The Author

Joachim Zuther, Lymphedema Specialist. Read more
Solaris
MediUSA

Tactile Ad

The Science behind Manual Lymph Drainage in the Treatment of Lymphedema

 

Manual lymph drainage (MLD) is a gentle manual treatment technique based on four basic strokes, which were initially developed in the 1930’s by Dr. Emil Vodder, a PhD from Denmark. These basic strokes known as the “stationary circle”, “pump”, rotary” and “scoop” techniques are designed to manipulate lymph nodes and lymphatic vessels with the goal of increasing their activity and promote the flow of lymph.

Movement of Lymph Fluid in Lymph Vessels

The common denominator of all strokes is the resting and working phase. In the working phase of the stroke lymphatic structures located in subcutaneous tissues are stretched, resulting in an increase of their activity (lymphangiomotoricity). In addition to increased lymphatic activity, the light directional pressure in the working phase of the strokes causes lymphatic fluid to move in the desired direction, thus contributing to the reduction of the swelling.

Certain MLD strokes are designed to manipulate lymph vessels located in the subcutaneous tissues of larger body surfaces, such as the trunk, other techniques are better suited to be applied on contoured surfaces, such as the extremities.

Stationary circle: This technique consists of an oval-shaped stretching of the skin with the palmar surfaces of the fingers or the entire hand. Stationary circles can be applied with one hand, or bimanually and are used on the entire surface of the body, but mainly on lymph node groups (axilla and groin), the neck and the face.

Pump technique: The entire palm and the proximal (upper) phalanges are used to apply a circle-shaped pressure on the skin, operating within almost the full range of motion in the wrist. Pumps are primarily used to manipulate lymph vessels located in the extremities and can be applied with one hand or bimanually.

Rotary technique: This stroke is used on large body surface areas, such as the trunk. The entire surface of the hand and fingers are used in an elliptical movement during the working phase. Like the scoop technique, rotaries are applied dynamically, meaning the working hand moves over the surface of the treated body part in a continuous fashion. If applied bimanually, the techniques are alternating.

Scoop technique: Scoops are applied mainly on the lower parts of extremities and consist of a spiral-shaped movement. During the working phase, which can be applied with one or both hands, the palmar surface of the hand moves dynamically over the skin. The hand movement is facilitated by transitional movement in the wrist, combined with forearm pronation and supination.

Lymph Vessels in the Skin

Compared to traditional massage, the pressure applied with manual lymph drainage is much lower in intensity. The goal of these techniques is to manipulate the lymphatic structures located in the subcutaneous tissues. In order to achieve the desired effect, the pressure in the working phase should be sufficient enough to stretch the subcutaneous tissues against the fascia (a structure separating the skin from the muscle layer) located underneath, but not to manipulate the underlying muscle tissue. The amount of pressure needed in MLD is sometimes described as the pressure applied stroking a newborn’s head.

In the resting phase of the stroke the pressure is released, which supports the absorption of lymph fluid into lymph vessels. To achieve the maximum effect with each technique, the working phase with every stroke should last about one second and should be repeated five to seven times.

The overall goal of MLD in the treatment of lymphedema is to re-route the flow of stagnated lymphatic fluid around blocked areas into more centrally located healthy lymphatic vessels, which eventually drain into the venous system.

In the case of upper extremity lymphedema caused by breast cancer surgery, it is necessary to re-route the flow of stagnated lymph in the subcutaneous tissues of the arm around the blocked axillary area towards and into the axillary lymph nodes on the opposite side and the inguinal lymph nodes on the same side the surgery was performed. These groups of lymph nodes represent the drainage areas for the stagnant lymph fluid located in the affected upper extremity and need to be manipulated prior to initiating the treatment of the arm itself.

 

In the case of lower extremity lymphedema the stagnated lymphatic fluid is generally re-routed around the blocked inguinal (groin) area towards and into the inguinal lymph nodes of the opposite side and the axillary lymph nodes on the same side of blockage. As with lymphedema affecting the upper extremity, these groups of lymph nodes represent the drainage area for the stagnated lymph fluid and need to be manipulated prior to starting treatment of the leg.

The manipulation of these drainage areas with MLD strokes creates a “suction effect” in the healthy lymph vessels located in the drainage areas, which enables accumulated lymph fluid to move from a region with insufficient lymphatic drainage into an area with normal lymphatic drainage, and eventually back into the venous system.

Following this preparation, the extremity itself is treated in segments; the proximal (upper) aspect of the affected extremity is decongested prior to expanding the treatment to the more distal (lower) aspect of the arm or leg. This segmented approach ensures that lymph vessels located in more proximal areas of the extremity are properly prepared to handle incoming lymphatic fluid from areas located more distally.

