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Manual lymph drainage (MLD) is an integral part of lymphoedema treatment but there is limited evidence to guide clinical practice. This paper outlines the historical background to MLD and provides insights into the evidence relating to the effect and efficacy of manual lymph drainage, highlighting considerations for lymphoedema practitioners.
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S18 Chronic Oedema, April 2010
Over 100 years ago, Winiwarter, a German
surgeon, described the use of massage to
‘promote resorption’ of fluid from swollen
tissues in people with lymphoedema (Winiwarter, 1892:
397). In the present day, manual lymph drainage (MLD),
a type of massage, has become established as an integral
part of lymphoedema treatment. However, the limited
empirical evidence base and lack of consensus on the
use and efficacy of MLD (Devoogdt et al, 2009) means
there is a lack of clarity regarding the application of MLD
for people with lymphoedema. Some lymphoedema
practitioners may have limited knowledge of MLD.
Those who have learned the techniques may have limited
resources or support to continue using them. The current
drive towards cost effectiveness also means that bodywork
treatments such as MLD may be given low priority in the
planning and resourcing of services.
This paper will provide a brief history and outline the
main features and principles of MLD. It will discuss the
evidence around the mechanisms through which MLD
may exert its effect, and then overview the findings from
studies that have examined the clinical and therapeutic
efficacy of MLD. Finally, it will discuss some implications
for clinical practice in lymphoedema treatment and care.
In the 1930s, his ill health forced Emil Vodder to abandon
medical studies and move from Denmark to the French
Riviera. Inspired by a deep interest in anatomy and
bodywork, and a fascination with the lymphatic system, he
intuitively developed a form of massage. Vodder presented
his method of manual lymph drainage at a conference in
Paris (Vodder, 1936), returning to Copenhagen before
the outbreak of World War 2 (Wittlinger, 2004). It was
nearly 30 years later that his lectures drew interest from
doctors and others who greatly admired his work and
recognized that this type of manual massage could benefit
people with lymphoedema (Asdonk, 1966; Fischer,
1967). In 1965, Vodder made a presentation in which he
described his conviction that MLD, along with breathing
and relaxation exercises and improved diet, would play
a key role in lymphatic disorders (Vodder, 1965). His
conviction holds true today.
While Winiwarter had described massage methods
such as ‘petrissage’, ‘efflurage’ and ‘friction’ (Winiwarter,
1892), Vodder’s technique was characterized by gentle,
pumping, circular movements using pressures of around
30mmHg, combined with a ‘zero’ or resting phase.
The aim was to enhance drainage of lymph from the
interstitial tissues without producing increased capillary
filtration (Wittlinger and Wittlinger, 1992). Until his
death in 1984, Vodder worked with many colleagues
from different countries. This collaborative work led to
the development of the conservative physical therapy
approach to lymphoedema management, combining
MLD with compression bandaging, skin care and exercise
(Földi et al, 1985). Inevitably, these techniques have
now developed in various directions, owing to specific
expertise and research. While different schools of MLD
have been established (Table 1), the underlying features
and principles of the MLD technique remain similar
across the different methods (Table 2). Importantly, each
MLD school insists on robust training and updating
methods to ensure practitioners are fully skilled, and use
their hands wisely, in order to achieve a good outcome
for people with lymphoedema and other conditions.
Evidence base
How does MLD exert its effect?
Although one of the first studies of MLD took place
40 years ago (Börcsok et al, 1971), the mechanisms through
which MLD has its effect are not fully established. In part,
this is owing to problems in differentiating the effect of
MLD from those of other interventions such as compression
therapy. Additionally, there are challenges in establishing
valid and reliable means of measuring the changes that
take place in the lymphatic and other systems, as a result of
MLD. Techniques to measure lymph flow can be complex
(Olszewski and Bryla, 1994) and many focus on the uptake
of radio-labelled proteins at lymph nodes (Mortimer et al,
1990; Szuba et al, 2002, Kafejian-Haddad et al, 2006). As
Manual lymphatic drainage: exploring
the history and evidence base
Anne Williams
Anne Williams is PhD Student, Edinburgh Napier University Email:
Manual lymph drainage (MLD) is an integral part of lymphoedema treatment
but there is limited evidence to guide clinical practice. This paper outlines
the historical background to MLD and provides insights into the evidence
relating to the effect and efficacy of manual lymph drainage, highlighting
considerations for lymphoedema practitioners
w Manual lymph drainage (MLD) w Lymphoedema w Evidence for
MLD w Therapeutic effect of MLD
Chronic Oedema, April 2010 S19
such, lymphoscintigraphy has been used in several studies,
for example to measure the rate of flow into lymph nodes
(Szuba et al, 2002) or visualize and describe changes in lymph
drainage patterns (Ferrandez et al, 1996). While this provides
some insights, the studies do not provide information on the
long-term effects of MLD on the anatomical, physiological
or functional aspects of the lymphatic system and other
tissues. Measurement of nodal uptake is also impractical
following lymph node dissection.
Table 3 summarizes reported effects of MLD and
highlights some interesting features. For example, Leduc
et al used lymphoscintingraphy to suggest that proximal
use of the ‘call-up’ technique influenced lymph flow in
distal lymphatics (Leduc et al, 1988). Evidence suggests
that MLD enhances movement of fluid into initial
lymphatics, and influences the contraction rates of pre-
collector and collector lymph vessels, moving lymph
towards deeper drainage trunks. MLD also appears to
influence lymph flow between lymph territories and has
also been surmised to lead to proliferation of collateral
lymphatics (Casley Smith and Casley Smith, 1997). Some
important considerations arise from the findings of
various studies and warrant further research. For example,
it is known that inflammatory mediators, present in
interstitial tissue as a result of lymph stasis, will influence
smooth muscle and alter lymph pumping mechanisms
(von der Weid and Zawieja, 2004). This might suggest
that MLD could have a role in reversing these processes
at an early stage in the development of lymphoedema,
reducing local inflammation and oedema, and restoring
the function of lymphatic vessels even before a clinically
obvious or chronic oedema has developed.
