Cranial Lymph Flow Impairment – its potential effects and the importance of Manual Lymphatic Drainage and associated methods in potentially alleviating them
Andrew Robertson BSc (Hons) MCSP MLD UK
A. Anatomical background
Apart from removal of excess fluid, proteins and fats, one of the other main purposes of MLD is to remove waste products, such as dead or cancerous cells, macrophages with phagocytized material, and foreign matter such as bacteria, from the interstitial fluid. The interstitial fluid surrounds the cells and helps to maintain a healthy environment for these cells, ensuring they receive efficient transfer of nutrients and oxygen across the transit gap from the blood capillaries, without which may lead to cell impairment or death. Efficient lymphatic flow is also important to transport antigens and dendritic cells to the lymph nodes for neutralisation by the T and B lymphocytes. A study by Louveau et al. (2015) confirmed that the meningeal CSF contained T and B lymphocytes and dendritic cells to fight bacterial and viral pathogens. The brain is no exception therefore to this requirement for removal of antigens and toxins (oligomers), and also excess soluble Amyloid Beta proteins which can either destroy or harm healthy brain cells if left too long when they become insoluble and could form plaques. Carare et al.(2008 & 2013). The fluids which remove these substances are Cerebrospinal fluid (CSF) and Interstitial fluid (ISF}. This flow of fluids from the brain forms then the connection between the brain and the body’s immune system.
Simon & Iliff (2016) stated that “ Cerebrospinal fluid (CSF) circulation and turnover provides a sink for the elimination of solutes from the brain interstitium, serving an important homeostatic role for the function of the central nervous system. Disruption of normal CSF circulation and turnover is believed to contribute to the development of many diseases, including neurodegenerative conditions such as Alzheimer's disease, ischemic and traumatic brain injury, and neuroinflammatory conditions such as multiple sclerosis. Recent insights into CSF biology suggesting that CSF and interstitial fluid exchange along a brain-wide network of perivascular spaces termed the ‘glymphatic’ system suggest that CSF circulation may interact intimately with glial and vascular function to regulate basic aspects of brain function. Dysfunction within this glial vascular network, which is a feature of the aging and injured brain, is a potentially critical link between brain injury, neuroinflammation and the development of chronic neurodegeneration.”
Walter et al (2006) had, following their research, stated that “This anatomical communication, thus, allows the central nervous system to connect with the lymphatic system. The presence of this route may play an important role in the movement of antigens from the subarachnoidal space to the extracranial lymphatic vessels, resulting in inducement of an immune response of the central nervous system”. Weller in his research also stated that “cellular and soluble constituents of the CSF have been shown to elicit immune responses in the cervical lymph nodes”. Weller (2010)
CSF is present in the brain’s subarachnoid spaces lining the brain and ventricles
ISF is present in the brain and spinal cord tissue
Both fluids drain to cervical and lumbar lymph nodes but the routes of this fluid carrying waste products out of the brain are however different:
CSF exits from the meninges lining the brain through the delicate cribriform plate at the front of the skull (Weller & Carare (2017), Weller, Kida, Zhang (1992), Norwood et al. (2019) , and finds its way mainly into the nasal mucosa, olfactory nerve perineuria, facial sinuses, pharyngeal and submandibular nodes and then eventually to the cervical lymph nodes. Jackson, Tigges, Arnold (1979), Goldman (2006) However CSF also exits however from the occiput region at the rear of the skull along spinal nerve root canals to the lumbar lymph nodes in the abdomen (See diagram by Weller in Appendix A) , and from there into the thoracic duct.
ISF on the other hand exits direct to the cervical lymph nodes in the neck via the outer muscular walls of the incoming cerebral arteries and capillaries using vasomotion i.e. in the opposite direction to the incoming blood flow within the lumen of the artery. This according to Weller and Carare, (2017) has been termed “IPAD” or intra – mural periarterial drainage.
