Complete decongestive therapy (CDT) is performed in two phases; in the first phase, also known as the intensive or decongestive phase, treatments are administered by trained lymphedema therapists on a daily basis until the affected body part is decongested.
The duration of the intensive phase varies with the severity of the condition and averages two-three weeks for patients with lymphedema affecting the arm. However, in extreme cases the decongestive phase may last longer and may have to be repeated several times.
The end of the first phase of CDT is determined by the results of measurements taken by the therapist on the affected body part. Once measurements approach a plateau, the end of phase one is reached and the patient progresses seamlessly into phase two of CDT, which is also known as the self-management phase.
Phase two is an ongoing and individualized part of CDT, in which the patient assumes responsibility for maintaining and improving the treatment results achieved in the intensive phase (phase one).
During the intensive phase patients are instructed by the therapist in the individual components of self-management, which include self-manual lymph drainage (self MLD, or simple MLD), a skin care regimen, home exercises, and the application of compression garments (and bandages).
The self-manual lymph drainage techniques are relatively easy to perform and therapists generally teach one or two MLD strokes that can be learned and safely performed by the patient. It may help if the patient’s spouse, a relative or a friend is present during the therapist’s demonstration of these strokes to observe, take notes, or record the techniques with a camera.
The strokes are based on the same principles as those performed by the therapist, and it is very important that the patient clearly understands the hand movements, specifically the principles of skin elasticity, the pressures used during the working and resting phases of the strokes, and in which direction the pressure should be applied.
To help understand the techniques of MLD it is advisable to read the following articles published on this blog:
The following techniques can be used for lymphedema affecting one arm; the illustrations and techniques describe the sequence used for lymphedema affecting the left arm. In this case the lymph nodes located in the opposite axilla (right armpit, underarm) and those in the groin of the same side (left) are unaffected and working properly.
This sequence should not be used in lymphedema affecting both arms, or if the axillary lymph nodes on the unaffected, or the inguinal (groin) lymph nodes on the affected side are removed, or non-functioning due to other reasons.
The techniques described are performed in the sitting position; ideally, self MLD should be applied at least once daily for 10-15 minutes, directly preceding the exercise program, and should be followed by appropriate skin care and compression therapy.
Each stroke should be repeated 5-7 times, and, if not noted otherwise, the hand of the unaffected side (in this case the right hand) should be used to perform the strokes.
The techniques and sequences below represent standard examples and may vary from those demonstrated by the therapist. Therapists may have different preferences, or the techniques may have to be adjusted to accommodate specific requirements or physical limitations of the individual patient.
- Stationary circles with flat fingers above the collarbone on both sides. The fingers of the right hand manipulate the skin above the collarbone on the left and the fingers of the left hand manipulate the skin above the collarbone on the right. The pressure is applied with the flat phalanges of the fingers (generally the index, middle and ring fingers) and the pressure is directed toward the neck. This technique can be applied simultaneously on both sides or on each side individually.
- Stationary circles with the flat hand in the center of the opposite axilla (armpit, underarm). The pressure is directed downward (deep) into the axilla and applied with the flat fingers and palm of the affected arm.
- Soft effleurage over the skin from the affected axilla to the axilla of the opposite side.
- Stationary circles with the flat hand in several placements from the axilla on the affected side to the axilla on the opposite side. The pressure is directed toward the axilla on the opposite side.
- Stationary circles with the flat hand (use hand of affected side) in the area of the groin lymph nodes (inguinal lymph nodes) on the same side. The hand is placed just below the inguinal ligament (in the green area depicted on the illustration on the very bottom of the page) and the pressure is directed toward the belly.
- Stationary circles with the flat hand in several placements from the axilla on the affected side to the inguinal lymph nodes on the same side covering the entire surface of the lateral trunk (flank). The pressure is directed toward the inguinal lymph nodes (same side).
- Soft effleurage over the skin of the arm from the hand to the top of the shoulder.
- Stationary circles with the flat hand and fingers in several placements on the upper portion of the lateral upper arm, from the shoulder muscle (deltoid muscle area) of the affected arm to the top of the shoulder. The pressure is directed toward the neck.
- Stationary circles with the flat hand and fingers in several placements from the medial (inside) portion to the lateral (outside) portion of the upper arm. With the pressure directed toward the lateral aspect of the arm, the entire upper arm from the top (just below the axilla) down to the elbow should be covered.
- Stationary circles with the flat hand and fingers in several placements on the lateral upper arm. The entire lateral surface of the upper arm, from the elbow to the shoulder should be covered, with the pressure directed toward the shoulder muscle.
- Stationary circles with the flat hand and fingers in several placements covering the entire frontal (anterior) aspect of the lower arm, from the elbow crease to the hand. In order to reach all aspects of the forearm, the arm should be held in supination with the palm of the hand pointing to the front. The pressure is directed toward the upper arm.
- Repeat step number 10.
- Stationary circles with the flat hand and fingers in several placements on the posterior aspect of the lower arm, from the elbow to the back of the hand. In order to reach all aspects of the forearm, the arm should be held in pronation with the palm of the hand resting on the thigh. The pressure is directed toward the upper arm.
- Repeat steps 1, 2, and 5. Other steps may be repeated as well.
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