It appears likely that MLD has local and systemic
effects, for example influencing the autonomic nervous
system (Hutzschreuter and Ehlers, 1986) and producing
significant changes in the secretion levels of serotonin,
histamine, adrenaline and noradrenaline (Kurz et al,
1978). However, the significance of these findings in
terms of using MLD for people with lymphoedema,
have not been established. Some studies have reported a
reduction in limb volume after MLD that did not appear
to correlate with a measurable change or improvement
in lymph flow (Francois et al, 1989; Kafejian-Haddad et
al, 2006), suggesting that changes in other aspects such as
blood flow may be significant. The potential for lymph to
return to the blood circulation at regional lymph nodes
(Levick and McHale, 2003), reflects the importance
of lymph node clearance, an important feature of the
MLD sequence. Additionally, the ways in which MLD
may reduce skeletal muscle spasm, and improve lymph
drainage, through its influence on connective tissue layers,
requires further consideration.
Clinical therapeutic effects of MLD in
Some of the early work into the therapeutic effects of
MLD was published in German and therefore not easily
accessible to an English-speaking audience. Additionally,
much of the work around MLD has been descriptive, or
has evaluated the effects of combined treatments, without
distinguishing the specific effects of MLD. The majority
of studies have been undertaken with women who have
breast cancer-related lymphoedema. Studies also tend
Vodder (Wittlinger and This method uses different hand movements on
Wittlinger, 1992) the skin called ‘pump’, ‘scoop’, ‘rotary’,
‘stationery circle’ and ‘thumb circle’, depending
on what area of the body is being treated (
1, 2
). It includes oedema movements at areas of
Földi (Földi and This method is based on Vodder strokes as above
Strößenreuther, 2003) with emphasis on a ‘thrust’ and ‘relaxation’ phase.
It includes edema strokes such as the ‘encircling
Casley-Smith (Casley- This method uses a slow and gentle ‘efflurage’,
Smith and Casley-Smith, with specific movements using the side of the
1997) hand, over the ‘watershed’ areas between
lymphotomes (skin lymph territories) (
Figure 3
Leduc (Leduc et al, This method uses specific techniques: ‘call up’ (or
1991) ’inciting’) and ‘reabsorption’ movements; this
reflects how lymph is absorbed into initial
lymphatics, then moves through larger pre-
collector and collector lymphatics
Table 1. Some features of different methods of MLD
Hand movements are used to stretch the skin in specific directions and
promote variations in interstitial pressures, usually without the use of oils
Movements are slow, repetitive and soporific, and usually incorporate a
brief ‘resting’ phase, where the skin is allowed to return to its normal
Pressures vary according to underlying tissues but aim to promote lymph
drainage without increasing capillary filtration and hyperaemia
Deeper or firmer movements may be incorporated when treating areas of
fibrosclerosis, with compression therapy usually applied afterwards
The MLD sequence starts proximally and centrally, often with treatment to
the neck (
Figure 4
Functional and healthy regional lymph nodes are treated, for example the
contralateral (opposite side) axilla and ipsilateral (same side) inguinal
nodes (
Figure 5
) in an upper limb lymphoedema, or both axillae in a lower
limb lymphoedema
Proximal areas such as contralateral and non-oedematous lymph territories
or lymphotomes are treated, including the midline or ‘watershed area’
between two skin lymph territories
The ipsilateral trunk and lymphoedematous limb are treated, starting
proximally, often with particular attention given to the root of the limb
Early in the treatment, emphasis may be on treating the anterior and
posterior trunk prior to treating the swollen limb.
Breathing techniques are commonly used with MLD, often combined with
controlled hand pressures by the therapist, to influence drainage in the
deep abdominal lymphatic vessels and nodes
Limb mobilization and relaxation techniques may be incorporated into the
MLD treatment session
Table 2. Features and principles of MLD
S20 Chronic Oedema, April 2010
to focus on changes in limb volume, using varied or
poorly defined ways to measure or calculate limb volume,
negating any opportunity for comparison or meta-
analysis. Other outcome measures such as tonometry to
assess changes in skin and tissues (Harris and Piller, 2003),
or measures of symptom changes or quality of life, also
require further validation as a means to evaluate MLD.
Table 4 highlights a sample of studies that have a particular
focus on MLD in breast cancer-related lymphoedema.
Most draw on small samples and some are not randomized
or controlled. Several studies suggest that in some patient
groups, MLD combined with compression bandaging may
be more effective than using compression bandaging alone
(Johansson et al, 1999; McNeeley et al, 2004). However,
specific details of how MLD was used or the effect
measured are often not made clear (Andersen et al, 2000).
Two studies from the UK investigated MLD and
patient-administered massage (Sitzia et al, 2002; Williams
et al, 2002). Williams et al (2002) undertook a randomized
controlled cross-over study and showed that MLD had
a significant effect in reducing excess limb volume
in women with breast cancer-related lymphoedema
(p=0.013) even without compression bandaging. Similar
results with a trend towards MLD being more effective
were reported by Sitzia et al (2002) although the authors
suggested a larger study sample was required.
