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Joachim Zuther, Lymphedema Specialist. Read more
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The Role of Manual Lymphatic Drainage in Fibromyalgia


Fibromyalgia, also known as fibromyalgia syndrome, fibromyositis and fibrositis, is one of the most common chronic pain conditions, affecting millions of individuals in the United States and worldwide. While numbers on the prevalence of fibromyalgia in the literature vary considerably, the American College of Rheumatology (2008) estimates the number of individuals affected in the be 5 million1. The National Fibromyalgia Association (NFA) estimates the number to be 10 million in the U.S., and 3-6% of the world population2.

While fibromyalgia can occur in women and men of all ethnic groups and ages, the condition is more common in middle-aged women (80%) and those women who have a family member affected by fibromyalgia are more likely to develop the condition themselves (American College of Rheumatology, 2004).

These numbers clearly indicate that fibromyalgia is a common condition; it is a syndrome rather than a disease, which includes a number of signs, symptoms, and medical problems that tend to occur together but are not related to a specific, identifiable cause.

The most prevalent symptom is chronic widespread pain and tenderness (sensitivity to touch), in muscles, joints and soft tissue, fatigue and sleep disturbances.
These main symptoms of fibromyalgia are identical with those of many other conditions, explaining why fibromyalgia is difficult to diagnose. Physicians often have to rule out other potential causes of these symptoms before making the diagnosis of fibromyalgia. The absence of diagnostic laboratory tests and no generally accepted, objective test for fibromyalgia present additional stepping stones in making the correct diagnosis.
Some physicians unfortunately may not be able to proper diagnose this condition and tell the patient there is little that can be done.

Specific causes for fibromyalgia are unknown, but it is thought that a number of factors may be involved that could trigger fibromyalgia, which may include

  • Physical or emotional trauma
  • Abnormal pain response, i.e. problems with how the central nervous system (brain and spinal cord) processes pain – areas in the brain that are responsible for pain may react differently in fibromyalgia patients
  • Infection, such as a virus – however, none has yet been identified

Diagnosis of Fibromyalgia

Physicians have to rely on the patient’s self-reported symptoms, the history and a physical examination, which includes checking of specific manual tender points.
This examination is based on criteria set by the American College of Rheumatology (ACR) for the diagnosis and classification of fibromyalgia3.

To receive a diagnosis of fibromyalgia, the patient must meet the following diagnostic criteria:

  • Widespread pain in all four quadrants of the body for a minimum duration of three months. The four quadrants include both sides of the body, above and below the waist line
  • Tenderness or pain in at least 11 of the 18 specified tender points when pressure is applied (see illustration)

    Fibromyalgia tender points


Individuals affected by fibromyalgia may feel pain at other sites as well, however, those 18 standard possible sites on the body are the criteria used for classification.


Due to the difficult nature of fibromyalgia, treatment requires a team approach including the patient, physicians familiar with the condition (rheumatologists, internists), physical-, massage- and occupational therapists, and other health care professionals.
The main goal is the relief of pain and other symptoms associated with fibromyalgia and helping the affected individual to cope with the condition.
Treatment may include physical therapy, stress-relief methods, including light massage and manual lymph drainage, and medication for pain and sleep management.
More information on these various treatment approaches is available on various online resources4, 5.

Manual Lymph Drainage

Several studies on the effectiveness of manual lymph drainage (MLD) in the treatment of fibromyalgia indicate that MLD yields positive results in terms of pain relief, stiffness, sleep and general health status6, 7, 8.

The result of a randomized controlled trial comparing manual lymph drainage with connective tissue massage in the treatment of women affected by fibromyalgia suggests MLD to be more effective in the treatment of fibromyalgia than massage6.

The Difference between MLD and Massage

As readers of this blog know, massage and manual lymph drainage are two very different manual treatment modalities. It is unfortunate that the term massage is often wrongly used to describe MLD. The origin of the word massage is derived from the Greek massain (to knead) and is used to describe such techniques as effleurage, petrissage, vibration, etc.
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 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.

More information on MLD is available here:

The Science Behind Manual Lymph Drainage
The Role of Manual Lymph Drainage in the Treatment of Lymphedema 


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  6. Comparison of manual lymph drainage therapy and connective tissue massage in women with fibromyalgia: a randomized controlled trial:
  7. Manual lymph drainage therapy using light massage for fibromyalgia sufferers: a pilot study:
  8. Systematic Review of Efficacy for Manual Lymphatic Drainage Techniques in Sports Medicine and Rehabilitation: An Evidence-Based Practice Approach:




14 comments to The Role of Manual Lymphatic Drainage in Fibromyalgia

  • Neva Rogers

    Thanks. I do have lymphedema in both my legs from the knees down. I was first diagnosed in 1998. Prior to that my legs were very painful to the touch. I never thought about fibromyalgia until I received your email. I never had a clue why my legs were so very sensitive to the touch.
    I was told by a lymphedema doctor that I may have a combination of lipodema and lymphedema. Since both are treated the same, it isn’t that important to know that.

  • molly morris

    After reading your article, and also after years of treating patients with all kinds of conditions, I imagine that MLD is an underutilized treatment modality. Does anyone do post op MLD with orthopedic, abdominal, back surgeries. I’ve also noticed that people who have fat tissue in abdomen benefit greatly and with some it seemed to trigger weight loss and a new direction for their body.

    As a Lymphedema Therapist, I would like to find more research based studies on these. Can you direct me to any sites that are valuable?

    thanks for all that you do!

