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The Five Elements of Complex Lymphatic Therapy
The elements of Complex Lymphatic Therapy (CLT) are similar to those of other effective lymphedema treatment protocols
such as the European protocol, Complete Decongestive Therapy (CDT).
1. Lymphatic Drainage
This
is a gentle massage-like manual technique.
The original Manual Lymph Drainage (MLD) was created in the 1930s by a
Danish therapist, Emil Vodder. Directly or indirectly, all the current methods of lymph drainage owe a great debt to him.
The version taught in CLT was developed by Judith Casley-Smith, and drew on the general priniciples of Vodder's MLD
as well as new knowledge about the lymphatic system, such as Stefan Kubik's work on lymphatic watersheds and lymphotomes and
the research on the microcirculation of the lymphatic system done by John and Judith Casley-Smith themselves.
The Casley-Smith
lymph drainage uses light slow easy-to-learn strokes to move fluid, proteins, and waste products away from regions where they
are accumulating and stagnating because of a problem in the lymphatic system, The strokes take this fluid across the 'lymphatic
watersheds' over to regions of the body with functioning lymph vessels and lymph nodes.
Ways it resembles Vodder's
MLD:
*The strokes are slow, gentle, and rhythmic
*The strokes create changes in the total tissue pressure
*The
strokes start proximal to the problem areas first and the direction of the strokes is towards areas with functional lymph
nodes
Ways it is different from Vodder's MLD:
*Many of the strokes move across the skin instead of
using stationary skin-stretching techniques
*In the swollen areas, the emphasis is on moving fluid through the tissue channels
rather than on trying to increase the pumping of lymph vessels in that area
*There are specific strokes done at the watershed
region
*The lymphotomes on the limbs (lymph drainage areas)are addressed more specifically
*The emphasis is on concentrating
on what you feel under your hands rather than on the precision of the strokes your hands are doing
2. Gradient
compression wrapping using padding and short stretch bandages
Starting with the fingers or toes and working
up to the top of the affected limb, stockinette, then various kinds of padding, and finally layers of short-stretch bandages
are applied. These provide a counterpressure to the tissues under the skin to keep fluid from accumulating and to promote
the flow of the fluid up the limb.
Careful attention is paid to layering the bandages to create a gradient with more
pressure distally and less as you go proximally up the limb.
3. Decongestive Exercises
Judith
Casley-Smith's contribution to the treatment of lymphedema includes the insight that an exercise sequence that mimics the
MLD sequence will be more effective than exercises performed in a random order.
The exercise sequence that is taught
to the patient starts with exercises of the neck and trunk, then moves to the muscles proximal in the limb before exercising
the muscles that are distal in the limb.
The Casley-Smith exercise sequence is also innovative in incorporating elements
of MLD such as deep breathing, stimulation of intact lymph nodes, and short segments of self-MLD. These enhance the effectiveness
of the exercises.
4. Skin Care
Infection is one of the
major triggers of lymphedema in those at risk; repeated infections lead to a worsening and progression of lymphedema. For
this reason meticulous skin care is important to help prevent the breaks in the skin that become sites of infection.
Some
of the elements of skin care include
*washing and drying the limb meticulously, using upward strokes
*using skin care
cleansers and lotions which are low pH to maintain an antibacterial protection on the skin
*taking precautions to avoid
cuts, nicks, burns, scrapes, bites, scratches, etc.
*taking care of any breaks in the skin immediately and monitoring them
carefully for signs of infection
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* The work of Dr. Gerusa
Dreyer in Brazil working with people with filarial lymphedema has demonstrated the dramatic improvement skin care and the
prevention of infections can have on even advanced stages of lymphedema.
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5. Instruction in self-management of lymphedema
One of the innovations of the Casley-Smiths
was developing techniques which people with lymphedema could do themselves or with the help of a family member, so that they
would not be dependent on returning regularly for follow-up treaments in order to maintain their reductions.
This was
a crucial consideration in Australia, where there were few lymphedema therapists and where people lived far away and scattered
out. It was also crucial in the places where the Casley-Smiths worked, such as India, where Judith first began developing
the manual drainage techniques of Complex Lymphatic Therapy. It has proved important in the US where distances and insurance
limitations as well as the scarcity of lymphedema therapists also require that patients be able to continue with self-care.
The elements of the home program are similar to the components of treatment during the intensive phase:
1.
Lymph drainage, now done by the patient, sometimes with the help of a family member
2. Gradient compression:
usually supplied by day with a compression stocking or sleeve and by night either by the gradient compression wrapping (now
done by the patient or family member) or with an alternatiave product such as Circaid, Jovi-Pak, Tribute, Reid Sleeve or one
of the other new products coming out on the market.
3. Decongestive exercises
4. Meticulous skin
care
5. Following certain precautions and making some modifications in activities to prevent
flare-ups of lymphedema
6, Doing self-measuring and self-assessment to recognize if there is improvement or
regression in the lymphedema.
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NOTE: When the Casley-Smiths
developed the techniques of CLT, an important adjunct was the oral or topical use of Coumarin, [Lodema]. This is a benzo-pyrone
which helped soften fibrotic tissue and made reduction of lymphedema faster and easier. However Coumarin never received FDA
approval in the US. In many countries where it had been in use it was taken off the market because the oral version led to
hepatotoxicity in a small number of cases.
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Three Phases
of Treatment
Phase I: Intensive
The patient comes 5 days a week, receives
at least an hour of lymph drainage, is taught the decongestive sequence of exercises, skin care, precautions, and is wrapped
in gradient compression which remains on until the next day when the patient returns. During this time patients and/or family
members are also instructed in other elements of the home program, including self-drainage and self-wrapping.
Phase II: Stabilizing
After the person has achieved maximum reduction in swelling and normalizing
of tissue texture during the intensive phase, the person is fitted for a compression garment to wear by day. If the person
is unable to self-wrap and does not have someone to help, they also can be fitted for an alternative compression product to
wear at night.
During the stabilization period, the person is no longer coming in for treatment but is doing daily
self-care at home: wearing compression round-the-clock, doing the decongestive exercises and/or self-lymph drainage every
day, and continung to follow precautions and skin care guidelines.
During this period, if the person is conscientious,
additional reductions may be achieved and skin that became loose after the intensive phase of volume loss can start to remodel.
The purpose of this phase is to consolidate the changes achieved during the intensive phase of treatment.
Phase
III: Maintenance, or "Getting on with your life"
In this phase the person starts to find the balance necessary to
shift the focus from lymphedema care to other priorities and get on with life, while still being able to maintain a satisfactory
control over the lymphedema. This may mean a gradual phasing out of certain aspects of the home program to less than daily.
It must be accompanied by self-measurement and self-assessment to be sure that the remaining elements of the home program
are sufficient to keep the lymphedema in check.
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