Implications for practice
Asdonk, a German GP who was one of the first to use
MLD extensively in his practice, highlighted the broad
Stretching effect on lymph collectors and local smooth muscle, increased the frequency of contraction of lymphangions/
lymph vessels and increased lymphatic transport capacity (Hutzschenreuter and Brümmer, 1988; Hutzschenreuter and
Herpertz, 1993)
Lymph flow increased (as measured by lymphoscintigraphy) possibly owing to increased rate of contraction of
lymphatics (Francois et al, 1989)
Variations in interstitial pressures led to enhanced filling and emptying of initial lymphatics (Casley-Smith and Björlin,
‘Call-up’ technique propelled lymph in the collecting lymphatics and exerted a suction effect on distal lymphatics; the
‘reabsorption’ technique moved proteins from a subcutaneous tissue injection site (Leduc, 1988)
Proximal MLD treatments produced a reduction in distal tissue pressure (Deryden et al, 1994)
‘Accessory routes’ within the lymph drainage system appeared to be ‘stimulated’ (Ferrandez et al, 1996)
Reduction in limb volume occurred, but was not consistent with increased lymph transport as measured by
lymphoscintigraphy (Kafejian-Haddad et al, 2006)
Blood flow increased in superficial blood circulation and peripheral arteries (Hutzschenreuter et al, 1989)
Blood flow increased through the femoral vein (Deryden et al, 1994)
The influence of MLD on the autonomic nervous system produced a calming effect (Hutzschenreuter and Ehlers, 1988)
Skin circulation improved (Hutzschenreuter et al, 1992)
Urinary secretion of serotonin, histamine, adrenaline and noradrenaline increased (Kurz et al,1978)
Breathlessness decreased and sleep improved (Williams et al, 2002)
• Microlymphatic hypertension reduced (Franzeck et al, 1997), although this appeared to be a combined effect of MLD and
compression bandaging
Table 3. Evidence summary: reported effects of MLD
Figure 1: MLD across the back using rotary technique: Vodder
Figure 2: Thumb circles to the dorsum of the hand: Vodder
Chronic Oedema, April 2010 S21
Authors Design Findings and comments
Johansson et al (1999) Non-randomized consecutive Data on 35 women showed:
Effects of
sample of women with breast • At end of Part 1 - mean reduction in excess
cancer-related lymphoedema. volume of 26%
bandaging with or
Part 1- women with limb volume • At end of Part 2:
without manual
excess of >10% received 2 weeks o Group 1 (CB/MLD) had further 11%
lymphatic drainage
of CB Part 2 - divided into 2 groups reduction in excess volume
in patients with
• Group 1 had a further 1 week o Group 2 (CB) had further 4% reduction
post-operative arm
of CB/MLD (Vodder MLD method) in excess volume
. • Group 2 had 1 week of CB alone • Both groups had improvement in symptoms
but MLD group had a significant reduction in
Setting: Sweden pain (p<0.03)
Andersen et al (2000) Prospective randomized study comparing Data on 42 patients showed:
Treatment of breast
standard treatment with custom-made • No evidence of treatment effect from MLD
information versus standard treatment and • Forty-eight percent reduction in absolute oedema
lymphedema with or
MLD (Vodder method ) with 8 MLD treatments volume at 3 months in MLD group
without manual lymphatic
over 2 weeks, in women with limb volume of <30% • Sixty percent reduction in same in non-MLD group
drainage. A randomized
• No difference in symptom scores between groups
. • Complex method of calculating limb volume
• Quality of life measured but data not reported
Setting: Denmark
Sitzia et al (2002) Prospective study of 28 women with unilateral Data from 28 women showed:
Manual lymphatic
arm lymphoedema . Women randomized to • Group 1- 33.8% reduction in excess limb volume
drainage (MLD) compared
two groups: • Group 2- 22% reduction in excess limb volume
with simple lymphatic
Group 1- 2 weeks CB/MLD (Leduc method) • Initial excess volumes of 68.3% in Group 1 and
drainage (SLD) in the
given by therapist 58.5% in Group 2
treatment of post-
Group 2- 2 weeks CB/SLD (a simple form of MLD) • Small pilot study suggested that MLD was more
mastectomy lymphoedema
. given by therapist effective than SLD but neither results were
A pilot randomised trial
significant and larger sample of 56 participants
required to achieve significance
Setting: UK
Williams et al (2002) Prospective cross-over study of 31 women with Data from 31 women showed:
A randomised controlled
limb volume excess of >10% (mean 35% excess) • MLD achieved a significant reduction in excess
crossover study of manual
Women randomized to two groups: volume (p=0.013)
lymph drainage (MLD)
Group A: 3 weeks (15 treatments) MLD (Vodder • MLD achieved a significant reduction in dermal
therapy in women with
method) combined with standard treatment of depth in the upper arm (p=0.03)
breast cancer-related
compression hosiery and information • MLD achieved a statistically significant
. Group B: 3 weeks of daily patient self-administered improvement in emotional function, dyspnoea,
massage combined with standard treatment with sleep disturbance and pain sensation
Setting: UK compression hosiery and information. • Self-administered massage had no statistically
‘Wash-out’ period of 6 weeks then participants significant effects
crossed over to: • MLD was used without CB in an attempt to isolate
Group A: 3 weeks SLD and compression hosiery the effect of MLD
Group B: 3 weeks MLD and compression hosiery • Longer than 3 weeks is required to evaluate self-
Measurement of change in excess limb volume, massage
dermal depth using skin ulstrasound, caliper ‘creep’ • Outcome measures such as caliper creep and
to assess trunk oedema and quality of life skin ultrasound need further validation
McNeeley et al (2004) Sample of 50 women who had lymphoedema Data on 45 women showed:
The addition of manual
after breast cancer randomized to 4 weeks of daily • Significant reduction in lymphoedema volume in
lymph drainage to
treatment with MLD (Vodder method) and both groups (CB and MLD/CB) with most benefit
compression therapy for
compression bandaging (CB) or CB alone. seen in the initial 2 weeks
breast cancer-related
Measurement of limb volume reduction expressed • Statistically significant greater limb volume
lymphedema: a randomized
as percentage change in excess limb volume reduction with MLD/CB in those with early
controlled trial
lymphoedema (p < 0.05)
• Better outcome with MLD/CB in those with mild
Setting: USA lymphoedema (<15% excess volume) than in any
other groups (p < 0.05)
• Range of movement and other aspects of quality
of life or symptoms not assessed
Table 4. Evidence: examples of studies of the therapeutic effect of MLD in women with breast
cancer-related lymphoedema
Figure 3. MLD across the midline or ‘watershed’ between two
skin lymph territories: Casley-Smith method
Figure 4: MLD to the neck: Casley-Smith method
Figure 5: MLD clearance of superficial inguinal lymph nodes
S22 Chronic Oedema, April 2010
range of conditions for which MLD may be indicated,
including post-thrombotic syndrome, degenerative
nervous system and inflammatory conditions (Asdonk,
1975). Recent papers report on MLD in sports medicine
(Vairo et al, 2009), conditions such as fibromyalgia (Ekici
et al, 2009) and reflex sympathetic dystrophy (Duman
et al, 2009). A potential role for MLD as part of a
lymphoedema prevention programme is also highlighted
(Torres Lacomba et al, 2010).