B. Reasons for restriction of flow
Some of the reasons why the CSF and ISF could become restricted:
• Age. As we age the outer walls of the cerebral arteries and capillaries can become atherosclerotic leading to reduced ISF flow (May et al, 1990; de Leon et al, 2004) and therefore there is a build up of unwanted Amyloid insoluble proteins in the brain. This is otherwise known as cerebral amyloid angiopathy leading to the formation of solid fibrils or plaques which can lead to Alzheimers and other brain diseases Ref: Carare et al. (2008 & 2013)
• Traumas. There might have been damage to the delicate cribriform plate due to injury or trauma to the front of the skull which can then restrict CSF flow. Surgical blockage by Mollanji et al (2002) of CSF outflow through the cribriform plate resulted in an increase in resting intracranial pressure.
• Infection. Infection to the dural lymphatics or meninges , from for example Lyme disease carried by the tick borne bacterium Borrelia Afzelii. This normally responds to antibiotics and the immune system’s lymphocytes and macrophages, however can persist in the cerebrospinal fluid for several years potentially causing acute lymphocytic meningitis, borrelial encephalomyelitis, and cranial neuropathy (Steere et al. 2004) and (Novak et al. 2019) .
• Temperature. Exposure to extreme cold temperatures can slow down the lymph flow (Solari et al. 2017)
• Abdominal lymph flow restriction due to surgery or other reasons restricting CSF flow to lumbar nodes (see App A diagram)
• Whiplash injuries affecting drainage of CSF drainage into spinal canal and lumbar nodes. An experiment with 24 patients revealed that 10 were completely symptom free of post traumatic oedema in the dorsal neck after 10 MLD treatments and the remainder had minimal symptoms.. (Hutzschenreuter 1986 )
C. Effects of restriction to CSF flow
An experiment by Foldi (1994) in which the cervical lymph vessels were surgically blocked found that there was a gradual degradation of the myelin sheath surrounding the brain’s nerve fibres and that “a reduction in the transport capacity of lymphatics draining the brain triggered a vicious circle with progressive cerebral deterioration” as well as a rise in intraocular pressure affecting eyesite , and there was also some hearing impairment. He provided evidence that MLD alleviated these conditions.
They also found that removal of the deep cervical lymph nodes restricting the drainage of CSF resulted in a build up in the number of meningeal T lymphocytes due to the drainage impairment, confirming the link between the CSF and the cervical nodes. They found that the meningeal lymphatic vessels possess anatomical and molecular features characteristic of initial lymph vessels and exhibited a non continuous membrane surrounded by anchoring filaments.
Caversaecio and Peschel (1996) found that raising the CSF pressure resulted in an increase in CSF drainage into the cervical lymph nodes. They concluded that the clinical importance of this lymphatic drainage confirmed the communication between the brain and the immune system of the head and neck.
There has been significant research into drugs to remove amyloid – beta protein plaques in the brain (leading to brain related disease such as Alzheimers) but these have not yet produced results with consequent abortion of these highly costly research projects. There is therefore a growing interest in the treatment of the underlying causes of these plaques which may involve restrictions in CSF flow through the olfactory tract and through the cribriform plate into the nasal submucosa (Ethell 2014) due to some of the reasons listed above. Ethell stated that “ Olfactory dysfunction is common in Alzheimers (Zou et al. 2016) and could be related to alterations in CSF flow, and that a restriction in CSF flow could also result in plaque formation, and that restoring this flow could enhance the drainage of Amyloid oligomers and other metabolites from the medial temporal lobe ”.
