Jan 29, 2015A Light Touch
A form of massage called lymphatic facilitation is gaining followers in athletics as it has been shown to help cut down on injured athletes’ recovery time.
By Patricia Archer
Patricia Archer, MS, ATC, LMP, has been a sports healthcare specialist and educator for over 30 years. She teaches continuing education seminars around the country in advanced therapeutic massage techniques and maintains a private practice at her clinic, Seattle Somatics. Pat can be reached at: [email protected].
What if you could learn a modality that helps athletes return to play faster than expected? I’m talking at least two to three days, and sometimes even a week or more earlier than the typical prognosis for their injury. In the world of competitive athletics, shaving that much time off an athlete’s recovery can be a big boost for not only the athlete, but the entire team.
What if I told you that no equipment was necessary for this modality–only your hands–and that a session can add just 15 minutes to an athlete’s treatment? And once an athlete has experienced the proper application and understands the rationale for the technique, they can often be taught how to perform the modality on themselves.
Lymphatic facilitation (LF) is an abbreviated form of the complex manual lymphatic drainage techniques used to treat lymphedema (a bodywide edema caused by dysfunction of the lymphatic system). A massage technique that improves edema removal and lymph flow, LF uses a gentle and rhythmic technique to manipulate the superficial tissues. Dale Perry, a licensed massage therapist and certified lymphatic therapist, developed LF in 1994, and he and I began using the technique early on in our eight years as massage therapists for the NBA’s Seattle Sonics (now the Oklahoma City Thunder). We found that adding LF techniques to standard treatment protocols greatly improved athletes’ progress through the healing cycle–sometimes returning them to play as much as two weeks earlier than expected.
Dale conceived LF after studying and then becoming certified in both Manual Lymph Drainage (developed by Emil and Estrid Vodder) and Comprehensive Decongestive Therapy (developed by John and Judith Casley-Smith). In addition to treating complex lymphedema, he recognized that these techniques could be modified to also effectively alleviate the temporary edemas associated with musculoskeletal injuries. Because athletes have healthy cardiovascular and lymphatic systems, LF techniques do not require the same kind of meticulous attention to detail as the lymphatic drainage techniques used in those with dysfunctions in those systems. Additionally, the positive effects of LF are measurable in the very short timeframe desirable in athletics.
I’ve also used LF techniques extensively with the swimming and track and field teams I work with, and again found it helps improve their recovery time. In sports like these where athletes often compete in two to three different heats or events in a single day at meets lasting four to five days, anything that helps keep muscles feeling light and loose is extremely beneficial.
Expedited recovery time isn’t very surprising once you understand the physiologic mechanisms of the lymphatic system and how LF stimulates these essential healing processes. The basic anatomy and physiology classes most of us took in college focused more on the immune functions of the system, which means we didn’t get a very clear understanding of how the lymphatic system carries out its role of fluid return–and how important this process is to our health. We’ll start with a brief description of how the lymphatic system works.
The lymph system is an open network of vessels that operates on the siphon principle to pick up interstitial fluid and return it to circulation. This means there must be negative pressure inside the lymph vessel network in order for interstitial fluid is to be picked up by the capillaries–a process called edema uptake. Negative pressure is created and maintained within the system by emptying the lymph back into venous blood at the subclavian veins. Like sucking on a straw, fluid is pulled into lymphatic capillaries because of the emptying process at the top of the system. Another important influence on edema uptake is the amount of interstitial pressure. When injury and swelling occur, the interstitial pressure increases, which creates the necessary pressure differential for fluid to be siphoned into lymphatic capillaries.
Once inside the system, the strongest influence on rate of lymph flow is the rhythmic contractions of the primary lymphatic vessels, called lymphangia. There is a smooth muscle that spirals inside the wall of the lymphangia, and its regular, but infrequent contractions (four to 10 times per minute) are essential to help propel lymph through the system. The autonomic nervous system controls this contractile rate, and research has shown that both the strength and rate of the contractions are increased when edema uptake and the siphon effect are enhanced.
