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

* 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. 
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 Casley-Smith 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 alternative 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 activitiesto prevent flare-ups of lymphedema

6, Doing self-measuring and self-assessment to recognize if there is improvement or regression in the lymphedema.

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.

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.  

Towards the end of this phase, the number of times a week is tapered off as the patient begins the transition to home management.

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.