Fluoroscopy Guided Medical Lymphatic Drainage
Fluoroscopy Guided Medical Lymphatic Drainage
By Melanie McCann, Macmillan Lymphoedema Nurse, Herts Community Trust
This article is taken from the Autumn 2016 issue of LymphLine, the LSN’s quarterly newsletter available to all LSN members. For details of how to become a member, click here.
I recently had the privilege of attending training on Fluoroscopy Guided Medical Lymphatic Drainage (FG-MLD) by Jane Wigg and Professor Belgrado through the Lymphoedema Training Academy. I asked the Lymphoedema Support Network if I might share my experience and explain a little of what I learnt and why I feel it is important for patients to be aware of what FG-MLD means today.
I have worked as a lymphoedema nurse for over a decade and feel fortunate to work in a role that I really enjoy. I undertook training in Manual Lymphatic Drainage (MLD) as part of my specialist training and continue to use this in day-to-day practice. The difficulty has always been that whilst patients have often found MLD helpful, there has been a lack of consistent evidence to support its effect. In health care, we are constantly aiming to ensure what we do is safe, effective and a prudent use of resources.
The development and validation of lymphofluoroscopy as a way of safely mapping superficial lymphatic drainage pathways is a tool that has opened up the opportunity to look at how lymph drains in ‘real time’ moving images in people who may or may not be affected by lymphoedema. This can help us understand more about what ‘normal’ looks like and how the body compensates (or does not compensate) when it is affected by events such as surgery or infection.
As the technique is both safe and reproducible, it is also possible to research people over time to see how lymph drainage alters through different life stages and stresses. So far, over 1,300 people have been ‘mapped’ to reveal how lymph drains individually for them. As there are some drainage pathways that are common to most, the findings from these people can be collated to give us a better understanding of how lymph drains and what affects that drainage for better or worse in most people.
Lymphofluoroscopy mapping is the technique of injecting a very small amount of ‘tracer’ (or dye) just under the skin. It is generally not painful and is extremely safe, being used for heart and eye assessments for over 20 years. The tracer then gets ‘excited’ by shining the right type of LED light at it and will produce a picture. This allows for the camera to see for the first time ever, fluid moving in the lymphatics or see where it is collected. There is no need for people to be individually mapped to receive FG-MLD and it is the hand movement and pressure that have been devised following the demonstration and practice on those having lymphofluoroscopy that has allowed for optimised movement to enhance drainage. Following the common pathways, but respecting that everyone is individual, the new MLD can be carried out. For enhanced drainage, individual pathways can be marked and recorded following lymphofluoroscopy, allowing for the therapist to drain to these routes. Training in a technique that has been proven to help lymph to be reabsorbed into the lymphatics and how to move it faster.
Lymphofluoroscopy mapping is available in the UK privately if a patient or health professional feels it is appropriate. Whilst the technique is simple, there are only a few clinics who are experienced in interpreting the results or use the set protocols, along with your history, so that they are meaningful to patients. There is only one person who is trained in the protocols and techniques used by Professor Belgrado. It is therefore important to ensure that the test and interpretation of the results are done by a specialist.
‘…for each new scan on all types of person and lymphoedema that is added to that collection, there will be more strength in our knowledge.’
From a professional perspective, if data are collected in a systematic, rigorous and repeatable fashion, this gives greater validity to the findings (i.e. one large dataset can give us better knowledge than lots of people doing things their own way). For me, it is hard to think that after 10 years there are things that I thought were right that are not, but that is the same with all knowledge. I am glad Professor Belgrado, Jane Wigg and others around the world are innovating and challenging previously held beliefs. I am impressed that they are not just looking at how lymph moves inside the body, but also thinking about how we measure that without performing lymphofluoroscopy on every patient and how we apply that learning to make treatments more effective.
Lymphofluoroscopy is not the only type of test to be helpful at looking at the lymphatic system but it offers a new tool with a lot of potential. Due to the limited number of people who have been scanned so far, it also raises more questions than answers for now and it certainly will never prove that ‘one size fits all’. Yet in this era of evidence-based practice facilitating personalised medicine, it is certainly a viable, sustainable and valid tool to help us today and continue building knowledge to help even more in the future as it is used and understood more.
In summary, lymphofluoroscopy, FG-MLD and the ‘fill and flush’ technique of massage may be terms and tools that are being more widely used and discussed for lymphoedema over time. I am glad to have had the chance to understand what this tool is and how I can use it today in practice. I am also glad that I will be asked to return and update myself next year as the knowledge and understanding we have today is developing and will evolve further. In one sense, it is a shame that this imaging can only be accessed privately, presently. However, for each new scan on all types of person and lymphoedema that is added to that collection, there will be more strength in our knowledge.
Note: Lymphofluoroscopy: A way of mapping a person’s lymph drainage pathways. It uses an intradermal injection of Indocyanine Green into the skin and then uses an infrared camera to visualise where and how this moves in the body.
Note: FG-MLD: A specific form of MLD that has been adapted and in response to what was found to be effective when MLD was carried out on people with and without lymphoedema.
A list of FG-MLD trained therapists can be found at: www.lymph.org.uk/directory-of-therapists