Roth (2016) reported results of their experiments on the effects of MLD on intracranial pressure (ICP) which showed that their data confirmed a significant reduction of ICP during therapy applying craniocervical MLD in patients with severe cerebral diseases. He stated that these findings also confirmed results by Ludemann et al. (2004) . Treatment of migraines with MLD has been found to alleviate these symptoms. This is because according to Uren (2003, p.572 ) such treatment widens the gaps in the overlapping endothelial cells of the initial lymphatic vessels and “increases the volume and flow of lymph”. However he also stated that pressure needed to be light since “even light external pressure significantly decreased lymph flow” ( Author note: Consider using low pressure kinesiotape instead of compression hosiery for limb oedema with some patients)
D. Effects of meningeal inflammation
In an abstract presented by Rathbone et al. (2015), their findings indicated that meningeal inflammatory responses and elevated cytokine levels in response to chronic infections such as the Borrelia bacterium ( Lyme disease) are associated with chronic migraines. They reported that post concussion syndrome was not only found in patients with previous head injury but also non head injury patients displaying inflammatory responses to bacteria and viruses. They mentioned that inflammation has also been proposed as a major player in the etiology of chronic fatigue syndrome because it often occurs after a viral infection and features abnormal cytokine profiles and altered immune cell activities (Lorusso et al.2009)
E. Patient studies
I have selected four of my past patients where the symptoms and my treatment relate to the above scientific findings:
• Patient H
o Clinical History.
H had been suffering from severe migraines for 10 years, had gone deaf in her left ear, and was beginning to lose her eyesight’s colour perception, as well as regular sinus blockages and infections. She had oedema also in the occiput region. More recently she had had a hysterectomy following a tumour removal in the lining of her large colon. She had a swollen abdomen and pain from scar tissue. On giving her patient history it transpired she had been mountaineering in China 10 years ago and had caught a nasty flu virus.
Over the course of 15 weekly MLD sessions I treated her face and neck, as well as the occiput region. During the first three sessions she experienced the same flu symptoms unique to the Chinese virus she had 10 years ago. After the next sessions she felt much more clear headed, her hearing was restored ( I treated her pre auricular and retro auricular nodes using Vodder fork method for extended periods), and her eyesight more became normalised.
My conclusion was that she had been suffering from a cranial lymph flow restriction, either ISF or CSF, possibly brought on either by the old infection or the extreme cold of her mountain expedition as lymph slows down in cold conditions. (Solari (2017) states that “the velocity of a biochemical reaction is deeply and directly affected by temperature, which therefore could also exert a significant effect on lymphatic vessel spontaneous contractions and thus alter lymph drainage and transport.” ) . I concluded that the flow restriction had trapped the toxins so that when I released the blockage into the lymphatics and thence into her blood circulation, she felt the same flu like symptoms for a short period. The lymph flow restriction had also caused her facial and auditory lymph vessels to function less efficiently causing the above symptoms.
Since the CSF drains also to the lumbar nodes (as stated above and see App A) behind the umbilicus, and since she was suffering from a build up of abdominal lymph fluid, this could have resulted in a build up of CSF pressure in the subarachnoid space causing her severe migraine. Further treatments included therefore deep abdominal MLD to the lumbar and other iliacal nodes. This resulted in a rush of trapped lymph fluid up the thoracic duct which made her shiver immediately on treatment. However it successfully reduced her abdominal oedema and at the same time she has not since had any more migraines at all, which I conclude was due to the reduction in cerebral pressure . She has also had a consistently lower diastolic blood pressure reading which had it seems been quite high prior to my first treatment, which may also have been due to the increased cerebral pressure.
• Patient C.
o Clinical History.
C had also been suffering from severe migraines, and protruding eyes with surrounding oedema. She had seen an ophthalmologist who confirmed no glaucoma and also had had a blood test to confirm no thyroid issues which can sometimes present with those symptoms.
She had however been bitten by a tick in her garden 7 years ago and had tested positive for the presence of Borrelia Burgdorferi due to Lyme’s disease. She was prescribed antibiotics. This particular bacteria is known to lodge in the meninges and can cause migraines and meningitis like symptoms (See B above). She also presented with an oedematous swelling on the right hand side of her occiput region which had always caused her discomfort and pain.
