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CLINICAL FOCUS
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.
History
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: A.Williams@napier.ac.uk
ABSTRACT
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
KEY WORDS
w Manual lymph drainage (MLD) w Lymphoedema w Evidence for
MLD w Therapeutic effect of MLD
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Chronic Oedema, April 2010 S19
CLINICAL FOCUS
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
lymphoedema
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 (
Figure
1, 2
). It includes oedema movements at areas of
fibrosis
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
stroke’
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
position
• 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
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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,
1985)
• ‘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
method
Figure 2: Thumb circles to the dorsum of the hand: Vodder
method
Chronic Oedema, April 2010 S21
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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
compression
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
lymphoedema
. • 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
cancer-related
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
study
. • 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
lymphoedema
. 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
(EORTC QLQ C30)
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
CLINICAL FOCUS
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
‘failures’.
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
occur.
summary
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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Figure 6: MLD to the head and neck region: Leduc method
(Coutesy of Leduc UK)
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Chronic Oedema, April 2010 S23
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CLINICAL FOCUS
S24 Chronic Oedema, April 2010
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General MLD information, training and therapist details:
http://www.mlduk.org.uk/
Casley-Smith method:
http://www.macmillan-lymphoedema-academy.org.uk/index.html
Leduc method: http://www.lymph.org.uk/
Vodder method:
http://www.vodder-school.co.uk/teachers/
USA-based school for Földi method:
http://www.klosetraining.com/
Further information
Börcsök E, Földi K, Wittlinger G, Földi M (1971) Zur therapeutischen
Beeinflussung des akuten experimentellen lymphostatischen Ödems mit
Vitaminen, vitaminartigen Naturstoffen sowie mittels Massage. Angiologica
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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
base
w Different schools of MLD have been established, but the underlying
principles of the MLD techniques remain similar across the various
methods
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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