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American Cancer Society Lymphedema Workshop

Supplement to Cancer

The Vodder School: The Vodder Method

Renato G. Kasseroller,
M.D.

BACKGROUND. The history and development of manual lymphatic drainage (MLD)

from Winiwarter to Vodder and the Vodder School of today are discussed.

The Vodder School, Walchsee, Austria.

METHODS. The Vodder technique differs in the use of adapted pressure and its
application. The constant change in pressure optimizes results, moving uid in the skin, increasing lymphomotoricity, and softening brosis, with the positive side effects of reducing pain and relaxing tense muscles. Another difference from other methods is the technique of stretching skin, not sliding it. Because of the uid content in lymphedema, which is different from all other edemas, the combination of MLD with compression treatment is the only solution for this pathology. Depending of it severity, each case requires individualized treatment. Phase I (intensive treatment) consists of daily treatment with up to two sessions per day for up to 2 hours. This phase is combined with special, individual skin care and remedial exercise. In phase 2, the goal of treatment is to maintain the results achieved in phase 1. The frequency of treatment is changed, but there is still the need for permanent, continued therapy. RESULTS. In phase 1, an average reduction of more than 40% of edema volume is achieved. In phase 2, the results are maintained and, with repetitions of phase 1, further improvement is possible. Thus, long term results with permanent improvement are possible. CONCLUSIONS. Because of the complexity of the technique, no one can learn MLD in 1 week. Students require a great deal of correction, and the technique must be checked constantly. To become a certied Vodder therapy, a 4-week education program must be completed, and reviews must be attended every 2 years to maintain certication. The best education produces the best results for patients as long as patients are compliant. Therefore, the Vodder School also includes a patient education program as part of its curriculum. Cancer 1998;83:2840 2. 1998 American Cancer Society.

KEYWORDS: manual lymphatic drainage, compression treatment, lymphomotoricity, the Vodder School.

Presented at the American Cancer Society Lymphedema Workshop, New York, New York, February 20 22, 1998. Address for reprints: Renato G. Kasseroller, M.D., The Vodder School, Alleestraase 30, A-6344 Walchsee, Austria. Received July 2, 1998; accepted August 20, 1998. 1998 American Cancer Society

he Vodder School, which started in Germany in the 1960s and then expanded to Austria, was the original school for manual lymphatic drainage (MLD) and, later, for combined decongestive physical therapy as well. Together with Dr. Vodder; the founders of the school, Gu nther and Hildegard Wittlinger, and physicians from different German Universities developed the modern technique of MLD. Vodder employed circular strokes in different varieties. In the 1960s and early 1970s, the founders of the school adapted these strokes to be modern edema technique,1,2 and, along with the edema technique, they combined treatment with compression because of the pathophysiological nature of edematous tissue based on scientic works by Professor Hutzschenreuter. The school bears Vodders name but uses and teaches modern techniques. The strokes that Vodder adapted after

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new research are only part of the lymphedema management program.3 In 1892, in Billroths book of German surgery, Winiwarter from Brussels described the four legs of lymphedema treatment: massage with very light pressure (from proximal to distal), nonelastic bandaging, special skin care, and exercises.4 Now, we call it complex physical therapy or complex decongestive therapy, bit it is very old, and MLD (the decongestion) is a part of it. With every kind of massage, there will also be some decongestion caused by increased tissue pressure. There will be better resorption, but that is not everything; resorption caused by tissue pressure is the lesser part of efcacy. We also move the uid in the connective tissue; but the most important result of the drainage is the activation of the lymphangion, the increased motoricity of lymph vessels, which was demonstrated by Mislin in the 1970s.5 We work with a very light pressure that is adapted to the different tissues and pathology. After a fresh injury, the pressure used is extremely light. In brotic tissue, we work with greater pressure, but not too much, to avoid redness. We do not slide over the skin: we push and stretch the skin in two different phases of our strokes. After this, we have a relaxing phase in which no pressure is applied, but there is perfect contact with the skin (the weight of a y is to much). This is one of the most important problems for students and needs a great deal of care and attention from the instructors. The permanent change in pressure, from pushing to zero pressure, creates the pumping efcacy. This change in pressure is in all the strokes. The skin is stretched; we do not slide along.6 The direction of the push and pressure depends on the direction of lymphatic ow in the skin. We always work with the hand, the only exceptions being the ngers; the handwork creates the push. It is important to allow enough time, because the strokes must be repeated. The rhythm and the monotone strokes inuence the vegetative system, creating a sympathicolytic effect. Today, we know a great deal about connective tissue, ow, retention of uid, proteins, and histologic structure. In particular, the research from Castenholz gave new information about the architecture of lymph vessels. There is suction at work by the lymph vessels. Some parts of the ow can be reached with external pressure, but we do not move all of the uid, especially not the proteins. Also, if the proteins are left, the brosclerotic changes, then the induration is started. We educate physical therapists, massage therapists, occupational therapists, and registered nurses in lymphedema management only those with basic medical knowledgeand the techniques are based on