  • Pat

    Again a very very big thanks for this important article. There are quite a few lymphers who also have fibro. It is an interesting connection. Fibro is considered an autoimmune condition and lymphedema seriously effect the cell mediated immune system of our bodies. It would be perhaps enlightening to see if there is a possible connection/interaction between the two. Thanks again!

  • Connie

    Thank you Jo, This article hit close to home for me. I have been practicing Lymphedema therapy for only 5years, and I have never thought of the treatment being very possibly helpful to my sister suffering with Fibro and Chronic fatique syndrom for several years now. I’m sure is very sensitive in these common trigger areas as she has tried some theraputic massage but it has to be very light or it just makes the pain much worse. My question would be: wouldnt you start the MLD in the more proximal painful areas of the neck and back like we do our lymphedema patients before working on a very painful area in the elbow or hip area? Or is the pain from the fibromalgia pain siginals very localized? Thank for your reply. Connie

    • Joachim Zuther

      Dear Connie: In this case it is not necessary to apply techniques on the neck. MLD in the treatment for fibromyalgia is geared toward pain management (gate-control theory)

  • Emmie Gorrell

    Hi and thanks for the interesting article. I have had FMS and CFIDS/ME for going on 15 years now. My dr. and I have talked about possible causes, and she’s talked with me about the probability that my cells are much more sensitive than the norm. I have to be put under general anesthesia in order to have a routine colonoscopy done.

    Also,I have read that the 11 out of 18 points being used for diagnosis assistance are now pretty obsolete, as people with FMS can have lots of pain in all sorts of places on their body. Have you heard anything about that?

    I was a public school Special Education teacher for 25 years before these two syndromes knocked me slap out and I was having such a terrible time even trying to get out of bed to get ready for work.I also earned a Massage Therapy credential while I was still able to be very active and energetic, butI can’t stand the thought of any massage therapist working on my lymphatic system, partly, because of the pain of being touched, and also, because of the after-effects of the therapy, in that it makes one feel much worse at first, while the toxins are clearing out and I am at a point that I don’t think I could stand any more pain.

    One rheumatologist thought that I might have Chronic Pain Syndrome, as the pain is everywhere. I do feel that retroviruses are going to eventually be found to be part of the FMS picture. When I have had to take an antibiotic, it seems to help my entire system feel a bit better for the time that I am taking the antibiotic. I also feel that there’s a good chance that govt. testing, using chemical/biological warfare, may come to light, as a cause, as especially with CFIDS/ME, it so often has occurred in clusters.

    Thank you so much for the information. Whenever I have tried to take Physical Therapy, it only made me feel worse and basically put me to bed for a week or so. But I do know that we are all different! Getting pain medication here in South Carolina has been made much more difficult, by the illegal use by drug abusers. So now, I have to go in once a month to my dr., in order for her to be allowed to write the prescriptions for my pain medications. They don’t take away the pain, but they do take the “edge” off, so that I can at least stand to be alive. This is a “new” regulation that, when I asked her why the change, she answered, “Politics.”

    What you say about the different names is interesting, as well. When my mother, now deceased, was a young adult, the dr. told her that she had Fibrocitis. She had a lot of pain, but it was thought to be pain from Osteo-Arthritis. She never had the debilitating fatigue or “fibro fog”, and throughout the years, she was diagnosed with such things as Carpal Tunnel Syndrome, which gave her terrible pain in her forearms, as she got older. I know that Fibromyalgia is a syndrome, but I’ve found that if I only refer to it as a syndrome, then folks don’t see it as anything to take seriously, like the response I’ve seen when I call it a disease.

    Take care and thanks again! Emmie Gorrell

  • Great article!

    I like that you have explained the difference between massage and manual lymph drainage.

  • I love the lymph drainage massage because of the impact for my body.

  • Linda

    currently working with some clients with fibro and would like to suggest MLD as a possible aide. how many sessions does it normally take for the client to experience positive results

  • Isabel Mangan

    I would appreciate if you could send me references of places where I can get MLD treatment in the Washington DC metropolitan area (Virginia Maryland) as I have all the symptoms described as fibromyalgia and have been in terrible pain for many years. Doctors never found an explanation.Have done physical therapy and acupuncture without any results.
    Thank you very much.

    • Joachim Zuther

      Please click on the “find a therapist” button on the top of the menu bar in order to locate a therapist in your area.

  • dave riley

    I’ve had FMS for 30 years and recently developed swollen legs over Summer (here in Australia) so I went for some Lymphatic Drainage from a masseur.
    It didn’t seem to do much so I explored my options and started manual dry skin brushing daily in order to alleviate the swelling. My edema was also in my arms and face so I brushed all over.
    I loved it. Great invigorating sensations for the 10-15 minutes.I was addicted.It enlived my day.
    Now I’m trying to recover from the meanest relapse I’ve had for some time. I feel like I’ve been poisoned.
    I am active. Do exercise. Sit and stand many times per day. I had been previously trained and worked as a massage therapist and have a medical background in nursing…but I do suspect that I bought on this state myself.
    But I can’t believe it: surely I wasn’t so full of gunk that I opened up the sewer gates to such an extent I polluted my being big time?
    If so…maybe I need to reduce the frequency of my sessions.I’ve stopped for now but then I’m waiting to recover my strength.
    My trigger is usually changes in the weather — the rate of change — so I’m rather barometric in mode. So maybe shifting fluid about as I did replicated that stimulus?
    After 30 years I get to know what the body throws at me, but this was –and for now, still is — a real mean relapse…