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Joachim Zuther, Lymphedema Specialist. Read more
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Self Manual Lymph Drainage for Lymphedema Affecting the Arm

 

Complete decongestive therapy (CDT) is performed in two phases; in the first phase, also known as the intensive or decongestive phase, treatments are administered by trained lymphedema therapists on a daily basis until the affected body part is decongested.

The duration of the intensive phase varies with the severity of the condition and averages two-three weeks for patients with lymphedema affecting the arm. However, in extreme cases the decongestive phase may last longer and may have to be repeated several times.

The end of the first phase of CDT is determined by the results of measurements taken by the therapist on the affected body part. Once measurements approach a plateau, the end of phase one is reached and the patient progresses seamlessly into phase two of CDT, which is also known as the self-management phase.
Phase two is an ongoing and individualized part of CDT, in which the patient assumes responsibility for maintaining and improving the treatment results achieved in the intensive phase (phase one).
During the intensive phase patients are instructed by the therapist in the individual components of self-management, which include self-manual lymph drainage (self MLD, or simple MLD), a skin care regimen, home exercises, and the application of compression garments (and bandages).

The self-manual lymph drainage techniques are relatively easy to perform and therapists generally teach one or two MLD strokes that can be learned and safely performed by the patient. It may help if the patient’s spouse, a relative or a friend is present during the therapist’s demonstration of these strokes to observe, take notes, or record the techniques with a camera.
The strokes are based on the same principles as those performed by the therapist, and it is very important that the patient clearly understands the hand movements, specifically the principles of skin elasticity, the pressures used during the working and resting phases of the strokes, and in which direction the pressure should be applied.

To help understand the techniques of MLD it is advisable to read the following articles published on this blog:

1. Manual lymph drainage and its role in the treatment of lymphedema

2. The Science behind Manual Lymph Drainage in the Treatment of Lymphedema

3. The Role of Complete Decongestive Therapy in Breast Cancer Related Lymphedema

4. Skin and Nail Care in Lymphedema Management

The following techniques can be used for lymphedema affecting one arm; the illustrations and techniques describe the sequence used for lymphedema affecting the left arm. In this case the lymph nodes located in the opposite axilla (right armpit, underarm) and those in the groin of the same side (left) are unaffected and working properly.
This sequence should not be used in lymphedema affecting both arms, or if the axillary lymph nodes on the unaffected, or the inguinal (groin) lymph nodes on the affected side are removed, or non-functioning due to other reasons.

The techniques described are performed in the sitting position; ideally, self MLD should be applied at least once daily for 10-15 minutes, directly preceding the exercise program, and should be followed by appropriate skin care and compression therapy.
Each stroke should be repeated 5-7 times, and, if not noted otherwise, the hand of the unaffected side (in this case the right hand) should be used to perform the strokes.

The techniques and sequences below represent standard examples and may vary from those demonstrated by the therapist. Therapists may have different preferences, or the techniques may have to be adjusted to accommodate specific requirements or physical limitations of the individual patient.

Neck

  1. Stationary circles with flat fingers above the collarbone on both sides. The fingers of the right hand manipulate the skin above the collarbone on the left and the fingers of the left hand manipulate the skin above the collarbone on the right. The pressure is applied with the flat phalanges of the fingers (generally the index, middle and ring fingers) and the pressure is directed toward the neck. This technique can be applied simultaneously on both sides or on each side individually.

    Step 1

  2. Stationary circles with the flat hand in the center of the opposite axilla (armpit, underarm). The pressure is directed downward (deep) into the axilla and applied with the flat fingers and palm of the affected arm.

    Step 2

  3. Soft effleurage over the skin from the affected axilla to the axilla of the opposite side.

    Step 3

  4. Stationary circles with the flat hand in several placements from the axilla on the affected side to the axilla on the opposite side. The pressure is directed toward the axilla on the opposite side.

    Step 4

  5. Stationary circles with the flat hand (use hand of affected side) in the area of the groin lymph nodes (inguinal lymph nodes) on the same side. The hand is placed just below the inguinal ligament (in the green area depicted on the illustration on the very bottom of the page) and the pressure is directed toward the belly.

    Step 5

  6. Stationary circles with the flat hand in several placements from the axilla on the affected side to the inguinal lymph nodes on the same side covering the entire surface of the lateral trunk (flank). The pressure is directed toward the inguinal lymph nodes (same side).Step 6

Affected Arm

  1. Soft effleurage over the skin of the arm from the hand to the top of the shoulder.
  2. Stationary circles with the flat hand and fingers in several placements on the upper portion of the lateral upper arm, from the shoulder muscle (deltoid muscle area) of the affected arm to the top of the shoulder. The pressure is directed toward the neck.

