Issue link: https://www.massageandbodyworkdigital.com/i/621015
also inconclusive. This means that other forms of evidence need to be used to justify massage benefits related to the lymphatic system. Expert opinion consensus is the primary type of evidence that currently supports the manual movement of tissue fluid and lymph. The foundation for this type of evidence needs to be based on known anatomy and physiology, changes that occur with pathology, and the ability to support normal function based on logical approaches that mimic normal function. When making statements related to the possibility of massage therapy, performed in a specific way, with the intent to influence lymphatic movement in the body, we need to provide a logical explanation or rationale (a "justification") and to explain to clients that although the methods appear to be clinically effective, research, as yet, is unable to prove the outcomes. Let's use our evidence to explore the possibility that massage can influence the lymphatic system in a beneficial manner and create a justification process for that possibility. JUSTIFICATION STEP 1— UNDERSTAND NORMAL FUNCTION OF THE LYMPHATIC SYSTEM The lymphatic system includes the spleen; thymus; lymph nodes and lymph nodules; the lymph capillaries, vessels, trunks, and ducts; and lymph and lymphocytes. It is a one-way system that begins in the tissues and ends when it reaches the blood vessels. The system helps the body maintain homeostasis by collecting accumulated tissue fluid around the cells and returning it to the bloodstream. The lymphatic system is an open- ended system, beginning in the interstitial spaces. The fluid located around the cells is called interstitial fluid. As fluid pressure increases between the cells, the cells move apart, pulling on the microfilaments that connect the endothelial cells of the lymph capillaries to tissue cells. The pull on the microfilaments causes the lymph capillaries 56 m a s s a g e & b o d y w o r k j a n u a r y / f e b r u a r y 2 0 1 6 STARTING WITH THE RESEARCH When we think of "evidence" for an evidence-informed practice, we most often think of scientific research studies. Yes, these are evidence, but the information is only as good as the study's design. Going a step further, it's important to look at both meta-analysis and systematic reviews when evaluating evidence to weed out poor research studies and seek common conclusions from higher quality ones. In relation to lymphatic techniques, I found three systematic reviews and a meta-analysis of randomized controlled trials (RCTs) related to manual lymphatic drainage (MLD): 1. "Systematic Review of Efficacy for Manual Lymphatic Drainage Techniques in Sports Medicine and Rehabilitation: An Evidence- Based Practice Approach," by G. Vairo et al., published in The Journal of Manual & Manipulative Therapy in 2009. 1 2. "Effects of Manual Lymphatic Drainage on Breast Cancer-Related Lymphedema: A Systematic Review and Meta-Analysis of Randomized Controlled Trials," by T. W. Huang et al., published in the World Journal of Surgical Oncology in 2013. 2 3. "Conservative Interventions for Preventing Clinically Detectable Upper-Limb Lymphoedema in Patients Who Are At Risk of Developing Lymphoedema After Breast Cancer Therapy," by M. M. Stuiver et al., published in the Cochrane Database of Systematic Reviews, 2015. 3 4. "Manual Lymphatic Drainage for Lymphedema Following Breast Cancer Treatment," by J. Ezzo et al., published in the Cochrane Database of Systematic Reviews, 2015. 4 While results varied, none of these reviews offered conclusive support for manual lymphatic drainage, and individual studies justifying the use of massage for lymphatic movement are few in number and to open like flaps, allowing interstitial fluid to enter the lymph capillaries. The moment interstitial fluid enters a lymph capillary a flap valve prevents it from returning to the interstitial space. Lymph capillaries join to form larger lymph vessels that resemble veins but have thinner, more transparent walls. Like veins, they have valves to prevent backflow. The large vessels continue to merge and eventually become two main ducts called the right lymphatic duct and the thoracic duct (left lymphatic duct) (Image 1). The right lymphatic duct drains the upper right half of the body and empties into the right subclavian vein. The thoracic duct drains the rest of the body and empties into the left subclavian vein. The lymph nodes play an active part in the immune defenses of the body by filtering out and destroying foreign substances and microorganisms. Interstitial fluid comes from blood plasma that seeps through capillaries. Interstitial fluid becomes lymph when it moves into the lymph capillaries, which are tiny, open-ended channels located in tissue spaces throughout the body. Lymph contains proteins and other cell by-products, as well as pathogens and cell debris. As lymph travels through lymph vessels, it is filtered by lymph nodes that remove the pathogens and cell debris, before traveling to the bloodstream and once again becoming plasma. Lymphatic circulation is separated into two layers: • The superficial circulation, which constitutes 60–70 percent of lymph circulation, is located just under the skin in the junction between the superficial fascia and the dermis. The superficial circulation is not stimulated directly by exercise but is influenced by the stretching and pulling of the skin and superficial fascia during movement. • Deep muscular and visceral circulation, below the fascia, is activated by muscular contraction, peristalsis, and respiration.