Providing MLD services to a client can be different, depending on the client's needs. Are you attempting to performing a full detoxification, reduce unilateral extremity lymphedema or did the client show up for a full body massage with a severely swollen knee sprain?
Because there are so many different situations that can be treated with MLD, we recommend breaking MLD treatments down into 3 different categories:
LOCAL MLD: Only work on the affected area of swelling. This appointment could be as short as 10-minutes or as long 30-minutes or more. Practitioners can work as long as agreed and as long as you do no harm.
HYBRID MLD: Provide regular services (i.e., full body massage), and then provide MLD to only the affected area of swelling while the rest of the body receives its normal course of treatment. In full body massage, if the therapist spends 10-minutes massaging one leg, then the therapist would spend 10-minutes on the opposite leg with MLD. The goal is to keep the appointment session fluid and even between the swollen and normal areas of the bodywork.
FULL BODY MLD: Full Body Lymphatic Drainage (i.e., detox treatment). Full body sessions on average take 90-minutes, but like almost any other bodywork, practitioners can modify the session to make it shorter or longer time.
To learn more about manual lymphatic drainage applications, please register for quality, affordable, professional training at: https://ceinstitute.com/
There is still some conflicting Information about the lymphatic system, and some unknowns as well. We are still LEARNING more about the lymphatic system every year as science and research continues to advance. For example, we still do not know why 75% of lymph is drained through the left side of the body to the cardiovascular system and 25% of lymph is drained through the right, as depicted in this infographic (pictured right). There are many theories why there is such uneven distribution of lymph collection and redistribution to the cardiovascular system, but none of these theories have been scientifically proven to be factually correct.
New research studies are providing new information and updates about the lymphatic system every year. In past MLD classes prior to 2015, it was regularly taught that there is no lymphatic tissue or intervention within the cranium or central nervous system. We now know that theory was wrong.[i]
One research study reported prior to 2015, that “The brain...has been thought to lack lymphatic vessels, as they’ve never been found….These vessels may have gone undiscovered until now due to their hidden location. The method the team used to prepare the meninges kept these layers intact. The researchers found similar structures in autopsy specimens of human meninges. Organization of the vessels in the human central nervous system will now need to be determined.”[ii]
Lymphatic vessels in the brains of mice were only recently discovered through use of new high-powered microscopes. Prior to 2015, we thought that the lymphatic system and central nervous system were two completely separate systems without intervention.
The cranial lymphatics (aka glymphatics) is a perfect example of a major discovery that was only made a few years ago.
Despite not having a total understanding of the lymphatic system, we have learned enough to know how to manipulate it to reduce swelling, with services such as manual lymphatic drainage.
To learn more about manual lymphatic drainage or the lymphatic system, please register for quality, affordable, professional training at: https://ceinstitute.com/
[i] Louveau A;Smirnov I;Keyes TJ;Eccles JD;Rouhani SJ;Peske JD;Derecki NC;Castle D;Mandell JW;Lee KS;Harris TH;Kipnis J; “Structural and Functional Features of Central Nervous System Lymphatic Vessels.” Nature, 16 July 2015, U.S. National Library of Medicine, https://pubmed.ncbi.nlm.nih.gov/26030524/.
[ii] “Lymphatic Vessels Discovered in Central Nervous System.” National Institutes of Health, U.S. Department of Health and Human Services, 14 Dec. 2021, https://www.nih.gov/news-events/nih-research-matters/lymphatic-vessels-discovered-central-nervous-system.
We have many manual lymphatic drainage students who wish to practice MLD techniques post-abdominoplasty procedure.
On April 5, 2022, the Journal of American Society of Plastic Surgeons published an article called: Changes in the Pattern of Superficial Lymphatic Drainage of the Abdomen after Abdominoplastyhttps://pubmed.ncbi.nlm.nih.gov/35383695/
This published research states: "A significant change in lymphatic drainage pathway occurred in the infraumbilical region after abdominoplasty. The axillary drainage path was predominant after the operation, in contrast to the inguinal path observed in the preoperative period."
There is a LOT to learn to accurately and efficiently applied MLD techniques with the lastest research, proven methods and adverse complications, such as this one. We teach about this and much more in our manual lymphatic drainage classes. For the latest, evidence-based methods in manual lymphatic drainage training, please register with us at: https://ceinstitute.com/collections/lymphatics
Greater research studies are showing the efficacy of bolstering clients with swelling, particularly during the practice of manual lymphatic drainage (MLD).
Manual lymphatic drainage utilizes light-pressure manual manipulation of the skin and underlying tissues to promote the movement of lymphatic fluid, usually from one area to another towards lymphatic node regions. MLD is not to be confused with a traditional massage, especially given the pressure and work directions can be quite different in MLD.