The lymph capillaries that pick up interstitial fluid have a unique arrangement of overlapping epithelial cells, looking something like fish scales, and each cell has a small hair-like extension called an anchor filament. These anchor filaments not only hold the lymph capillary in place in the interstitium, but they also open the vessel to let fluid flow in (presuming negative pressure) when the tissue is stretched slightly. These initial lymph capillaries are extremely superficial, located just underneath the epidermis of the skin. Therefore, opening the initial vessels requires a very light touch that stretches the epidermis only. Anything deeper, and the initial vessels will be compressed into a closed position rather than an opened one.
The above anatomic and physiologic facts have several key implications for athlete wellness. First is the simple recognition and appreciation of how essential the lymphatic system’s role is in maintaining homeostasis.
Even in healthy tissue, the cardiovascular system leaves behind a minimum of 10 percent of the total volume of capillary filtrate in the interstitium. This leftover filtrate then becomes the sole responsibility of the lymphatic system. Our body relies on this system to pick up the interstitial fluid, filter out metabolites, waste products, and cellular debris, and then enrich that fluid with immune cells before returning it to circulation.
For the average human, approximately three liters of fluid are filtered, enriched, and returned to circulation every day via the lymphatic system. While our natural tendency is to think about the nutrient-waste exchange as happening directly between blood and cells, in actuality, it occurs between cells and interstitial fluid. Without the lymphatic system, all of our cells, organs, and tissues would be floating around in dirty bath water, which is completely inefficient. Cellular transportation mechanisms would be compromised, waste removal and immune responses would slow, and the delivery of nutrients and repair cells would be inhibited.
This inefficiency has a negative impact on athletes in particular since the daily load of metabolic byproducts and low-grade inflammation due to micro-trauma is extremely high. This escalates the importance and value of using lymphatic facilitation in sports healthcare. By stimulating edema uptake and lymph flow, we enhance the body’s natural fluid refreshing and recovery processes, which should help athletes recover from exertion more quickly.
While sufficient research to support this hypothesis does not exist, my experiences and those of my colleagues who use LF show strong anecdotal evidence that it does have a positive influence on recovery from, and reduction of, general muscle soreness. Even when I’m working with non-athletes in my massage therapy practice, I’ve found that finishing a session which included a lot of muscle specific and myofascial techniques with LF greatly reduced the residual soreness for the client.
A second implication is that stimulation of the body’s natural edema removal system is key to improving their rate of progression through the injury cycle. Current standard treatment protocols for injury–rest, ice, compression, and elevation–all minimize tissue necrosis and manage initial hemorrhage (primary edema). However, none of these measures stimulate edema uptake or lymph flow. In fact, ice and deep compression together specifically shut down edema uptake and lymph flow.
LF, on the other hand, stimulates edema uptake and the removal of protein from the interstitium, which helps limit secondary edema formation and decrease the risk of excessive scar tissue development. The rhythm and movement of LF can also help decrease pain via gate control and by reducing the pressure on nociceptors (sensory receptors that send “pain” signals to the brain).
The simplicity of the strokes and sequences in LF makes it easy to employ in athletic environments. Only two basic strokes are used: stationary circles, which are used to clear the lymph node beds (called catchments in lymphatic terminology) at the site of edema, and traveling long strokes, which clear the superficial pathways between the edema and the catchment.
The strokes are similar in that they are light, rhythmic, and slow. Remember, the initial vessels are located just beneath the epidermis, so the correct amount of pressure is essential. You can compare it to the amount of pressure needed to slide your eyelid over your eyeball. The LF strokes use repetition instead of pressure to achieve the desired effect, meaning each light stroke is repeated over the same area of tissue 10 to 20 times to fully absorb edema and/or move lymph along in the system.
