Update on ICG

I've had a few emails lately from therapists who are concerned about courses being offered in Australia using ICG imaging to guide treatment. Apparently the claim is that there is only one technique that shows movement in the lymph vessels when this imaging method is used - and that the Dr Vodder method does not.

Near Infrared fluoroscopy (NIRF) uses a fluorescent dye injected into the subcutaneous compartment. As all dyes are lymph obligatory load this is taken up by the superficial lymphatics and can be seen by a specialised camera. B Aldrich M, Marshall M, Sevick E, Lanza G, Kotyk J, Culver J, et al. Seeing it through: Translational validation of new medical imaging modalities 2012. 764-76 p.

It is easy to see how lymphoedema therapists can be so willing to jump on every new bandwagon when we are faced daily with such a recalcitrant condition to treat, and I have seen this happen with other 'new' techniques in the past. But you have to be careful about who is delivering the message. If the information given is that Dr Vodder's MLD does not work as shown by ICG - and you are hearing that in a course that is promoting a different technique - then the risk of bias will be quite high. Unfortunately therapists often don't have the kind of natural skepticism that would allow them to question this information and many will accept these claims at face value.

In fact there is published research that shows that MLD increases the contractile activity of superficial lymph vessels as imaged by ICG. The following paper offers details of how Vodder techniques increases contractile pumping of the vessels.

I. C. Tan et. al: Assessment of Lymphatic Contractile Function After Manual Lymphatic Drainage Using Near-Infrared Fluorescence Imaging. Arch Phys Med Rehabil Vol 92, May 2011 Click on the image to see the full text

And this video shows how the lymph vessels respond to MLD.

Image from Sevick-Muraca EM. Translation of Near-Infrared Fluorescence Imaging Technologies: Emerging Clinical Applications. Annual Review of Medicine. 2012;63(1):217-31. https://www.youtube.com/watch?v=YmwC0A3PWhM

The other thing to consider here is the conflation of the imaging technique and the massage method. These are separate procedures and the imaging method does not 'belong' to any particular treatment technique.

And then there is the extrapolation of seeing the immediate effect of a particular method in the superficial system vs total treatment outcomes. I'm sure that some firm lymphatic effleurage will give you an excellent result in visibly moving fluid through the superficial vessels and I have seen lovely ICG images of someone doing it by running the shaft of a pencil along the skin - but will you get a good result for your client if that is all you do?

When we start to see papers of good methodological quality showing the result of full treatment of patients with fill and flush, then we can start to say it is a valid method. And then when we have a randomised controlled trial on the comparison of two methods, we can say one method is better than another. Where are the publications of the effect of the fill and flush technique on meaningful outcomes such a volume reduction, increased ROM, increased QOL etc??

It will be lovely when we get to the point where our patients can have access to ICG imaging in cases where it may help us direct our treatment more effectively. This case study on diagnosis of lymphatic dysfunction in lower limb oedema is a great example.

Rasmussen JC, Aldrich MB, Guilliod R, Fife CE, O'Donnell TF, Jr., Sevick-Muraca EM. Near-infrared fluorescence lymphatic imaging in a patient treated for venous occlusion. Journal of Vascular Surgery Cases. 2015;1(3):201-4. Click on the image to go to the full text

At the moment this can only happen in research settings in Australia as it is an off label use of the ICG.

My view is that at the moment ICG is being used a somewhat of a gimmick to sell courses, which in my view is putting the horse before the cart. First we need to do some proper evidence based research on the technique.

The Dr Vodder method if MLD has stood the test of time, and there are multiple research articles, using ICG or not, that attest to the effectiveness of MLD in stimulating lymphatic pumping, and in reducing swelling in many forms of oedema, including lymphoedema.