To learn more, specifically in how to apply manual lymphatic drainage, please register for one of our MLD classes at: https://ceinstitute.com/collections/lymphatics. Home study classes are immediately available 24/7, until your course access expires.
In this training video, we will show you the order in which to bolster extremities (both arms and legs) during MLD practice:
Manual Lymphatic Drainage is NOT A MASSAGE. In massage therapy, we primarily work with muscle and other soft tissue structures. In Manual Lymphatic Drainage, we primarily work with FLUID.
While the lymphatic and cardiovascular systems both transport fluid throughout the body, the lymphatic system is thought to be a “less robust” system than the cardiovascular system, in-part, because the lymphatic system does NOT have a PUMP. The cardiovascular system's pump is our human heart and cardiac muscle.
Interstitial Fluid
In manual lymphatic drainage, we are trying to absorb and propel a milky white and often colorless fluid that bathes the tissues and drains through the lymphatic system into the bloodstream. It contains: water, proteins, cells, toxins, fats, waste, bacteria, viruses, etc.[i]
“The only difference between lymph and interstitial fluid is its location. If the milky white fluid is found in the spaces between body tissues, it is called interstitial fluid. If it is found in the lymphatic system, it is called lymph.”[2]
Here is an instructor demonstration of belly pumping, which is thought to promote stagnant lymph to propel superiorly towards the subclavian veins to be "dumped" in the cardiovascular system for appropriate filtering and/or elimination:
[i] Reference.com IAC Publishing Labs Company, found online June 24, 2016,
https://www. reference. com/science/lymph-differ-interstitial-fluid-cbe413fad52593d
[2] Reference.com IAC Publishing Labs Company, found online June 24, 2016, https://www. reference. com/science/lymph-differ-interstitial-fluid-cbe413fad52593d
Plastic surgeons often refers patients for post-surgical manual lymphatic drainage to relieve pain and swelling, or they may prescribe deep tissue massage for new muscular contracture over an implant or filler, or more.
Even with a doctor’s written prescription and direction, shifting or migration of fillers and implants could happen or be blamed on the therapist's manual therapy, and shifting could have already occurred, hence the referral.
It's important for massage therapists to remember that working over fillers or implants is contraindicated. Shifting and migration could occur with the manual therapy, and it is not worth the risk to try to achieve the benefit, especially given the lack of certainty with both. Therapists, clients and doctors cannot always control shifting and migration issues within the human body. This is one of many reasons why working over foreign materials implanted in the body is a massage and bodywork contraindication.
Migration and shifting are terms used to describe when a foreign material has moved away from its original placement site. This can also be called displacement.
Migration is the term commonly referenced when a foreign material has migrated to places such as the client’s bloodstream. Shifting is the term commonly referenced when a foreign material has shifted away from its original placement site, such as instances with physical force, capsular contraction or aging.
Migration and shifting issues of foreign materials within the body can cause physical disfigurement, swelling, pain, obstruction of circulation and even death in some cases.
Shifting of foreign materials can also occur over time and for other various reasons. Skin thickness, gravity, muscular contractures and more could all cause undesirable shifting issues.
While temporary fillers such as Juvéderm and Restylane are considered safer than a permanent filler, there is still concern that shifting or migration could occur with any foreign material, regardless if the foreign material is considered temporary, permanent, synthetic, or living tissue including fat.
MTs Cannot Reliably Control Foreign Material Shifting
Sometimes, massage or bodywork will be prescribed by a physician in an attempt to purposely influence foreign material shifting. The problem is, a practitioner cannot always control where the foreign material will shift to with their hands-on work, and sometimes shifting can result in an undesirable placement.
What is important to remember is the client’s wish to change their physical appearance is met by having a foreign material placed at a specific site in their body. That physical appearance can be drastically changed or undesirable when the foreign material shifts away from its intended placement site.
Permanent Silicone Injectables
Silicone injectables are an example of fillers used that are not approved by the FDA because they are permanent and remain within the body. The FDA warns, “It can move throughout the body and cause serious health consequences, including death. In fact, when injected into areas with many blood vessels, such as the buttocks (butt), silicone can travel through those vessels to other parts of the body and block blood vessels in the lungs, heart, or brain. This can cause a stroke or even death.”
The FDA’s warning of foreign material migration is a huge concern for massage practice. Massage should not be applied over foreign materials; it is simply ill-advised.
It should be noted that whole and intact silicone implants used for cosmetic procedures such as breast augmentation would not apply to this referenced FDA migration warning. While silicone implants have their own worrisome concerns such as they can shift away from their original placement site with incorrect placement or when they are too large for the area and more, this FDA warning is about siliconeinjectables.
To learn more, please register for quality affordable professional training at: https://ceinstitute.com/
Please click HERE if you would like to read our article on Massage Magazine's website.
