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Aqua Lymphatic Therapy (ALT) The Tidhar Method (click to visit website with instructional videos)

Article ~ For Managing Lower Extremity Lymphedema

From the Journal of the American Academy of Dermatology

Volume 59, Issue 6, Page 1092 (December 2008)

To the Editor:

We read with great interest the August 2008 article by Kerchner et al1 entitled ‘‘Lower extremity lymphedema update: Pathophysiology, diagnosis, and treatment guidelines.’’  The authors reviewed the pathophysiology, diagnosis, and treatment guidelines for lower extremity lymphedema.  Management options that were mentioned included extremity elevation, exercise, compression garments, manual lymph drainage, skin care, surgery, and drug therapy.

We would like to call attention to a novel treatment approach, called aqua lymphatic therapy (ALT), that gives another treatment option for lymphedema patients.2,3  It provides patients in the maintenance phase of lymphedema with the opportunity to treat them in a group setting once a week.  Lymphedema must be treated on a daily basis; therefore, ALT is an active method performed entirely by the patient and not by the physical therapist.

During the weekly group session, the physical therapist measures girth before and after each session to monitor the effectiveness of treatment and to enable patients to track and modify their individual maintenance plans.  ALT uses the properties of water - buoyant force, hydrostatic pressure, water viscosity, and water temperature - to maintain or improve reductions in lymphedema that are achieved during intensive treatment phase.  The hydrotherapeutic pool has a graduated depth of 1.2 to 1.6 m.  It is monitored for pH (7.02), chloride concentration, bacteriologic control, and water clarity.  Participants with infections are not allowed to participate.

Each session includes a few basic elements:

(1)    skin care - patients apply a silicone cream to protect the skin before each session;

(2)    manual massage - patients carry out self-massage and water massage;

(3)    compression - the hydrostatic pressure of water at 328C gradually increases with greater depth; therefore, the limb benefits from pressure gradients, which influence the direction of lymphatic flow; and

(4)    exercise - exercises are carried out in the pool to allow the patient to benefit from the properties of the water itself.  The viscosity of water provides resistance to body movement, which promotes strengthening and improves lymphatic clearance.  Because water resists movement in any plane, a variety of limb movements may be used to offer differing pressures on the skin; this may improve pumping of the lymphatic vessels.

ALT endorses self-advocacy.  It educates patients about a particular series of motions in order to reduce their edema and to take control of their own care.  While learning and practicing this technique with others, they enjoy the advantages of being part of a support group that addresses qualitative issues.3 

Further clinical research is needed to provide additional data on its usefulness in patients with lymphedema resulting from different medical conditions and to adjust the techniques for treatment of a variety of patient populations.

Avi Shimony, MD                                                 Dorit Tidhar, BPT,

Department of Cardiology,                                  Department of Physiotherapy,

Soroka University Medical Center,                      Maccabbi Health Care Services,

Ben Gurion University of the Negev,                   Netivot, Israel

Beer Sheva, Israel

Funding sources:  None.

Conflicts of interest:  None declared.

Correspondence to:  Avi Shimony, MD, Department of Cardiology, Soroka University Medical Center, Ben Gurion University of the Negev, PO Box 151, Beer Sheva 84101, Israel, E-mail:


1.   Kerchner KL, Fleischer A, Yosipovitch G. Lower extremity lymphedema update: pathophysiology, diagnosis, and treatment guidelines. J Am Acad Dermatol 2008;59:324-31.

2.   Tidhar D, Drouin J, Shimony A. Aqua lymphatic therapy in managing lower extremity lymphedema. J Support Oncol 2007;5:179-83.

3.   Tidhar D, Shimony A, Drouin J. Aqua lymphatic therapy for post surgical breast cancer lymphedema. Rehab Oncol 2004;6:22.

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