However, for those using MLD within their daily
practice, a number of questions arise concerning how
MLD should be used with different groups. As yet, the
evidence to inform these decisions is limited and as a
result, it is important that practitioners reflect critically on
their practice in using MLD. Measurement of outcomes
using standardized, valid and reliable methods is crucial,
as is the sharing of results in terms of ‘successes’ and
It is likely that some patient groups may respond
better to MLD than others. For example, there is some
indication that MLD may be more effective in those with
‘mild’ lymphoedema (McNeeley et al, 2004). Certainly
it is possible that the presence of fibrosclerotic tissues
influences the effect of MLD, rendering it less effective
and indicating that compression therapy in the form of
bandaging may more effective as a first line treatment in
some groups. Equally this may be an indication for early
intervention with MLD to reverse the changes that may
lead to long-term tissue fibrosis.
While MLD is frequently used in combination with
bandaging, some groups will require MLD as the first-line
treatment. For example, those with oedema of the trunk
and midline are a particular priority for MLD and there
are papers describing the use of MLD in genital oedema
(Katz et al, 2004), breast oedema (Mondry et al, 2002)
and head and neck oedema (Figure 6) (Reiss and Reiss,
2003). Clinical experience suggests that women who have
breast oedema after breast cancer treatment will respond
readily to MLD, with good long-term outcomes. This is
a particular group who may be motivated towards self-
management approaches and may be taught self-massage
of the breast area during a course of MLD. Importantly, the
use of MLD in this group may highlight how bodywork
provides a means through which health professionals can
enable people to adjust to and accept changes in their
body after cancer treatment.
The theoretical debate that MLD may somehow promote
metastatic cancer is not substantiated in the minimal
literature (Preisler et al, 1998), nor in clinical practice.
However, this highlights the need for lymphoedema
practitioners to work closely with medical colleagues
to ensure that MLD is appropriately given. It is usually
advisable to delay MLD treatments if someone is receiving
cytotoxic chemotherapy, particularly as the chemotherapy
itself may alleviate an obstructive oedema by reducing
tumour bulk. However, if the focus of care is palliative, it
may not be appropriate to delay lymphoedema treatment,
as swelling may become poorly controlled. In these
situations, MLD can also play an important role in the
management of other symptoms such as pain, dyspnoea
and constipation.
While MLD should not be used in the presence of
acute infection, once antibiotic therapy has begun and
systemic symptoms have passed, MLD can be considered.
MLD is also useful in those with chronic inflammatory
conditions. If recurrent infection has been a problem,
antibiotic therapy may be indicated during the MLD
period as temporary exacerbation of symptoms can
MLD has a long history and a limited, but growing
evidence base to guide practice. This paper has identified
some of the principles and possible effects of MLD and
discussed some implications for lymphoedema practice.
The effects and efficacy of MLD will depend on
various factors relating to the person, the nature of their
lymphoedema, and the way the practitioner uses the MLD
techniques in combination with other interventions such
as compression therapy and self-management support.
There is still much to learn about how MLD should best
be used in order to ensure effective and equitable treatment
for all individuals with lymphoedema. However, fundamental
to this is the need for collaborative working and research.
Good quality information about MLD is also required for
people with lymphoedema, other colleagues, and those
involved in managing and developing services. Practitioners
should be aware of the current evidence around MLD and
ensure they are appropriately educated in the techniques and
supported with applying them in practice. BJCN
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Casley-Smith method:
Leduc method:
Vodder method:
USA-based school for Földi method:
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manual lymphatic drainage. J Ma Vasc 21(5): 283–9
Fischer M (1967) 30 years of manual lymphatic drainage according to Vodder.
A special form of massage for decompression of the tissue. Landarzt 43:
Földi E, Földi M, Weissleder H (1985) Conservative treatment of lymphedema
of the limbs. Angiology 36: 171–80
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edn. Elsevier Mosby, Missouri
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lymphedema act by increasing lymph flow? VASA Band 18(4): 281–7
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KEY pOInts
w Manual lymphatic drainage (MLD) is often used in combination with
compression bandaging, exercises, skin care and self-management
support in the management of lymphoedema
w Manual lymph drainage has a long history but a limited empirical evidence
w Different schools of MLD have been established, but the underlying
principles of the MLD techniques remain similar across the various
w Research studies have described many different ways in which MLD may
exert its’ effect on lymphatic, vascular and other systems
w Hands-on treatment to the body, such as MLD, can be important in helping
individuals to adjust to body changes after cancer treatment
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... M anual lymphatic drainage (MLD) was developed in 1936 by Danish biologist Emil Vodder and his wife Estrid Vodder 1 and matured by Földi et al. 2 MLD, one of the components of complex decongestive physiotherapy, is a treatment application mainly used to accelerate lymph flow. 2,3 MLD, which is mainly used in lymphedema treatment, is also used in traumatic injuries, muscle fiber tears, dislocations, complex regional pain syndrome (sudeck disease), scar treatment, rheumatoid diseases, headache, and migraine in a wide range of diseases and symptoms. 3 Special training is required to apply MLD. ...