The stroke techniques are applied in the same general direction as lymph flow–toward the catchment for that region of tissue, which is generally (but not always) toward the heart. Both LF strokes start with a light stretch of the epidermis and finish with a sudden release of this tissue so it “snaps back” to its original position. The slight stretch of the epidermis pulls on the anchor filaments to open the initial vessel for edema uptake, and the sudden release of the tissue creates a slight push, like slamming a door, that propels fluid deeper into the lymphatic network.
All LF sequences follow the same three steps. First, start the siphon by increasing lymph flow back into the cardiovascular system at the terminus, which is the junction between the two major lymphatic ducts and the subclavian veins (at the base of the neck just above the collarbones and lateral to the sternocleidomastoid muscle attachment point). Next, clear the pathway by emptying the catchments and superficial pathways proximal to the edema. Clearing the catchments is an essential step in improving lymph flow because flow through the lymph node beds is 100 times slower than movement throughout the rest of the system. Functionally, slow flow through the catchments is helpful for immunity, but bad for edema removal. So clearing the catchments is essential for edema removal but should be avoided during infection or illness. Finally, site-specific application of LF strokes will promote edema uptake and enhance lymph flow through the superficial vessels in the area of swelling. (For an example of a general recovery sequence, see “LF For Tennis” below.)
When LF is used for treatment of injury, a thorough treatment session averages about 15 minutes. However, allot 20 to 30 minutes for severe injuries with lots of edema because you may have to clear the catchments more than once and work several different points along the periphery of the edema. The further the edema is from the lymphatic terminus the more steps in the sequence. For example, an acute ankle sprain should be given a full 30 minutes because it requires clearing three more catchments and all of the tissue from ankle to groin before addressing the swelling in the ankle.
Because lymph flow follows a predetermined path, LF treatment sequences are based on the body region rather than the type of injury. So whether you’re treating epicondylitis, a rotator cuff strain, or a sprained wrist, the sequence is essentially the same. However, the patterns of lymph flow are a bit more complicated in the body’s lower extremities, so treatment sequences here require more steps, more strokes, and more detailed knowledge of lymphatic processes that can be found in a book about LF or learned in a class.
Another important consideration when using LF in conjunction with other modalities is to remember that the lymphatic system “cleans things up,” so it should follow other treatments, especially any cryotherapy. Standard protocols should always be the first step in any treatment, and LF is the final step.
When using LF to help athletes recover faster after competition, the same physiologic and technique principles apply, but the pace is a little faster and fewer strokes are applied to each site. The first question to ask any athlete before they get their post-event massage is whether their arms or legs feel heavy or tight. If they say yes to both, you need to do some general massage and muscle-specific work before finishing their session with LF. If they say they just feel heavy, you can have them feeling refreshed and invigorated with a 10- to 15-minute LF sequence.
My experience using LF with athletes has shown me the technique is effective for edema removal, pain reduction, prevention of residual soreness, and enhancing recovery from exertion. Hopefully this article has provided you with a better understanding of the importance and physiologic rationale for stimulating the lymphatic system, as well as some basic information on the LF technique itself.
If your interest has been piqued, seek out further information and training in this important form of manual therapy. I think you’ll be amazed and delighted at how it enhances the effectiveness of your treatments.
Sidebar: LF FOR TENNIS
For a sport like tennis, which sees many upper-body injuries, here’s what a general recovery sequence of lymphatic facilitation (LF) would look like. The entire sequence should take only 15 minutes once you are proficient in the techniques.
Begin with the athlete in a supine position.
Start the siphon the same as you would for any treatment session by clearing the axillary catchment with 10 stationary circles.
Apply five to eight long strokes to the brachium and five to eight long strokes to the forearm.
Clear the axilla again.
Apply a series (three to five sets) of stationary circles to the chest before turning the athlete to prone position and applying another series of stationary circles to the back.
Finish with 10 stationary circles at the terminus.