Lymph vessels make an intimate meshwork that covers every inch of your skin, and surrounds each organ in great detail. The lymph vessels start very small in what are called the initial lymphatic. Over 70% of the initial lymphatics are in and just under the skin. The initial lymphatic is a very delicate structure, one cell thick. Those cells are supported within the connective tissue by collagen and elastin fibers that help to anchor them in place. When the pressure within the interstitial space increases due to a buildup of fluid, or when the skin is slightly stretched, the filaments deform the wall of the initial lymphatic, opening it up. Then the interstitial fluid flows in and starts to move along the channel. At this point we start calling it lymph. Although only 2-3 liters of lymph is filtered through the lymph system per day, it is vital because it helps to remove proteins that that are too large to get back through the capillary wall. (Guyton and Hall, Human Physiology and Mechanisms of Disease, 6th edition, W.B Saunders Company, Philadelphia, 1997, page 139) The spaces that open in the initial lymphatic are 4 to 6 times bigger than the spaces in the capillaries. Removal of protein is essential because proteins draw water to themselves, so excess protein in the interstitial spaces causes swelling or edema. The lymph vessels also collect dead cells, waste products, bacteria, viruses, inorganic substances, water and fats.
By performing lymphatic drainage massage correctly, we can stimulate the opening of the initial lymphatic and increase the volume of lymph flow by as much as 20 times. But if we push too hard, we collapse the initial lymphatic, diminishing the lymph flow. Excessive pressure can even break the filaments that hold the initial lymphatic in place. This is one reason that Deep styles of massage are contraindicated in areas of edema. Luckily if deep pressure has broken any filaments, they usually reform within 24 hours.
After the lymph has entered the initial lymphatic, the lymph moves into a larger vessel called the pre-collector, and then into even larger vessels called the collectors. The collectors are 100-600 microns in diameter. These vessels have one-way valves every 6- 20 mm that only allow the lymph to move in one direction. When you??re performing lymphatic drainage massage, you never have to worry that you are damaging your clients by pushing the lymph in the wrong direction- because it literally can??t flow backwards. Pushing in the wrong direction won??t be very effective, but it won??t hurt your client unless you are using deep pressure- and in that case, you are not doing lymphatic drainage massage.
From one one-way-valve to the next is called a lymphangion. The lymphangions have a layer of smooth muscle that spirals around them. Angion means heart- so this is really the pump that pushes the lymph. Each lymphangion has an internal stretch sensor. The walls of the lymphangion stretch when they fill up with lymph, and then the stretch sensor tells the muscle to contract. This spiraling muscle contracts squeezing the lymph into the next chamber. This swells the next lymphangion, which then contracts, pushing the fluid down the line. At the same time the lymphangion is pushing the lymph forward, it also is creating a vacuum behind it. It is partly because of this vacuum effect that the lymph gets pulled into the initial lymphatic in the first place. (Kasseroller, R., Compendium of Dr. Vodder’s Manual Lymph Drainage, Haug, Heidelberg, 1998)
Once the lymphangions begin contracting, they cause a chain reaction, or a wave of contractions that start to push and pull the lymph through the body. In this way stimulating lymph flow in one area can increase lymph flow in another. Other factors that can assist the movement of the lymph are skeletal muscle contractions, breathing, the pulsing of arteries, as well the ability of the angions to contract independently of the stretch receptors. Lymphatic Drainage Massage??s effectiveness lies in its ability to activate the stretch response, which significantly increases the pulsation rate of the lymphangions, increasing lymph flow through the vessels.
Eventually, all lymph vessels lead to lymph nodes. Lymph nodes can be as small as the head of a pin, or as big as an olive. There are 400-700 lymph nodes in the body, half of which are located in the abdomen, and many are in the neck and axilla (armpit).