In order to prevent reaccumulation of the fluid evacuated from the extremity, it is necessary that the MLD treatment is followed up with compression, which depending on the stage of treatment, is applied either with specialized padded bandages or compression garments.

Manual lymph drainage presents a unique opportunity for health care professionals to specialize and opens the door to treat and manipulate a variety of conditions associated with dysfunctions of the lymphatic system. However, the unique techniques of manual lymph drainage deviate considerably from traditional manual techniques and therefore require specialized training.

Join Lymphedema Guru, a Facebook page solely dedicated to inform about all things related to lymphedema – news, support groups, treatment centers, and much more

48 comments to The Science behind Manual Lymph Drainage in the Treatment of Lymphedema

  • Debbie McKay

    I am looking for a Lymphedema Center in the Hollywood/Fort Lauderdale, Florida area. I Have lower extremety lymphedema. Can anybody help me?

    • Joachim Zuther

      Dear Debby: You can use the therapist finder on top of this website to locate a therapist in your area. Here is the name of a clinic in the area I am familiar with:
      Healing Hands of Lymphatics in Hallandale Beach – their email is info@lymphatictouch.com
      There is also a clinic in Boca Raton, called Lymphatix, their email is bocalymphatx@yahoo.com

      Hope this helped.

  • C C

    Thank you for this information. As a person with Lymphedema in my
    leg below the knee and extending down to my foot and involving my ankle, it would be even more helpful to watch an actual demonstration video of this massage technique.

  • Aira

    And wat do you say in the case of secondary upper extremity lymphedema caused by breastcancer surgery but when the cancer and lymphadenectomy ist in both sides?

    I wish to know also your opinion about the use of compresssion pumps in breast cancer related lymphedema?
    Is it a good or bad therapy? And if the surgery was in both sides?
    Maybe another article about “pressotherapy”??

    • Joachim Zuther

      Dear Aira: In this case, the stagnated lymphatic fluid is generally moved towards the lymph nodes in your groin (inguinal lymph nodes); however, the treatment protocol may differ from case to case, a trained therapist will determine the correct approach.
      Advanced and newer compression pumps consist of multi-chambered inflatable sleeves that include trunk garments containing inflatable chambers designed to prepare drainage areas on the trunk prior to moving fluid from the extremities.

      Pneumatic compression used to treat extremity lymphedema without treatment of adjacent body quadrants and drainage areas using complete decongestive therapy bears a significant risk of moving lymphedemateous fluid from distal to proximal, where it accumulates. This may cause protein molecules to accumulate in this area, forming a fibrosclerotic ring, truncal quadrants previously not swollen to fill with fluid.
      Recent studies suggest that multi-chambered sequential compression devices that include trunk and extremity garments and deliver the pressurized air in individual patient-oriented patterns may be beneficial as an adjunct treatment to effectively control lymphedema in the self-administered maintenance phase (Phase II of CDT), especially in those cases when physical limitations of the patient may result in challenges controlling the lymphedema independently with self-MLD.

  • Carol

    Thank you for this detailed, crystal clear explanation. I do have a related question: I had breast reconstruction after bilateral mastectomy, using the d.i.e.p. autologous flap method–meaning that fat and blood vessels were taken from the lower abdomen and repurposed to form the replacement breasts. I have a continuous scar below the belly button, running about 60%-70% around the body. And I have lymphedema, which presents at the upper arm and in the trunk under the axilla. To compound matters, I find that fluid pools just above the scar as the day progresses (recedes during sleep).

    All of this detail leads to the question: For MLD to successfully nudge lymph toward the inquinals, the lymph would have to travel under, through, or over that scar, because ‘around’ is not possible due to its length. Is there hope that with patience and some kind of scar massage, the superficial lymphatic vessels can eventually cross that barrier? My lymphedema therapist has suggested moving the lymph around the back and toward nodes located near the pierformis muscle in the hip–I think I would have to be a circus contortionist to make this work!

    Many women are getting diep reconstructions, and the loss of a pathway to the inguinal nodes seems to invite midriff swelling, which is a common complaint after reconstruction. For those of us with lymphedema, it also results in blocking access to one of the destinations for redirecting upper-quadrant lymph. Lots of us will look forward to your comment, so many thanks in advance if you can take time to answer.

    • Joachim Zuther

      Dear Carol: The answer to your question is yes; lymph vessels are able to reconnect through scar tissue, depending on the width and tissue quality of the scar. Lymph fluid can also be re-routed around scars using the superficial lymph vessel plexus.

