure within safe limits, clinicians can support lymphatic health and recovery without risking further compromise to the lymphatic vessels to achieve the optimal result for each client.
Guidance for Self-Massage: Tailoring Pressure to Personal Needs
For people living with lymphoedema, daily, personalised self-care is key. Lymphatic massage performed at home should follow a sequence that takes into account the specific needs of the person. A universal approach such as is often seen on social media may miss the mark, and a bespoke self-care program based on individual needs and capabilities should be adopted.
In areas with free-moving fluid, use lighter, longer strokes and do the massage more frequently. Frequent short sessions can be very effective in preventing fluid build-up, so long gentle strokes over fluid rich regions can be done a few strokes at a time all day long.
For more fibrotic regions, smaller firmer movements will need to be applied for more sustained periods to soften the tissue and free up trapped molecules. This can be interspersed with longer strokes to move any molecules that have been softened and released, towards your open pathways.
The pressure and direction of self-massage should be adjusted using feedback based on how the feel of the tissue changes during treatment, and your perceived feelings of where the fluid is going.
Online videos can be useful but often fail to capture the nuanced needs of you the individual, and may lead to spending your time and energy on ineffective techniques.
In conclusion
Achieving the right balance in lymphatic massage pressure is vital. Individualised pressure phases, based on disease stage and tissue type will enhance the effectiveness of MLD and align treatment with person-specific needs. A personalised approach for optimal lymphoedema self-management should also be prioritised over generalised techniques and recommendations.
Xing N, Liu D, Chen L, Wang G, Tian Y, Yang C, Leng Y, Jiang X, Li C, Xie R et al: Quantitative analysis of pressure levels in manual lymphatic drainage across stages of breast cancer-related lymphedema: implications for optimized treatment protocols. Breast Cancer Res Treat 2024.
DOI 10.1007/s10549-024-07540-2 https://link.springer.com/article/10.1007/s10549-024-07540-2
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