Establishing consistent opening rituals could prove to be beneficial, especially in group practice. Spending one minute or more with anything that feels familiar at the start of any session could feel comforting when an old client quickly reconnects with familiar touch. Many clients could instantly relax when they recognize what they are feeling and receiving.
In this article, we focused mostly on opening rituals, and added in a few common closing rituals as well. We provided sample and common rituals for the following massage therapy and soft tissue bodywork applications:
Abhyanga & Ayurvedic Massage
Aromatherapy Massage
Craniosacral Therapy
Chair Massage
Cupping Massage
Deep Tissue Massage
Geriatric Massage
Hot Stone Massage
Ice Massage
Lomi Lomi Massage
Manual Lymphatic Drainage
Myofascial Release
Neuromuscular Therapy
Oncology Massage
Post-Surgical Bodywork
Prenatal Massage
Reflexology
Reiki
Sports Event Massage
Swedish Massage
Thai Massage
Trigger Point Therapy
Here is a list of common closing rituals that can be commonly practiced amongst all modalities:
Thank the client for their time.
Express wishful thoughts silently or aloud for the client.
Apply a hold with static placement of their hands on the client’s body.
Ask the client to take some deep breaths.
Perform body brushing techniques.
Use a towel to remove massage medium from the client’s skin.
Assist a client off the treatment table with select services or customers.
Turn up any dim lighting so the client has greater visibility and acclimation back to reality.
Of course, no one has to follow these lists and practitioners can make up their own opening and closing practices as well! What's most important is allowing your client to feel comfortable and instantly relax in your work area.
To learn more, please register for quality affordable professional training at: https://ceinstitute.com/
You can read this article in full at Massage Magazine by clicking HERE.
Evidence-based massage practice applies a hands-on researched protocol to a client. The objective is to simulate hands-on applications with methods and protocols found to be beneficial in research or provide therapeutic outcomes, similar to what was achieved in the research study.
Sometimes a researched protocol which show what is not appropriate in massage therapy or bodywork practice. Studies often exclude subjects with various disqualifications which create various parameters for the student. Sometimes these exclusions are born from massage contraindications which are important to follow. from participating due to various constraints or contraindications. This is why the entire study must be read and considered prior to real-time application or practice for evidence-based massage therapy practice.
To learn more, please register for quality, affordable, professional training at: https://ceinstitute.com/
To view our evidence-based massage article in full, published @MassageMag, please click HERE!
by Selena Belisle, Founder/Instructor, CE Institute LLC
One of my favorite goats named Creamy has developed caprine arthritis encephalitis which is also known as CAE. Creamy was delivered to us with an original herd of approximately 100 goats. She is of unknown age but is likely over five years old, and she has a lovely cream colored coat which contributed to her name.
We were told that CAE did not exist within the herd when it was acquired, despite there appearing to be visual scars on the animals that indicated otherwise. CAE is a devastating disease which usually results in culling the herd, and termination of infected animals.
Creamy has been with us for a couple years without any signs of CAE. Then, during her last pregnancy and delivery, things went awry. She was pregnant with two calves which is fairly normal for a goat. She delivered one calf, and then didn't deliver the second calf until five days later.
CAE Symptoms Develop
Immediately after delivery, Creamy started showing significant symptoms of CAE. They were gradual and became worse with each day, until she was walking on three legs only within about 2-weeks. She was separated from the herd, kept dry with a sawdust bed, provided anti-inflammatories and other medicine to no avail.
Her right front knee was excessively swollen, and I thought I may be able to manually manipulate the fluid away from the knee joint, but despite Creamy being an incredibly patient and mild mannered goat, she wouldn't allow me to touch her knee for very light manual lymphatic drainage techniques. At one point, during her medical care, her knee was shaved which provided better access to directly manipulate the skin with MLD, but unfortunately she was not having it, and I did not press the matter to avoid distressing the animal.
Creamy's Weight Loss
It took about 2-weeks of non weight-bearing on Creamy's right front leg before her right shoulder atrophied. The atrophy was slight but clear between her right and left shoulder. Creamy also lost weight which is normal for goats after delivering their calves, so it's unknown if Creamy's weight loss was from her delivery or CAE or likely both.
Goat with CAE Gets Even Dirtier
Like all farm animals, goats can be fairly dirty and Creamy was no exception. Unfortunately this situation worsened when another animal peed on her which was weird given she was fairly isolated. I found half her head and a rear back quarter soaked in urine. It might have been possible that she hobbled to one of the horse stalls and laid down in the urine too. Unfortunately we'll never know how it happened, but it was important for me to remove it and get her clean.
Making the Decision to Provide a Caprine Spa Session to an Ill Goat
I asked Creamy's more experienced care givers if it would be acceptable to wash Creamy and we were all at a loss. This was a no win situation where the animal's coat would have either remained soaked in urine for a good amount of time, or risked health issues from being wet in the cold.