She had 18 treatments with me carrying out full face Vodder MLD, deep abdominal MLD with longer focus on the lumbar nodes (in view of the above findings from Weller et alia) , and also Vodder MLD to occiput area and nape of neck. Now her migraines have not returned which she was extremely pleased about. Also her eyes and surrounding oedema have returned to more normality due to reduced intraocular pressure and improved drainage to submandibular nodes. (Foldi (1994) stated that “MLD of the head and neck can alleviate retinal oedema in cases of lymphostatic encephalopathy and related opthalmopathy”)
• Patient K
o Clinical History
K came to me in January this year with neck and occiput oedema following CA of the tonsils in 2019 when he had had RT and CT treatments. There had been no lymphadenectomy. However he also complained of Tinnitus in his left ear which he had had consistently since a triple cranial fracture in 2007
I successfully eliminated his oedema over 3 treatments using MLD, Kinesiotape and low level laser therapy.. Also during the three treatments the Tinnitus reduced from a high pitched tone to a low tone and then completely disappeared and has not returned since which he reported tome in a follow up call to him. It is speculation, but I can only assume that the accident caused a CSF cranial lymph flow restriction causing a build up in lymph fluid around the ear which was then released during my treatments
• Patient S
o Clinical history
S came to me last year with severe abdominal lymph swelling. She had last year had a total hysterectomy. However when she saw me she had just been released from hospital after a two day stay to investigate a spike in her diastolic pressure to 110 from its norm of 75. The cardiologist discharged her with a prescription to lower the pressure but with no explanation as to what had caused the spike which she had never experienced before.
In view of the findings of Professor Weller linking the drainage of CSF to the lumbar nodes in the abdomen (See App. A) which in her case was blocked with fluid, I thought that could have backed up causing a rise in her CSF pressure and therefore potentially also her blood pressure. I therefore gave her two treatments of deep abdominal MLD. This had the effect of releasing the abdominal blockage (she felt an enormous rush of fluid up her thoracic duct) and reducing her oedema considerably, but also had the effect of normalising her blood pressure which has remained normal ever since. Her abdominal oedema still requires occasional treatment.
My summary conclusions are as follows. There is clear evidence from the above that:
• There is a clear link between the brain’s CSF& ISF and the lymphatic vessels in both the neck (cervical nodes) and abdomen (lumbar nodes), and therefore t the body’s immune system, in order to neutralise the antigens and toxins accumulating in the brain.
• Any restrictions to this flow could lead to neuropathy and memory related neurological disorders such as Alzheimer’s, MS and Dementia. It could also contribute to the formation of fibrotic AB protein plaques found in patients with these disorders.
• Manual lymph drainage can speed up the flow of CSF and ISF out of the meningeal and dural lymphatics to the nasal and aural lymphatics as well as the lumbar nodes. This will then more efficiently transport antigens and toxins from the brain to the lymph nodes for neutralisation by the lymphocytes, macrophages and dendritic cells in the body’s extra cranial immune system.
I find the linking up of the clinical and scientific research into cranial lymph flow with practical patient treatments to be highly effective and rewarding. However I believe more research needs to be carried out into the effects of cranial lymphostasis and whether patterns of vascular amyloid β aggregation and pathways of interstitial solute clearance can be determined. More research needs to be carried out on the causes of the build up of insoluble extra cellular amyloid beta and intra cellular TAU proteins which cause this cranial plaque build up leading to neurological diseases and dementias associated with age related failure of the brain – especially Alzheimers, dementia and multiple sclerosis. I believe that cranial and deep abdominal MLD in the meantime can however play a significant role in alleviating and slowing down the advance of such conditions, and the associated symptoms.
APPENDIX A - Slide produced by Professor Weller.
Note link between Cerebro Spinal Fluid and Lumbar lymph nodes in deep abdomen as well as drainage to cervical lymph nodes
Carare RO et al. (2008 & 2013)
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