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 lower extremity. 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), abdominal breathing techniques, 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:
- Manual lymph drainage and its role in the treatment of lymphedema
- The Science behind Manual Lymph Drainage in the Treatment of Lymphedema
- Skin and Nail Care in Lymphedema Management
- Primary Lymphedema
- Secondary Lymphedema
The following techniques can be used for lymphedema affecting one leg; the illustrations and techniques describe the sequence used for lymphedema affecting the left leg. In this case the lymph nodes located in the opposite groin (right) and those in the axilla of the same side (left) are unaffected and working properly.
This sequence should not be used in lymphedema affecting both legs, or if the axillary lymph nodes on the affected, or the inguinal (groin) lymph nodes on the unaffected side are removed, or non-functioning due to other reasons.
Ideally, self MLD should be applied at least once daily for 15-20 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.
The techniques and sequences below are 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.
Preparation and Abdominal Breathing:
- 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 axilla (armpit, underarm) on the same (affected) side. The pressure is directed downward (deep) into the axilla and applied with the flat fingers and palm.
- Stationary circles with the flat hand in several placements from the waist on the affected side to the axillary lymph nodes on the same side covering the entire surface of the lateral trunk (flank). The pressure is directed toward the axillary lymph nodes (same side).
- Stationary circles with the flat hand in the area of the groin lymph nodes (inguinal lymph nodes) on the opposite side. The hand is placed just below the inguinal ligament (in the green area depicted on the illustration on the very bottom of this page) and the pressure is directed toward the belly.
- Stationary circles with the flat hand in several placements from the groin (inguinal) area on the affected side to the groin (inguinal) area on the opposite side. The pressure is directed toward the groin (inguinal) area on the opposite side.
- Diaphragmatic (abdominal) breathing:
It is important to discuss any possible contraindications for this technique with the therapist!
Abdominal breathing is done by contracting the diaphragm, a muscle located horizontally between the chest cavity and stomach cavity. As air enters the lungs this deep breathing is marked by expansion of the abdomen rather than the chest when inhaling. During the inhalation both hands that are placed flat on the belly provide resistance to the expanding abdomen.
During the exhalation the hands follow the belly and at the end of the exhalation, the hands press gently downward and upward toward the chest.
This technique should be repeated five times.
- Soft effleurage over the skin of the entire leg from the ankles (or knees) to the waist.
- Stationary circles with the flat hand and fingers in several placements on the lateral (outside) thigh and hip. The pressure is directed toward the waist.
- Stationary circles with the flat hand and fingers in several placements from the medial (inside) portion to the lateral portion of the thigh. With the pressure directed toward the lateral aspect of the thigh, the entire thigh from the top (just below the groin) down to the knee should be covered.
- Stationary circles with the flat fingers of both hands behind the knee. The pressure is directed upward toward the thigh.
- Stationary circles with the flat fingers of both hands on the medial (inside) lower leg. With the pressure directed toward the thigh, the entire area between the knee and the medial ankle bone should be covered.
- Stationary circles with the flat hand and fingers of both hands on the inner and outer surface of the lower leg. With the pressure directed toward the thigh, the entire area between the area below the knee and the ankle bones should be covered.
- Repeat as many of the steps on the leg as you wish.
- Repeat steps 2, 4, and 6
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