... 2,3 MLD, which is mainly used in lymphedema treatment, is also used in traumatic injuries, muscle fiber tears, dislocations, complex regional pain syndrome (sudeck disease), scar treatment, rheumatoid diseases, headache, and migraine in a wide range of diseases and symptoms. 3 Special training is required to apply MLD. There are many schools offering MLD training (e.g., Vodder, Földi, or Leduc). ...
... MLD enables lymph and tissue fluid to move forward and also increases the frequency and amplitude of the contraction and relaxation movement of lymph collectors called lymphangiomotoric. 3 Tan et al. evaluated lymphatic flow velocity and time to escape lymphatic fluid with near infrared (NIR) fluorescence before and after MLD to 22 subjects (10 subjects with a diagnosis lymphedema and 12 healthy control subjects). Indocyanine green was injected intradermally in bilateral arms or legs of these subjects and NIR fluorescence images were collected. ...
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Introduction: Manual lymphatic drainage (MLD), one of the components of complex decongestive physiotherapy, which is accepted as the gold standard in the treatment of lymphedema, is used for therapeutic purposes in many diseases. The most well-known feature of MLD is that it helps to reduce edema. In addition to reducing edema, MLD has many effects, such as increasing venous flow, reducing fatigue, and raising the pain threshold. To the best of our knowledge, there is no study examining the effects of MLD other than its effects on edema in detail. The aim of this study is to compile effects of MLD and to provide a better understanding of the effects of MLD. Methods: A literature search was conducted in Medline, Embase, and the Cochrane Library in July 2019, to identify different effects of MLD. The articles were chosen by, first, reading the abstract and subsequently data were analyzed by reading the entire text through full-text resources. To undertake the study, we have collected information published about different effects of MLD over the last 30 years (1989-2019). According to our results, 20 studies met inclusion criteria. Conclusions: This study suggests that MLD can be used in symptomatic treatment of various diseases (multiple sclerosis, Parkinson's disease) considering the effects of MLD on the systems.
... soften fibrosis and increase lymph drainage into venous circulation by stimulating superficial lymphatic contraction and rerouting lymphatic fluid into adjacent functioning lymphatic systems [7,8]. Historically, several MLD schools have been founded, with the most recognized and widely used including Vodder, Földi, Casley-Smith and Leduc [9]. Qualified lymphedema therapists use specialized slow repetitive hand movements, gently massaging along anatomical lymphatic pathways over affected areas, attempting to stimulate lymphatic flow and drainage [8,9]. ...
... Historically, several MLD schools have been founded, with the most recognized and widely used including Vodder, Földi, Casley-Smith and Leduc [9]. Qualified lymphedema therapists use specialized slow repetitive hand movements, gently massaging along anatomical lymphatic pathways over affected areas, attempting to stimulate lymphatic flow and drainage [8,9]. Firmer movements over areas of fibrosclerosis may be used, with MLD generally starting proximally and centrally, before moving distally in segments with massage performed in the direction of lymphatic flow [10]. ...
... Firmer movements over areas of fibrosclerosis may be used, with MLD generally starting proximally and centrally, before moving distally in segments with massage performed in the direction of lymphatic flow [10]. However, the effect MLD has on lymphedema management is still poorly understood, partly due to limitations in establishing valid and reliable measures to assess lymphatic flow changes and difficulties in distinguishing the effect MLD has on lymphedema outcomes from other interventions, such as compression therapy [9]. ...
Full-text available
PurposeManual lymphatic drainage (MLD) massage is widely accepted as a conservative treatment for lymphedema. This systematic review aims to examine the methodologies used in recent research and evaluate the effectiveness of MLD for those at-risk of or living with lymphedema.Methods The electronic databases Embase, PubMed, CINAHL Complete and Cochrane Central Register of Controlled Trials were searched using relevant terms. Studies comparing MLD with another intervention or control in patients at-risk of or with lymphedema were included. Studies were critically appraised with the PEDro scale.ResultsSeventeen studies with a total of 867 female and two male participants were included. Only studies examining breast cancer-related lymphedema were identified. Some studies reported positive effects of MLD on volume reduction, quality of life and symptom-related outcomes compared with other treatments, while other studies reported no additional benefit of MLD as a component of complex decongestive therapy. In patients at-risk, MLD was reported to reduce incidence of lymphedema in some studies, while others reported no such benefits.Conclusions The reviewed articles reported conflicting findings and were often limited by methodological issues. This review highlights the need for further experimental studies on the effectiveness of MLD in lymphedema.Implications for Cancer SurvivorsThere is some evidence that MLD in early stages following breast cancer surgery may help prevent progression to clinical lymphedema. MLD may also provide additional benefits in volume reduction for mild lymphedema. However, in moderate to severe lymphedema, MLD may not provide additional benefit when combined with complex decongestive therapy.