    Step 8

  3. Stationary circles with the flat hand and fingers in several placements from the medial (inside) portion to the lateral (outside) portion of the upper arm. With the pressure directed toward the lateral aspect of the arm, the entire upper arm from the top (just below the axilla) down to the elbow should be covered.

    Step 9

  4. Stationary circles with the flat hand and fingers in several placements on the lateral upper arm. The entire lateral surface of the upper arm, from the elbow to the shoulder should be covered, with the pressure directed toward the shoulder muscle.

    Step 10

  5. Stationary circles with the flat hand and fingers in several placements covering the entire frontal (anterior) aspect of the lower arm, from the elbow crease to the hand. In order to reach all aspects of the forearm, the arm should be held in supination with the palm of the hand pointing to the front. The pressure is directed toward the upper arm.

    Step 11

  6. Repeat step number 10.
  7. Stationary circles with the flat hand and fingers in several placements on the posterior aspect of the lower arm, from the elbow to the back of the hand. In order to reach all aspects of the forearm, the arm should be held in pronation with the palm of the hand resting on the thigh. The pressure is directed toward the upper arm.

    Step 13

  8. Repeat steps 1, 2, and 5. Other steps may be repeated as well.

    Inguinal Ligament Step 5

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14 comments to Self Manual Lymph Drainage for Lymphedema Affecting the Arm

  • Andrea

    I am looking for a therapist in the Stroudsburg , Pa area.

  • Marie Williams

    Thank you so much for this article. I have become “lax” in my manual lymph drainage at home and this will help remotiveate me.

    Do you have any diagrams or pictures on the types of exercises I can do? The ones that I have are hand drawn and starting to wear out.

    • Joachim Zuther

      Marie – there are articles on exercises on this blog; just select “Exercises for Lymphedema” in the category box on the right of the page.

  • barbara stone

    Thank you for sharing this info, photos are worth a million words and will be so helpful with teaching new patients bes pt clt

  • Liz

    Dr. Zuther, I have lower body (hip to toe) secondary LE of my right leg. LE and Lipedema in my buttocks and thigh. My LE started as a result of a puncture wound and infection, and came out as I was flying around the country on assignment. It’s gotten progressively worse over the years, and 2 hospitalizations for Cellulitis infections, never with an observable entry point.

    I’ve been through probably 12 courses of MLD/CDT over the 20 years I’ve had this condition, and the results have been highly mixed. The initial treatment brought me the most reduction. And over the years, with each successive MLD/CDT, I find the results to be minimal. I wear 2 stockings each day. One knee high, level 1, and a thigh high, level two. I wear one over the other. And I am still very swollen. Should I NOT be? Am I supposed to be normal sized? Not since my initial treatment was I ever close to that. Now, my right leg is close to double the size of the left leg, and I do daily Pilates Mat classes, and drink Apple Cider Vinegar, and keep my skin supple. I just don’t have any reduction whatsoever and I am surprised to read here that I shouldn’t have swelling.

  • J.B. Jones

    I went through the Academy of Lymphatic studies and completed the CDT course in August of 2011. I have a person who has been diagnosed with multiple myloma IGA-L. He has had one stem cell transplant; and was going to receive a 2nd one in January 2013. He was not able to receive a 2nd one due to Lambda counts of over 500 (changed from 50 to 560). He is currently receiving chemotherapy orally. He is interested in trying alternative interventions to help promote a healthy lymphatice system. His doctors are not sure if MLD would be of help. Can you provide feedback..regarding if MLD would be C.I. Or other sources to reseach Thanks

    • Joachim Zuther

      I would not recommend MLD or CDT to be performed in this case. Lymphedema is not present and the immune system is depressed following stem cell transplant and oral chemotherapy. Anything that could trigger an infection – and that includes MLD as a manual technique should be avoided if possible.

  • Jessica

    Thank you for this website and the great explanation with pictures. I am a Physical Therapist just learning about lymphedema. This will provide the needed education for my patients!

  • I was just looking up something like this for my girlfriend, who’s mom has lymphedema from breast cancer. Liked the self-care aspect, so hopefully my girlfriend can get her mom to do this.

  • I had surgery 4years ago. and my arm is extream big ihave wrap massage but dosent go down. I don’t know where to do for my swollen arm. my doctor is telling there is a surgery to remove the groin and replace back under the arm pit. but its not guranrteed 100 effective.i really don’t want more surgery. I heard about this sleeve put your arm in. I hope it can get me the results I need. if anyone know of any cure or treatment ,please send me an e mail. thank you

    • Joachim Zuther

      Dear Dawn: I strongly suggest seeking the advice of a certified (!) lymphedema therapist. Please click on the “Find a Therapist” tab on top of this page in order to locate a trained therapist in your area

  • Nicole Tramontano

    Will you allow me to use these self MLD instructions and photos in a handout to give to my patients? I am a PT in Hawaii that was just got my CLT and getting ready to take the LANA exam.

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