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L i s te n to T h e A B M P Po d c a s t a t a b m m /p o d c a s t s o r w h e reve r yo u a cce s s yo u r favo r i te p o d c a s t s 43 WHERE DOES MASSAGE FIT? In pulling together resources to write this article, I came across some problematic statements about the role of manual therapy for people who have lipedema. Specifically, I saw in more than one place the idea that "massage can break down fibrosis." I would like to voice some healthy skepticism on this point. Massage therapy may alter the quality of the tissues that are involved in fibrotic deposits, so that freedom of movement and local fluid flow is improved, and pressure may be taken off of irritated tissues and nerves. But to claim that manual therapy will reduce or break down fibrosis is probably erroneous. What can we do? Our work can relieve swelling and pain. This is a substantial benefit! "I've seen that manual lymph drainage can have an analgesic effect, so it can reduce their pressure sensitivity and make their uber- important compression garments easier to tolerate."—MB That said, it is interesting to note that the two types of massage therapy most often recommended for people with lipedema are at the opposite ends of the spectrum of intensity. On the one hand, lymph-focused techniques are frequently recommended for people who choose both noninvasive and surgical interventions. These techniques are feather-light, and work by way of inducing parasympathetic response and capillary dilation, which allows the movement of fluid out of congested areas. Clients find this deeply relaxing, and often report feeling lighter and more mobile after sessions. And at the other end of the scale, instrument-assisted massage therapy turns up in the descriptions of work done by massage therapists as a successful intervention for some patients. This includes cupping, foam rollers, Graston technique, gua sha, and some other modalities—presumably to address fibrosis. This seems surprising, in light of the fact that many people with lipedema report a low pain threshold and easy bruising in their affected areas. But the discomfort of these interventions appears to be worth it to some patients who find that these techniques give them improved mobility and the reduction of symptoms. "Lipedema is totally different in each person who has it. It requires a totally customized approach to treatment. That's why massage is such a great fit: customized approaches are what we do."—KL If lipedema is as common as some experts suggest, then many massage therapists are probably already working with clients who have it in its early stages. Knowing more about this condition, and how to enlist the lymphatic system to assist in treating some of the symptoms— especially pain, congestion, and ease of movement—could make manual therapy even more helpful. Advanced education in lymphatic work is invaluable for this population. I expect as the condition of lipedema continues to be explored and understood by the medical community, we will find increasing demand for our work. Affected patients look for coping strategies and ways to prevent their situation from getting worse, and many prefer to explore noninvasive interventions to manage their condition. "If you announce that you specialize in lymphatic drainage on the internet, people find you from all over. There aren't enough of us— we need more people in this tribe."—KB Perhaps one of the most important things massage therapists can bring to the quality of life for people who live with lipedema is our unconditional positive regard. Our culture already has deep- rooted and unpleasant prejudices about people who are overweight. In the two- part series on obesity that appeared in Pathology Perspectives ("Demystifying Obesity," Massage & Bodywork, July/August 2018 and September/October 2018), we addressed some of these prejudices and the ways massage therapists can be aware and sensitive about how they communicate with and support their clients who are above average in size. Because lipedema is so frequently mistaken and misdiagnosed for obesity, and because the typical interventions for obesity have virtually no impact on lipedema at all, it is easy to see how people with this condition can feel abandoned and disrespected by the medical community. If these clients are willing to come for massage (which could be painful both physically and emotionally), we owe them respect and appreciation for their courage. It is a privilege to work with people whose body image is so negatively affected by media messaging, but who still feel safe enough to be willing to receive our work. Ruth Werner is a former massage therapist, a writer, and an NCBTMB- approved continuing education provider. She wrote A Massage Therapist's Guide to Pathology (available at booksofdiscovery. com), now in its seventh edition, which is used in massage schools worldwide. Werner is available at or PATHOLOGY PERSPECTIVES SCAN AND WATCH "Fast Fat Facts"

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