... 5,6,9,11 Manual lymphatic drainage techniques can decrease edema and are 1 of the 4 components of complete decongestive therapy, which is considered the "gold standard" treatment for lymphedema. [12][13][14] Manual lymphatic drainage techniques are gentle and rhythmic soft tissue techniques that stimulate the lymphatic structures without promoting erythema or inflammation 1,15,16 while supporting the absorption of excess fluid, protein, and waste products. The abolishment of an inflammatory reaction and associated edema is not expected from MLdT because this requires multifaceted treatment interventions. ...
... The abolishment of an inflammatory reaction and associated edema is not expected from MLdT because this requires multifaceted treatment interventions. Although preliminary studies provide evidence to the effects of MLdT, [15][16][17] the mechanism for these effects are still under investigation. From a physiological perspective, the gentle pressure and stretching components of MLdT stimulate the intrinsic and extrinsic lymph pumps, which increases lymph velocity via the contraction of smooth muscles within the lymph collector vessel. ...
... Its main objectives are to increase absorption of liquid and proteins from the interstitium by the lymphatic capillaries, increase the contractility of the lymphatic collectors, and increase liquid lymph node absorption, thus increasing the amount of liquid that returns to the venous system through the lymphatic system. 18 In addition, because they are maneuvers that involve superficial touching, MLD can also promote quality of life improvement, sleep improvement, and reduction of pain, anxiety, and other symptoms. [19][20][21] However, the effectiveness of manual lymphatic drainage for reducing lymphedema is not yet clear in the scientific literature. ...
Full-text available
This article aims to discuss the possibilities of conservative and non-pharmacological treatments for lymphedema. A non-systematic review of the literature was carried out, including studies involving human subjects with different types of lymphedema. Several approaches to lymphedema treatment have been reported and Complex Decongestive Therapy (CDT) has been considered the most effective treatment for limb lymphedema. Other conservative treatments have been proposed such as Taping, Extracorporeal Shock Wave Therapy, Acupuncture, Photobiomodulation Therapy, Endermologie, Intermittent Pneumatic Compression, and Low-frequency, Low-intensity Electrotherapy. The choice of the therapeutic approach to be employed should consider lymphedema characteristics, the therapist's experience, and the patient's wishes. In addition, since this is a chronic condition, the patient must adhere to the treatment. To this end, the therapeutic proposal may be the key to better control of limb volume.
... 6,8 A possible explanation for the effectiveness of this method includes slowly increasing pressure to shift lymph, creating a "pumping" response from frequent rest breaks dispersed within exercise and lymphatic stimulation through massage, as proposed by Williams. 19 According to Beursken et al., ROM and strengthening exercises are an essential component in the improvement of upper limb function in a land-based setting. 20 This is consistent with this review's findings, where all studies that investigated upper limb function had positive improvements. ...
Cancer is a leading cause of death and disability around the world. Of all cancers, breast cancer commonly ranks amongst the top three. Surgical intervention for breast cancer is common and a possible side effect of this is breast cancer related lymphoedema (BCRL). Women with breast cancer related lymphoedema commonly have regional limb swelling and pain, which can negatively impact mental and social well-being as well as upper limb function. Hydrotherapy is therapeutic modality which may be used as an adjunct to self-management strategies after the intensive phase of lymphoedema management. Yet despite its popularity, recent research has questioned its effectiveness in clinical practice. Purpose: To determine the effectiveness of hydrotherapy as an adjunct treatment to usual care on arm volume and pain when compared with usual care alone for women with breast cancer related lymphoedema. Method: A comprehensive search of eight electronic databases, including Medline, Embase, CINAHL, Scopus, Web of Science, AMED, The Cochrane Library and PEDro was completed. Studies of adult women with secondary upper limb lymphoedema following breast cancer surgery, which measured lymphoedema volume, pain, upper limb and QOL outcomes were included. Methodological quality was assessed using a modified CASP tool for randomised controlled trials. The NHMRC FORM methodology was utilised to synthesise the evidence and provide an overall grade of recommendation. Results: Four randomised controlled trials and one controlled clinical trial were included in this systematic review. Critical appraisal of the included studies revealed overall methodological quality to be moderate. Hydrotherapy interventions duration varied between 8 to 12 weeks with some similarities between outcome measures assessed. Collectively, there is mixed evidence to support the positive impact of hydrotherapy as an adjunct treatment on reducing lymphoedema volume in the short-term and emerging evidence for upper limb function, pain and QOL. Conclusion: A small number of studies have investigated the effect of hydrotherapy as an adjunct treatment in the breast cancer related lymphoedema population. Hydrotherapy could be considered as an adjunct treatment for women with breast cancer related lymphoedema, although the evidence base is mixed. Hydrotherapy may have positive physiological as well psychosocial impacts, as it is delivered in a group setting. However, the current literature base is limited by small sample size, lack of standardised exercise parameters, inadequate baseline characteristic assessment and limited long-term follow-up.
... In MLD, movements of the hand are used to stretch the skin in a specific direction and to promote variations in interstitial pressures, aiming to enhance the filling and emptying of lymph vessels and over all contributing to improve transport of fluid [10]. These movements are slow, repetitive and usually incorporate a brief resting phase, allowing the skin to return to its initial position [8]. ...
The aim of this study was to provide a systematic review on the applicability of manual lymphatic drainage (MLD) in improving edema and clinical presentation postmusculoskeletal injuries. A review of the literature was performed in CINAHL, MANTIS, Medline, SPORTDiscus and Google Scholar, yielding a total of 8 articles. Half of the studies showed a strong quality assessment. Results from our work support the use of MLD for reducing edema reduction and pain as well as enhancing range of motion and patients' quality of life and satisfaction. Further research is needed to apply these findings to a broader range of musculoskeletal injuries and conditions.
... MLD may be one of the reasons for this decrease because MLD has shown to reduce lymphatic stasis, increases protein resorption, and opens lymphatic collaterals. 16 Also, we know that MLD increases arm lymphatic flow. 17 Further publications are needed to understand which component of CDP is the cause of this decrease. ...