TABLE 1 The Vodder School Curriculum: Manual Lymphatic Drainage Course and Lymphedema Management (Medical class)
First session Introduction Physiology of the nervous system, gate control, immunological system Histology and physiology of connective tissue, body uids, contents Physical and chemical transportation Anatomy of blood vessels and lymph vessels Histology of lymph vessels Contraindications Second session General pathology: edema, brosis, inammation and infection, wound healing Classication of edema and lymphedema Classications of stages of lymphedema Basic knowledge for practical treatment with manual lymphatic drainage Third session Primary and secondary lymphedema of arm and leg, had and facial edema Cyclic idiopathic edema, lip edema, varicose veins, phlebedema Traumatology, rheumatology Fourth session Special indication from neurology, pediatric, dermatology

published research, medical reality, and no hypothesis. Students learn about all of the pathologies that involve lymphostasis and other pathologies in which MLD can be applied because of its decongestive effect on edema. There always seems to be a need for this, because the students knowledge is sometimes poor in this regard. However, the most important part of the training is the practical education. This complicated manual technique cannot be learned in a few days if perfect results are to be achieved, and perfect results for the patient should be the goal. In his studies, Hutzschenreuter demonstrated the efcacy of the neuronal structure to the lymph ow.7 Humans have receptors in the tissue, in the skin, that react through neuronal reexes to the lymphangions. OUr manual work with these receptors creates increased contractions, and it must be combined with pressure to continue the efcacy. These receptors, which react only to changing stimulation, are different from other receptors, like the noiceptors. They lymphangions work like little hearts: They also have a refractor period, which is another reason for the different pressures used. Each patient with lymphedema presents a unique, individual case because of the anatomic varieties of the lymphatics and the different surgical techniques. Also, other inuences, like radiation or local inammation, accelerate the pathophysiological alterations. To address all of these problems, we teach our technique and pass on our wide experience. Depending on the severity of lymphedema, different dosages of treatment are required. Stage 1 edema requires less treatment than stages 2 or 3. With the

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CANCER Supplement December 15, 1998 / Volume 83 / Number 12 TABLE 3 Lymphedema Management
Lymphedema management is a combined therapy with active and passive treatment by specially educated therapists in two stages Stage 1 Improving and decreasing the limb volume by therapists Stage 2 Maintaining the results from stage 1 by therapists and self treatment of the patients Treatment Assessment by the physician Physical examination, measurement, documentation by therapists and/or physicians Manual lymph drainage Bandaging Remedial exercises Skin care Additional medical treatments (e.g., skin care, ulcer treatment) Instruction in self bandaging Instruction in exercise treatments Instruction in nutrition Additional psychological advice Supervision in additional secondary pathological problems Additional physiotherapeutic treatments Adapting physiotherapeutic treatments Adapting custom-made compression garments Wound care program

TABLE 2 The Vodder School CurriculumPracticea

Week 1 Basic technique Neck-face, scoop technique Leg-arms, rotary technique Back, nape, loin Breast, stomach Whole body repeat Week 2 Face with special technique, neck (mouth inside) Arm with special technique (epicondylitis) Leg and special technique (loin and special technique, Cox) Nape and special technique (periarthritis) Back and special technique Stomach and special technique, bandaging I Week 3 Repeat bandaging II and III, lymphedema after mastectomy, secondary lymphedema leg Cranial secondary lymphedema, pathology in head Trigeminus, meniere, eyes, Bells palsy Hip, elbow, shoulder Abdomen, repeat postmastectomy lymphedema Week 4 Secondary leg edema, bilateral mamma, bilateral leg edema Burns, ulcer, primary leg edema Primary leg edema, mamma, bandaging IV Special pathologies Final test
a

The complete course consists of 160 hours.

treatment in stage 1, we prevent more severe pathology. In our hospital, we treat all stages of edema on an inpatient and outpatient basis. We distinguish between two phases of treatment: the intensive phase and the maintenance phase. The intensive phase includes the complete decongestion program with MLD and bandaging twice daily for 45 minutes or more at each session. Skin care and exercises are applied two or three times daily. Self-treatment instructions and dietary programs are optional. In the maintenance phase, MLD and compression garments or bandaging are used on an individual basis for one session every 2 weeks up to three session per week. In the long term, it is apparent that the earlier treatment starts and the longer it continues, the better and more cost effective are the results achieved. In later stages 2 and 3 of treatment, there should be no more that 15 months between intensive treatment, and the maintenance phase should be a continuous treatment without long breaks.8

Tables 13 show the training curriculum for MLD and compression therapy. After certication, therapists must attend a review every 2 years. Their technique is checked and corrected, and their knowledge is increased with the latest standards. Only then will they receive recertication from the Vodder School.

REFERENCES
1. 2. 3. 4. Vodder E. Le drainage lymphatique, une novelle methode therapeutique. Paris: Sante ` pour tous, 1936. Vodder E. Die technische Grundlage der manuellen Lymphdrainage. Physikalische Therapie 1983;1. Kurz I. Textbook of Vodders manual of lymph drainage, vol II. Heidelberg: Haug-Verlag, 1989. Winiwarter F. Die chirurgischen Krankheiten der Haut und des Zellgewebes. Billroth Chr., Deutsche Chirurgie, Lieferung 23. Stuttgart: Verlag Ferdinand Enke, 1892:152292. Mislin H. Handbuch der allgemeinen Pathologie, 3, Band 6. Teil: Springer Verlag, 1972. Kasseroller R. Kompendium der Manuellen Lymphdrainage nach Dr. Vodder. Heidelberg: Haug-Verlag, 1996:198 209. Hutzschenreuter P, Brummer H. Die Wirkung der manuellen Lymphdrainage auf die Vasomotion. Aktuelle Beitra ge zur manuellen Lymphdrainage 19. Heidelberg: HaugVerlag, 1992. Kasseroller R. The lymphedema and CPT: Proceeding of XVI. ISC Congress, Madrid: 1997.

5. 6. 7.

8.