American Cancer Society Lymphedema WorkshopSupplement to Cancer

The Vodder School: The Vodder Method

Renato G. Kasseroller, M.D.

The Vodder School, Walchsee, Austria.

Presented at the American Cancer SocietyLymphedema Workshop, New York, New York,February 20–22, 1998.

Address for reprints: Renato G. Kasseroller, M.D.,The Vodder School, Alleestraase 30, A-6344Walchsee, Austria.

Received July 2, 1998; accepted August 20, 1998.

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

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

METHODS. The Vodder technique differs in the use of adapted pressure and its

application. The constant change in pressure optimizes results, moving fluid in the

skin, increasing lymphomotoricity, and softening fibrosis, 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 fluid

content in lymphedema, which is different from all other edemas, the combination

of MLD with compression treatment is the only solution for this pathology. De-

pending of it severity, each case requires individualized treatment. Phase I (inten-

sive 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 improve-

ment 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 certified Vodder therapy, a 4-week education

program must be completed, and reviews must be attended every 2 years to

maintain certification. 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.

The Vodder School, which started in Germany in the 1960s and thenexpanded to Austria, was the original school for manual lymphatic

drainage (MLD) and, later, for combined decongestive physical ther-apy as well. Together with Dr. Vodder; the founders of the school,Gunther and Hildegard Wittlinger, and physicians from different Ger-man Universities developed the modern technique of MLD. Vodderemployed circular strokes in different varieties. In the 1960s and early1970s, the founders of the school adapted these strokes to be modernedema technique,1,2 and, along with the edema technique, they com-bined treatment with compression because of the pathophysiologicalnature of edematous tissue based on scientific works by ProfessorHutzschenreuter. The school bears Vodder’s name but uses andteaches modern techniques. The strokes that Vodder adapted after

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© 1998 American Cancer Society

new research are only part of the lymphedema man-agement program.3

In 1892, in Billroth’s book of German surgery,Winiwarter from Brussels described the four legs oflymphedema treatment: massage with very light pres-sure (from proximal to distal), nonelastic bandaging,special skin care, and exercises.4 Now, we call it com-plex physical therapy or complex decongestive ther-apy, bit it is very old, and MLD (the decongestion) is apart of it. With every kind of massage, there will alsobe some decongestion caused by increased tissuepressure. There will be better resorption, but that isnot everything; resorption caused by tissue pressure isthe lesser part of efficacy. We also move the fluid inthe connective tissue; but the most important result ofthe drainage is the activation of the lymphangion, theincreased motoricity of lymph vessels, which wasdemonstrated by Mislin in the 1970s.5

We work with a very light pressure that is adaptedto the different tissues and pathology. After a freshinjury, the pressure used is extremely light. In fibrotictissue, we work with greater pressure, but not toomuch, to avoid redness. We do not slide over the skin:we push and stretch the skin in two different phases ofour strokes. After this, we have a relaxing phase inwhich no pressure is applied, but there is perfect con-tact with the skin (“the weight of a fly is to much”).This is one of the most important problems for stu-dents and needs a great deal of care and attentionfrom the instructors. The permanent change in pres-sure, from pushing to zero pressure, creates thepumping efficacy. This change in pressure is in all thestrokes. The skin is stretched; we do not slide along.6

The direction of the push and pressure depends on thedirection of lymphatic flow in the skin. We alwayswork with the hand, the only exceptions being thefingers; the handwork creates the push.

It is important to allow enough time, because thestrokes must be repeated. The rhythm and the mono-tone strokes influence the vegetative system, creatinga sympathicolytic effect. Today, we know a great dealabout connective tissue, flow, retention of fluid, pro-teins, and histologic structure. In particular, the re-search from Castenholz gave new information aboutthe architecture of lymph vessels. There is suction atwork by the lymph vessels. Some parts of the flow canbe reached with external pressure, but we do not moveall of the fluid, especially not the proteins. Also, if theproteins are left, the fibrosclerotic changes, then theinduration is started.

We educate physical therapists, massage thera-pists, occupational therapists, and registered nurses inlymphedema management— only those with basicmedical knowledge—and the techniques are based on

published research, medical reality, and no hypothe-sis. Students learn about all of the pathologies thatinvolve lymphostasis and other pathologies in whichMLD can be applied because of its decongestive effecton edema. There always seems to be a need for this,because the student’s knowledge is sometimes poor inthis regard. However, the most important part of thetraining is the practical education. This complicatedmanual technique cannot be learned in a few days ifperfect results are to be achieved, and perfect resultsfor the patient should be the goal.

In his studies, Hutzschenreuter demonstrated theefficacy of the neuronal structure to the lymph flow.7

Humans have receptors in the tissue, in the skin, thatreact through neuronal reflexes to the lymphangions.OUr manual work with these receptors creates in-creased contractions, and it must be combined withpressure to continue the efficacy. These receptors,which react only to changing stimulation, are differentfrom other receptors, like the noiceptors. They lym-phangions work like little hearts: They also have arefractor period, which is another reason for the dif-ferent pressures used.

Each patient with lymphedema presents a unique,individual case because of the anatomic varieties ofthe lymphatics and the different surgical techniques.Also, other influences, like radiation or local inflam-mation, accelerate the pathophysiological alterations.To address all of these problems, we teach our tech-nique and pass on our wide experience.