Full-text available
Objective: The aim of this study is to investigate the effect of complex decongestive physiotherapy (CDP) plus intermittent pneumatic compression (IPC) applications on upper extremity circumference and volume in patients with lipedema. Methods and Results: All participants included in the study were included in a treatment protocol consisting of CDP and IPC. The Perometer 400 NT was used in the measurement of upper extremity volume and circumference before and after treatment. The measurements were performed in four reference points. According to the Perometer results before and after CDP, statistically significant reduction was found in the circumference of 3 of the 4 points of measurements performed in each of the left and right upper extremities. When the volume assessments were compared, it was seen that statistically significant reduction was found in the volume of both limbs. Conclusion: A treatment program consisting of CDP and IPC can be effective in reducing the circumference and volume of the arm in patients with upper extremity lipedema. So, CDP applications can help prevent the development of complications such as lipolymphedema, hypertension, and heart failure. Clinical Trial Registration number: NCT04643392
... 14 Conventional methods of MLD aim at enhancing lymphatic drainage by shifting fluid toward adjacent functioning lymph node regions. 14,15 However, despite its long history, evidence to support the use of MLD is scarce. 13,15 Further, self-MLD has been reported to be the least effective therapy, 16 and patient compliance is generally poor. ...
Background: The Australian Lymphoedema Education, Research and Treatment Program (ALERT) at Macquarie University in Sydney, Australia is one of the flagship programs of Australia's first fully integrated academic health sciences centre, MQ Health. The aim of this study was to describe our findings of compensatory drainage demonstrated by indocyanine green (ICG) lymphography in cancer-related upper and lower limb lymphedema and how this may be translated into clinical practice. Methods and Results: Retrospective data from 339 patients aged between 18 and 90 years with secondary cancer-related unilateral or bilateral lymphedema of the upper or lower limb who underwent ICG lymphography assessment at the ALERT clinic between February 2017 and March 2020 were analyzed. In patients with upper limb lymphedema, the ipsilateral axilla was the most frequent drainage region (74.9%), followed by clavicular (41.8%) and parasternal (11.3%). For patients with mild upper limb lymphedema, 94.4% drained to the ipsilateral axilla. No patients drained to the ipsilateral inguinal region. For lower limb lymphedema, drainage to the ipsilateral inguinal was most common (52.3%), followed by contralateral inguinal (30.7%), popliteal (26.1%), and gluteal (21.6%) regions. Three main patterns of superficial lymphatic compensation were identified based on which anatomical structure carried lymph fluid. Manual lymphatic drainage (MLD) was used to facilitate movement of the dye. A light/effleurage technique was sufficient to move the dye through patent lymphatic vessels; a slow and firmer technique was required to move the dye through areas of bridging dermal backflow. Conclusion: The introduction of ICG lymphography to our program and its use in guiding personalized conservative management plans, including facilitative MLD techniques, has translated into clinical practice and changed research and educational priorities within the ALERT program.
... MLD reduces lymphatic stasis, increases protein resorption, and opens lymphatic collaterals. 19 In literature, there are studies that support and studies that oppose the use of this method in lipedema. There are publications saying that the use of MLD is not indicated in lipedema because there is no lymphatic disorder. ...
Background: The aim of this study is to investigate the effect of complex decongestive physiotherapy (CDP) plus intermittent pneumatic compression (IPC) applications on lower extremity limb circumference and volume in patients with lipedema. Methods and Results: In measurement of limb volume and circumference measurement, the Perometer 400 NT was used before and after treatment. The perometer measurements in this study were performed in the certain five reference points (cB, cC, cD, cE, and CF). All participants included in the study were included in a treatment protocol consisting of CDP and IPC. It was seen that statistically significant reduction was found in the circumference of 3 of the 5 points of measurements performed in the left limb, whereas statistically significant reduction was found in the circumference of 4 of the 5 points of measurements performed in the right limb. When the assessments of limb volume performed with the perometer were compared before and after CDP, it was seen that statistically significant reduction was found in the volume of both limbs. Conclusion: This reduction indicates that CDP is effective in the treatment of lower extremity lipedema. with an ID of NCT04492046.
Metastasis to distant organs is the most important factor related to cancer survival. Tumor cells spread via blood and lymphatic vessels, systems responsible for transporting fluid and cells. Besides its structural role in cancer metastasis, the lymphatic system displays a critical functional interaction with developing tumors. In clinical settings, full evaluation of the lymphatic system involvement is crucial for treatment and prognosis in cancer patients. Comprehension of physiological and pathological processes involving the lymphatic system is a continuously growing field of basic and clinical research due to recent advances in molecular Lymphology. However, the most interesting biological aspects of lymphatic metastasis of cancer are beyond our objective in this chapter. Here we will focus on the consequences of cancer spread and therapeutic approaches and their impact on the lymphatic system. The knowledge of basic function, structure and distribution of the lymphatic system is essential to diagnosis and treatment in Oncology. In this chapter we will highlight relevant aspects of lymphatic anatomy as well as current topics in conservative and surgical treatment of lymphedema.
In an experimental study on rats and sheep we demonstrated by means of light reflexion rheography and laser doppler fluxmetry that manual lymphatic drainage therapy causes vessel narrowing followed by increased blood flow in the arterioles, capillaries and venulae of the skin as well as in peripheral arteries and an increased lymph flow in lymphatic collectors. A clinical pilot study on patients with obliterative arterial diseases who underwent eight lymph drainage treatments over a four-week period under clinical conditions confirmed this observation.