We ultimately agreed that I if I worked quickly to clean Creamy and dry her, it could be successful. Luckily, I was able to clean Creamy in local spots only with multiple, inexpensive disposable washcloths within about 30-minutes, then quickly dry her within another half hour, so her health was not compromised with her quick and efficient, one-hour caprine spa session.
Goat Spa Session
Our barn is in northern Vermont where it is very cold in the Winter, so washing an ill animal during sub-zero temperatures (end of February) in a moderately heated barn was undesirable. Nevertheless, I wanted this goat to feel clean while ill, so I did it. I purchased:
From Dollar Tree at $1.25 each:
Disposable washcloths
Extra large puppy pads
Animal brush
From Walmart:
Heated radiator ($50)
Hair dryer ($10)
Set of towels ($10)
Oatmeal gentle dog wash ($5)
Creamy received similar to what most ICU patients would receive as a sponge bath with the following steps:
I collect a clean pail of tepid water
I dunked an individual disposable washcloth into the tepid water
I rinsed Creamy with the disposable washcloth
I repeated this process over and over with clean cloths, until all urine was removed from her coat
I did not use the oatmeal cleanser on Creamy. The disposable washcloths seemed to have some type of gentle cleanser on them which satisfied the cleansing and rinsing process with individual cloths.
Once Creamy was clean in the two areas that were soiled of urine, I then used a hair dryer to dry the areas that were cleaned. It was important to get Creamy as dry as possible to prevent pneumonia or other illness in the dead of Winter with this severely compromised goat.
Spa Session Tired Goat with CAE
Creamy was fairly tired when I finished her mini-spa session. She was standing on three legs the entire time, leaning into me. I also believe the hair dryer noise was likely unnerving to her, but she accepted it without much issue. It's almost like she was aware that it was necessary, and the warm heat of the hair dryer might have even felt good to her. It's hard to say given the goats cannot speak and you have to take their physical cues as communication.
A Satisfied Clean Goat
Creamy jumped up onto her three legs to greet me the next time I entered the barn after her spa session. It's like she wanted to show me that she was doing much better. Please keep in mind that Creamy has been receiving round-the-clock medical care from her care givers, so I will never know if her improvement was from her spa session or medical care or both. But there was no mistaking that she was happy to see me again, and excited to get another rub down.
Eating During Massage
Creamy is a hearty goat and she continued to eat despite being ill. Sometimes when I went to the barn to massage Creamy, she would eat the hay that was left for her. Prior to her spa session, she would be lying down and she would not get up when I entered which was sad to see, given during previous visits without CAE, Creamy would patiently follow me around with the rest of the herd until it was her turn for attention. Some of the goats demanded immediate and nonstop attention, but Creamy was patient and different. Very loveable. I also do not know if Creamy was eating before I arrived for her rub down, or if she started eating while I massage her, but she did eat during her massage and she seemed to enjoy it.
Creamy's Rub Down
Massaging Creamy was simple bodywork, and similar to what she's been receiving from me for two years now. I applied a circular effleurage/friction technique. The goat herd seems to favor this style of massage over anything else such as traditional straight effleurage or petrissage.
I usually wear either vinyl or nitrile gloves when physically working with the goat herd. This herd has the common orf virus which can be transmissible to humans; however, the herd did not have any active outbreaks during this Winter 2022 visit.
The goats favorite circular therapy technique is bilateral alternating massage with both hands on their lower mandible or hips. The more mild manner goats enjoy their mandible massaged, and all of the goats enjoy the alternating bilateral circulatory massage of their hips. They'll either stay in place until you stop, or start leaning into you for more pressure. Then when you do stop, they'll usually follow you around for more.
Important Disclosure
It is important to note that I am NOT an expert in animal care nor caprine livestock, despite being a born and raised Vermonter. I have bottle fed over 100 calves from this goat herd, and massaged them all. But, my real health care experience is massage therapy practice for over three decades, and I have provided spa services for the past 27 years - for humans (although some humans have equally behaved like animals if not worse). Today, I teach CE hours for the massage, nursing and cosmetology fields as an expert instructor of multiple modalities for human health and cosmetology care.
I am often asked about bodywork techniques including MLD for animals, especially given equestrian massage has been a nonstop growing industry for years. While I have multiple horses available to work with including beautiful Clydesdales, I prefer to work most with the goat herd and their kids. These goats are the most affectionate, loving animals and a true pleasure to work on.
To learn more, please register for quality, affordable, professional training at: https://ceinstitute.com/
Our school received approval this morning from the Florida Board of NURSING to teach CE hours! YAY!
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Right now we have only approved our MLD training for FL Board of Nursing credit, but if you would like Florida Nursing CE credit for any of our other subjects, pls kindly send us an email so we can follow-up!