Depending on the severity of lymphedema, differ-ent dosages of treatment are required. Stage 1 edemarequires less treatment than stages 2 or 3. With the

TABLE 1The Vodder School Curriculum: Manual Lymphatic Drainage Courseand Lymphedema Management (Medical class)

First sessionIntroductionPhysiology of the nervous system, gate control, immunological systemHistology and physiology of connective tissue, body fluids, contentsPhysical and chemical transportationAnatomy of blood vessels and lymph vesselsHistology of lymph vesselsContraindications

Second sessionGeneral pathology: edema, fibrosis, inflammation and infection, wound healingClassification of edema and lymphedemaClassifications of stages of lymphedemaBasic knowledge for practical treatment with manual lymphatic drainage

Third sessionPrimary and secondary lymphedema of arm and leg, had and facial edemaCyclic idiopathic edema, lip edema, varicose veins, phlebedemaTraumatology, rheumatology

Fourth sessionSpecial indication from neurology, pediatric, dermatology

The Vodder Method/Kasseroller 2841

treatment in stage 1, we prevent more severe pathol-ogy. In our hospital, we treat all stages of edema on aninpatient and outpatient basis. We distinguish be-tween two phases of treatment: the intensive phaseand the maintenance phase. The intensive phase in-cludes the complete decongestion program with MLDand bandaging twice daily for 45 minutes or more ateach session.

Skin care and exercises are applied two or threetimes daily. Self-treatment instructions and dietaryprograms are optional. In the maintenance phase,MLD and compression garments or bandaging areused on an individual basis for one session every 2weeks up to three session per week. In the long term,it is apparent that the earlier treatment starts and thelonger it continues, the better and more cost effectiveare the results achieved. In later stages 2 and 3 oftreatment, there should be no more that 15 monthsbetween intensive treatment, and the maintenancephase should be a continuous treatment without longbreaks.8

Tables 1–3 show the training curriculum forMLD and compression therapy. After certification,therapists must attend a review every 2 years. Theirtechnique is checked and corrected, and theirknowledge is increased with the latest standards.Only then will they receive recertification from theVodder School.

REFERENCES1. Vodder E. Le drainage lymphatique, une novelle methode

therapeutique. Paris: Sante pour tous, 1936.2. Vodder E. Die technische Grundlage der manuellen Lym-

phdrainage. Physikalische Therapie 1983;1.3. Kurz I. Textbook of Vodder’s manual of lymph drainage, vol

II. Heidelberg: Haug-Verlag, 1989.4. Winiwarter F. Die chirurgischen Krankheiten der Haut und

des Zellgewebes. Billroth Chr., Deutsche Chirurgie, Lief-erung 23. Stuttgart: Verlag Ferdinand Enke, 1892:152–292.

5. Mislin H. Handbuch der allgemeinen Pathologie, 3, Band 6.Teil: Springer Verlag, 1972.

6. Kasseroller R. Kompendium der Manuellen Lymphdrainagenach Dr. Vodder. Heidelberg: Haug-Verlag, 1996:198 –209.

7. Hutzschenreuter P, Brummer H. Die Wirkung der man-uellen Lymphdrainage auf die Vasomotion. Aktuelle Bei-trage zur manuellen Lymphdrainage 19. Heidelberg: Haug-Verlag, 1992.

8. Kasseroller R. The lymphedema and CPT: Proceeding of XVI.ISC Congress, Madrid: 1997.

TABLE 2The Vodder School Curriculum—Practicea

Week 1Basic techniqueNeck-face, scoop techniqueLeg-arms, rotary techniqueBack, nape, loinBreast, stomachWhole body repeat

Week 2Face 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 techniqueStomach and special technique, bandaging I

Week 3Repeat bandaging II and III, lymphedema after mastectomy, secondarylymphedema leg

Cranial secondary lymphedema, pathology in headTrigeminus, meniere, eyes, Bell’s palsyHip, elbow, shoulderAbdomen, repeat postmastectomy lymphedema

Week 4Secondary leg edema, bilateral mamma, bilateral leg edemaBurns, ulcer, primary leg edemaPrimary leg edema, mamma, bandaging IVSpecial pathologiesFinal test

a The complete course consists of 160 hours.

TABLE 3Lymphedema Management

Lymphedema management is a combined therapy with active and passivetreatment by specially educated therapists in two stages

Stage 1 Improving and decreasing the limb volume by therapistsStage 2 Maintaining the results from stage 1 by therapists and self treatment of

the patientsTreatment

Assessment by the physicianPhysical examination, measurement, documentation by therapists and/or

physiciansManual lymph drainageBandagingRemedial exercisesSkin careAdditional medical treatments (e.g., skin care, ulcer treatment)Instruction in self bandagingInstruction in exercise treatmentsInstruction in nutritionAdditional psychological adviceSupervision in additional secondary pathological problemsAdditional physiotherapeutic treatmentsAdapting physiotherapeutic treatmentsAdapting custom-made compression garmentsWound care program

2842 CANCER Supplement December 15, 1998 / Volume 83 / Number 12