The primary function of lymph nodes is to filter and purify the lymph. The lymph nodes produce various types of lymphocytes. Lymphocytes destroy harmful substances within the body, and are a big part of the immune system. The lymph nodes reabsorb about 40% of the liquid content of the lymph. This makes the lymph much thicker. Because of this thickening and the filtering process, the lymph nodes offer the greatest resistance to the flow of lymph. In fact the lymph nodes offer about 15 times more resistance than the vessels themselves. Lymphatic drainage can help overcome this resistance and get the lymph flowing.
Figure 1 shows some of the main nodes, and how the lymph drains to them.
Each cell is nourished by the nutrients, oxygen and proteins that flow across the walls of capillaries into the interstitial fluid. There is a dynamic balance between the forces that help those nutrients to first exit the capillaries, and then get reabsorbed back into the blood stream. Proteins play a big part in this transfer because they have a tendency to draw water to themselves. This means that the proper amounts of protein on both sides of the capillary wall are vital to keep the tissues balanced. If there are too many proteins within the interstitial spaces, fluid will start to accumulate, causing edema. The lymph system??s role of removing proteins is vital to keeping edema down. If the lymph system becomes sluggish, or is damaged by surgical removal of lymph nodes, edema can develop. This type of edema is called lymphostatic edema- or a high protein edema. Lymphatic drainage can be helpful in reducing this type of edema because the cause is a reduced functioning of the lymph system.
Other causes of edema can be a chemical imbalance in the body caused by liver disease, diabetes, or a variety of other ailments. This type of edema is called lymphodynamic edema, and requires other forms of therapy due to the fact that it is a chemical imbalance. (Kasseroller, R., Compendium of Dr. Vodder’s Manual Lymph Drainage, Haug, Heidelberg, 1998)
Lymphatic drainage massage is a profound technique to help increase lymph flow. With an increase of lymph flow immune function is increased. Harmful substances are removed from the tissues and neutralized in the nodes. It has also been shown that an increase in lymph flow stimulates an increased production of lymphocytes- enhancing immune function.
Lymph drainage massage is excellent for women who have had breast cancer and had some axillary lymph nodes removed. When these nodes are removed, it is more likely that the arm may develop edema. Lymphatic drainage massage can help to get the lymph flowing up the arm, and around the removed nodes. This work activates the lymph vessels that are still intact- clearing the arm of swelling. If there is a great deal of swelling, then this is out of the scope of practice for a most massage therapists due to the need for bandaging. These patients should work with a group of MDs, Pt or massage therapist with an in-depth training in dealing extreme cases of edema. If the swelling is minor then a massage therapist with a good knowledge of contraindication and some basic training can do a great amount of good. When working with anyone who has recently received cancer treatment, make sure to work in conjunction with the M.D. who is responsible for that patient??s treatment.
Lymphatic drainage is also very helpful for clients who are suffering from a lack of energy, a sluggish immune system or sports injuries. After the initial inflammatory stage has passed, lymphatic work can be applied after Sports or Neuromuscular massage has been completed. This will help to clear the tissue of debris, and help to reduce the minor edema that sometimes occurs after deep massage. Continued applications of lymphatic drainage while the client is healing can help to enhance the tissue regeneration process by keep the tissue as health as possible.
Not only is lymphatic drainage useful for sports injuries, but it can also help scars. (Godart, S., “Lymphatic regeneration after second degree burn,” Progress in Lymphology, 1975/ Hutzshenreuter, P.O. and Brummer, H., “Manual Lymph Drainage used for Scar Healing,” University of Ulm). Lymph work has been shown to help the scarring process by enhancing circulation and immunity. As the lymph flow around the scar is increased, lymph vessels that have been damaged are stimulated to heal, and the increased lymph flow also draws away toxins, improving the health of the tissues
When attempting to assist healthy scar formation, it is important not to push the lymph into the scar, which can cause the formation of keloids (a buildup of collagen fibers). All scar work should be done without deforming a newly forming scar- so as to not rip the tissue. One way is to work above the scar (closer to the node that drains the area). For example, a lymph therapist could work in the axilla and upper arm to help increase the lymph flow around a scar in the forearm.