  • Cheri

    Thank you, I enjoy all of your information. The last paragraph especially. I am a certified lymphedema therapist interested in the application of MLD for various other conditions. What would be your recommendations for further education, training, information, anything and everything pertaining to the benefits of MLD? I am absolutely fascinated with the lymphatic system and the future possibilities of MLD. Thank you much and I look forward to hearing from you. Cheri

  • Jean Repose

    I find it hard to self massage. I always tend to want to press harder than I should.

  • Jean Repose

    I have very slight lymphedema on my right arm just below the elbow only. I wrap my arm every night but as soon as I am up for the day gravity pulls the fluid down the arm again so I keep a compression sleeve on all day. Do you have any other tips for daytime that would help. Like I said mine is very minimal hardly noticable. Others don’t really see it till I bring it up.

  • Celia

    Wondering what are your views regarding treating a breast cancer patient with active cancer. Cancer has metastised in bone. Affected arm is 17% bigger than normal arm. Lower arm mostly affected. Patient’ current Tamoxifen + Zomelda ongoing.

    • Joachim Zuther

      CDT can be performed in patients with active malignancies as long as a doctors order is present. Withthese patients it is even more important to ensure that treatment does not cause any pain or discomfort, so adjustments to modalities may be necessary

  • Teresa Ret

    Thank you for this wonderful explanation of MLD. I have been certified through AOLS, and I love what I can do for people with lymphedema. If a person has skin grafts, how will this affect the lymph system? If the grafting completely covers the around the wrist area, is it possible for vessels to reconnect?

  • Lisa

    In reference to treating pt’s with active cancer w/mets–How high of a risk is there in causing more metastsis with the use of MLD? and do you have any research articles to use as a reference

  • Sandra

    Joachim- I’m 38 with primary lymphedema, bilateral lower extremity, asymptomatic in my right leg, diagnosed through lymphocintogram at 35, after14 years of no diagnosis (frustrating) symptoms appeared suddenly at age 21 after a new years eve wearing tight shoes. I visited a lymphatic care center, the course of treatment and subsequent wrapping required of both legs up to my goin totally terrified me. Other than elevating my leg at night, I have done no treatment, head in the sand syndrome, I feel intimidated my this condition and long term prospects. Do you have advice for how a person like me should handle this condition, when it’s not debilitating, but definitely impacts my life, my mobility and my self esteem in enormous ways?

    • Joachim Zuther

      Dear Sandra: While you are correct thatthe treatment of lymphedema using Complete Decongestive Therapy would involve the application of short-stretch bandages to the legs, this would be only a temporary situation. Bandages are applied until the limb is decongested to a normal or near normal size, at which point you would be measured for compression garments. Garments are much less bulky and are very effective to maintain the results achived during the therapy phase. Without the use of any form of compression, there is a good chance that tyhe swelling will ncrease over time. While elevation is certaionly helpful, deep breathing (abdominal breathing) exercises would be very beneficial as well. However, ultimately the best option would be to seek the services of a trained lymphedema therapist.

  • Jacqueline Smith

    I had an appendectomy at age 17, forty years ago and developed lymphedema as a result of that surgery. At that time I was told NOTHING could be done and in Texas where I live, there was no known methods of treatment. I found about a lymphedema clinic 3years ago(37 years later) and began treatment. I think I had one of the worse case senerio of lymphedema possible, with huge thighs, legs ankles and feet.

    After therapy, bandaging and pumping, mt legs are much better, but my trouble area are the thighs. It is extremely hard to keep bandaged and I have not been able to find compression wear that fit or require 2 or 3 people to help with putting them on. I am dealing with this condition and I try to do all I can and know how to do.

    Any help, advice or suggestions would be greatly appreciated.

    • Joachim Zuther

      Dear Jacqueline: It often helps to place a nylon pantyhose or spandex shorts over the completed bandage in order to keep the bandages in place on the thigh. You may also want to look into alternative bandage options, such as Solaris or CircAid products

  • Glenda

    Please advised where in Dothan, AL I would find a person that accepts Medicare payment for services rendered. I really have a swollen RIGHT ARM caused from sugery and rad. treatments after lump removed 4/17/2003.(need lump. drain treatments soon)

    • Joachim Zuther

      Dear Glenda: Please click on the “Find a Therapist” button on the top of this page. This will open up search options for therapists in your rea.

  • Thanks for sharing,looking at the picture i see myself(bc survivor from 2009 end up with lymphedema in right arm after treatment.I want to ask why does my arm got a burning sensation when wrapping,when taking the bandages of hand feels dead wrapping not tight at all.Like your lymphatic drainage example on the picture,where the arrow show down alot of pain there that goes into the hip and to the back.I thought its some artritis can the pain be from the lymphnode.