Manual lymphatic drainage is used in physiotherapy of limb lymphedema in combination with other physical techniques. In order to assess the effectiveness of the method, 47 patients with upper limb lymphedema after radiosurgical therapy for breast cancer underwent lymphoscintigraphy. The examination was performed after subcutaneous injection of technicium-labeled colloid via the fourth and first interdigital space on the hand of the limb with lymphedema. The level of the technicium label was compared on scintigraphies performed before and after manual lymph drainage. Results were analyzed as a function of the clinical characteristics of the edema. Manual lymphatic drainage produced an effective progression of the label in 25 cases (53.2%), independent of radiotherapy. Contralateral lymph nodes were reached in 5 cases and the homolateral internal mammary nodes in 2. These nodes were visualized only after manual lymphatic drainage. The visualization of the drainage routes in unexpected areas demonstrated the effectiveness of the technique in stimulating accessory routes useful for resorption of lymphedema. The use of two injection sites on the hand is also discussed. This study demonstrated the effect on a single session of manual lymphatic drainage and should be completed with an assessment of a complete series of manual lymphatic drainages.
Hintergrund: Nach der Operation und Bestrahlung von Kopf-Hals-Tumoren kommt es in diesem Bereich häufig zur Ausbildung von sekundären Lymphödemen, die durch ihre exponierte Lokalisation die Lebensqualität der Patienten stark mindern. Als Therapie kommt die manuelle Lymphdrainage in Frage, deren Einsatz wegen theoretisch möglicher Tumorzellverschleppung aber kontrovers diskutiert wird. Patienten: In einer retrospektiven Studie wurden 191 Patienten, die wegen Kopf-Hals-Tumoren behandelt worden waren, anhand eines Fragebogens auf den Einsatz der manuellen Lymphdrainage und den Erfolg der Behandlung untersucht. In die Auswertung gingen die Rezidivrate, das Tumorstadium, die Histologie und die in sano/non in sano Resektion des Primärtumors ein. Ergebnisse: Von den 191 Patienten hatten 100 manuelle Lymphdrainage nach der onkologischen Therapie erhalten, 91 zählten zum Kontrollkollektiv. 37 Patienten hatten ein loko-regionäres Rezidiv, von denen 18 manuelle Lymphdrainage erhalten hatten. Die Inzidenz war bei Tumoren der Tumorstadien 3 und 4 in beiden Gruppen am höchsten. Besonders häufig rezidivierten Tumoren mäßiger und vor allem geringer Differenzierung, mit Lymphangiosis carcinomatosa und bei non in sano Resektion des Tumors. Dabei bestand zwischen der Therapie- und Kontrollgruppe kein signifikanter Unterschied, eine erhöhte Rezidivrate durch Anwendung der manuellen Lymphdrainage ergab sich nicht. Schlußfolgerung: Zurückhaltung beim Einsatz der manuellen Lymphdrainage ist bei einer Lymphangiosis carcinomatosa und der non in sano Resektion des Tumors zu empfehlen, da hier eine Verschleppung von Tumorzellen und eine Aktivierung des Tumors denkbar ist. Bei allen übrigen in sano operierten Kopf-Hals-Tumoren ist die manuelle Lymphdrainage eine für die Lebensqualität gewinnbringende Maßnahme und wichtiger Bestandteil in der Rehabilitation der Patienten. Summary Background: Secondary lymphedema of the head and neck can develop as a result of obstruction of lymphatic channels following the surgical removal of lymph nodes and fibrosis due to irradiation. This can be treated with manual lymphatic drainage. An increase of tumor recurrence due to this therapy is at controversial discussion. Patients: In a retrospective study 191 patients treated for head and neck cancer were questioned on occurrence of lymphedema and therapy with manual lymphatic drainage. Results: 100 patients had received lymphatic drainage, whereas 91 patients belonged to the group without lymphatic drainage therapy. In 37 cases a tumor recurrence or local metastases were reported, 18 of whom had received lymphatic drainage and 19 belonged to the control group. Among these 37 patients neither the group with lymphatic drainage nor the control group differed significantly concerning stage of cancer, histopathological grading, the in sano/non in sano resection of the primary tumor and a lymphangiosis carcinomatosa. An increased recurrence rate among patients who underwent a lymphatic drainage therapy could not be found. Conclusion: A lymphatic drainage therapy for patients presenting with lymphedema after the oncological therapy does not increase the rate of local recurrencies. Moreover it improves the quality of life after the cancer therapy. As only few data are available for cases with non in sano surgery and tumors with lymphangiosis carcinomatosa these cases should be excluded from a lymphatic drainage therapy. A spreading of occult tumor cells in these patients might be possible.
Selon son origine, un oedeme peut etre traite par medicament ou par diete. Dans certains cas, principalement en cas d'oedemes combines, un drainage lymphatique manuel peut etre efficace. Dans certaines formes d'oedemes, seul un drainage lymphatique d'apres Vodder, Asdonk et Kuhnke est indique puisque les medicaments n'ont pas d'effets sur le systeme lymphatique. Le drainage lymphatique manuel est une methode speciale de massage. Ce travail traite des lymphoedemes primaires ou secondaires de la sphere oro-faciale. Les lymphoedemes secondaires sont causes par un traitement chirurgical ou antitumoral, par une irradiation ou par une tumeur respectivement par une metastase. Le drainage lymphatique manuel est palliatif selon la maladie primaire.
(1) A plethysmographic method has been deviced which measures oedema of the muzzle and neck with high accuracy. (2) Acute lymphostatic oedema of the muzzle and neck was induced by ligation of the cervical lymph glands. (3) By the treatment with various vitamins and vitamin-like substances on the one hand and by massage on the other a statistically significant protection can be achieved against acute lymphostatic oedema.Copyright © 1971 S. Karger AG, Basel