Beyond its application for injuries, Estheticians have been using lymph drainage massage for years to enhance the quality of the skin, especially on the face. When the lymph is flowing, the cells are being bathed in fresh fluid, causing the skin to look fresh and alive. We have all experienced having minor edema in our faces- that puffy feeling and baggy eyes when we first wake in the morning after a long night. Usually after a few minutes of being vertical the lymph system starts to drain the face. A great way to see the power of lymph drainage is to apply a few strokes on one of those mornings, and watch in just a few minutes the tissues drain right before your eyes- leaving you looking vibrant and healthy.
For the most part lymphatic drainage massage is safe. With such a light touch, the danger of causing damage to the tissue is slim. However, there are a few conditions that are contraindicated, and these happen when an increase of lymph flow would be detrimental. It is a good idea to get clearance from their doctor if you ever feel uncertain about working on someone. Acute inflammation, Malignant tumors, Thrombosis and major heart problems are all contraindications to lymphatic drainage massage. Lets look at these one at a time.
Acute inflammation caused by bacteria, viruses, poisons or allergens is contraindicated. You can tell if this is the case because the tissues will be red, hot, and painful, with congestion accompanied by fever. Lymphatic drainage massage will push these substances into the lymph channels before the body has a chance to eliminate them through phagocytosis in the interstitial spaces. If you perform lymphatic drainage you can spread the toxic substances throughout the body. Wait a few days until the condition is not acute, and the body has had a chance to clean up the area.
Malignant tumors are a contraindication for lymphatic drainage massage because of the fear of spreading the cancer. There is some debate about this, however, and the current trend is moving toward using lymphatic work to aid healing of the body during and after the cancer treatment. This type of work should be coordinated with the patient??s medical doctor.
Thrombosis and phlebitis are two conditions that can lead to free floating blood clots. Usually people with these conditions will be in a hospital on blood thinners. If you are working in a hospital setting, do not work on these patients. In your practice, one indication of a possible femoral thrombosis is when the client has pain in one leg and a sudden swelling and bluish discoloration of the skin. People who are bedridden have a greater likelihood of developing thrombosis in the legs.
Major heart problems. If the heart is not fully functioning the edema can be lymphodynamic, due to lack of venous return. Putting more fluid into the heart would only stress it more, worsening the condition.
After reading the contraindications for a modality, many therapists experience fear of working on anyone. The most appropriate response to this list is to add it to your client intake questionnaire. It should also make you take pause to reflect on the power of this type of work- to do harm as well as good. By being informed of the benefits as well as the contraindication, you, your client and your client??s doctor should be able to decide when the use of lymphatic drainage massage would be most beneficial.
Lymphatic drainage massage is a great ally in any massage therapist’s tool kit. By being able to address the lymph system directly, client’s immune system function can be significantly increased. For women who have had lymph nodes removed, this work can be a great ally in keeping the lymphatic vessels flowing throughout the affected side. Having an active lymphatic system will help strengthen the immune system. When we have a strong immune system, we are happy, balanced and whole. Lymphatic drainage massage can go where Deep Tissue and Swedish cannot- into swollen areas. The paradox is that such a superficial technique has such a deep impact.
To start learning more about Lymphatic Drainage Massage, get the video Lymphatic Drainage Massage by Sean Riehl.
Sean Riehl has practiced massage for over 11 years, and has been a massage instructor since 1993. He has worked with clients with edema in his private practice, and finds lymphatic work a valuable asset to his other treatment skills. He is the author of the video Lymphatic Drainage Massage, two Myofascial Release videos, two videos on Deep Tissue and Neuromuscular Therapy as well as the video Heal Your Wrist Pain, Naturally. He lives in Santa Barbara, California and operates Real Bodywork. He can be reached at firstname.lastname@example.org.