  • Natalie Miller

    I have had a couple of sessions of MLD, but both of them made me feel very unwell fro 36 hours after the session. I felt dizzy and so unwell that I felt as if I was having chemotherapy again for my grade 3 stage 1 triple negative breast cancer. Lymphoedema occurred after my mastetomy, but prior to chemotherpay and radiotherapy. My lymphoedema nurse has refused to continue treating me until my doctor says I can continue. (The doctor I went to see for permission didn’t even know what MLD was!) I am desperate to restart the MLD as after the 36 hours I felt absolutely fantastic – the fatigue I have had for 4 years since treatment disappeared and I have started to feel normal again. Do you know why MLD made me feel so unwell afterwards and is it a common thing that cancer fatigue can be done away with by dealing with lymphoedema in this way.

    Many thanks
    Natalie

  • [...] for yourself if you are facing the challenges of dealing with disease, or the prevention of it. Rebounder Exercises Stimulate the Lymphatic System Kids love to jump up and down all the time; it se… jumping and sit around not realizing the affect all this sitting around has on the lymphatic [...]

  • [...] specialist Joachim Zuther in his article The Science behind Manual Lymph Drainage in the Treatment of Lymphedema says: Compared to traditional massage, the pressure applied with manual lymph drainage is much [...]

  • Ralph

    Question if the lower extremity massage is not done proper can the fluids get stuck in the heart or around your heart?

  • I had lymphoma of the breast 6 years ago and quadruple bypass heart surgery 6 months ago in April.
    Would MLD be benificial for me?

  • Ann

    Where does one go to purchase leg garments if money is an issue. Cannot afford to spend hundreds of dollars.

  • […] specialist Joachim Zuther in his article The Science behind Manual Lymph Drainage in the Treatment of Lymphedema […]

  • Anne

    has anyone had trouble being out of work because of this? I have it in my lower leg and drive a long distance to work everyday. By the time I get to work my leg is swollen again and twice now have gotten cellulitis.

  • Desira

    Its very disheartening to be told that unless you are a nurse, you can not go anywhere to learn the massage needed. I have spent years watching what was once my life, draining away:( My husband feels so helpless.We do not have insurance and spent over 10k on professional therapy which never led to my being able to wear compression stockings. We want to learn PROPER massage.This is a “LIFER”. Why cant we be taught and certified for the massage? I just dont get it. I have machine here that now I am afraid to use. I now have the belly apron.Its disgusting and painful. I have huge lumps on my thighs. All from IMproper massage of the toxins. Its truly a living hell. :( I cant be the only one who feels this way. How can we go about CHANGING it?

  • Brigette

    I’m impressed, I have to admit. Rarely do I encounter a blog that’s both
    educative and engaging, and without a doubt, you’ve hit
    the nail on the head. The problem is something which too few people are speaking
    intelligently about. I’m very happy I came across this in
    my hunt for something concerning this.

  • Justholistic

    Hello,

    I have recently qualified with the Dr Vodder school & went on to do T2 & T3… I work mainly with women after mastectomy & resulting arm lymphedema … Apart from that I treat women in a slimming clinic & offer detox etc

    I have had a request from a fybromyalgia suffer wanting me to treat her…. Would you be able to advise me regarding a treatment plan ? She has had MLD for this condition in the past but it was not successful ….I know that it can be very successful in treating her condition & I don’t want to let her down ..

    Any advice or references would be appreciated
    Many thanks

  • Shelia

    I have lymph edema in my right leg and I have been bandaging and my leg has gone down dramatically. I have started getting swelling in my stomach on the right side and my right but cheek. I have been trying to do MID on it, but nothing is happening. Is there something some where to help in this area or do you have any suggestions.

  • George Locker

    I have lymphedema in my left leg from a cancerous lymph node 20 plus years ago in my groin….All said and done it has been kinda OK up until about 4 years ago…I had a hernia in the same area and all about the same time I fell and have nerve damage on my left side and that is the affected area. My question is and of course the surgeon says no , but could the hernia surgery and mesh screen disrupted the natural migrating flow the area had acquired on it’s on? Is there anything that could help it now? Has anyone ever heard of anything like this. I have plenty of problems now…Thanks

    • Joachim Zuther

      Dear Mr. Locker: While it is possible that the hernia surgery caused the worsening of your symptoms, it is unlikely. The most important issue is to consult with a trained lymphedema therapist to reduce the swelling and make sure it does not get worse. Please use the link “Find a Therapist” on the menu bar on top of this page. This link will assist you in locating a trained lymphedema therapist in your area.

  • kamal absili

    thank you Joe for this easy to read and easy to understand article.
    the general public and L/O consumers will be able to comprehend and identify with the content.
    kamal

Leave a Reply

 

 

 

You can use these HTML tags

<a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>