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

 
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 lower extremity. 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), abdominal breathing techniques, 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. Skin and Nail Care in Lymphedema Management
  4. Primary Lymphedema
  5. Secondary Lymphedema

The following techniques can be used for lymphedema affecting one leg; the illustrations and techniques describe the sequence used for lymphedema affecting the left leg. In this case the lymph nodes located in the opposite groin (right) and those in the axilla of the same side (left) are unaffected and working properly.

This sequence should not be used in lymphedema affecting both legs, or if the axillary lymph nodes on the affected, or the inguinal (groin) lymph nodes on the unaffected side are removed, or non-functioning due to other reasons.

Ideally, self MLD should be applied at least once daily for 15-20 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.

The techniques and sequences below are 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.

Preparation and Abdominal Breathing:

  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 axilla (armpit, underarm) on the same (affected) side. The pressure is directed downward (deep) into the axilla and applied with the flat fingers and palm.

    Step 2

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

    Step 3

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

    Step 4

  5. Stationary circles with the flat hand in several placements from the groin (inguinal) area on the affected side to the groin (inguinal) area on the opposite side. The pressure is directed toward the groin (inguinal) area on the opposite side.

    Step 5

  6. Diaphragmatic (abdominal) breathing:
    It is important to discuss any possible contraindications for this technique with the therapist!
    Abdominal breathing is done by contracting the diaphragm, a muscle located horizontally between the chest cavity and stomach cavity. As air enters the lungs this deep breathing is marked by expansion of the abdomen rather than the chest when inhaling. During the inhalation both hands that are placed flat on the belly provide resistance to the expanding abdomen.

    Step 6 – Inhalation

    During the exhalation the hands follow the belly and at the end of the exhalation, the hands press gently downward and upward toward the chest.

    Step 6 – Exhalation

    This technique should be repeated five times.

Leg

  1. Soft effleurage over the skin of the entire leg from the ankles (or knees) to the waist.

    Step 7

  2. Stationary circles with the flat hand and fingers in several placements on the lateral (outside) thigh and hip. The pressure is directed toward the waist.

    Step 8

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

    Step 9

  4. Stationary circles with the flat fingers of both hands behind the knee. The pressure is directed upward toward the thigh.

    Step 10

  5. Stationary circles with the flat fingers of both hands on the medial (inside) lower leg. With the pressure directed toward the thigh, the entire area between the knee and the medial ankle bone should be covered.

    Step 11

  6. Stationary circles with the flat hand and fingers of both hands on the inner and outer surface of the lower leg. With the pressure directed toward the thigh, the entire area between the area below the knee and the ankle bones should be covered.

    Step 12

  7. Repeat as many of the steps on the leg as you wish.
  8. Repeat steps 2, 4, and 6

    Inguinal Ligament, Groin Lymph Nodes – Step 4

 

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24 comments to Self Manual Lymph Drainage for Lymphedema Affecting the Leg

  • i am interested in learning the exercises by linphedema, i have in two legs.

    Thank you

    Yadira

    • Joachim Zuther

      Dear Yadira: Please choose “Exercises for Lymphedema” in the category box on the right of this page. You will find a list of articles covering exercises

  • Rebecca

    If both legs are involved — what is the sequence?

    • Joachim Zuther

      You would do the following:
      1. same
      2. perform on both sides (left and right sides)
      3. perform on both sides (left and right sides)
      4. do not perform
      5. do not perform
      6. same
      7-12 perform on both sides (left and right sides)
      13. same
      14. same, except: do not perform #4

  • I would like to see the arm sequence again. You put it out last week, I believe, I accidentally deleted it :) Thanks.

  • Molly Nettles

    Thank you for the clearly written directions and images!

  • [...] Self Manual Lymph Drainage for Lymphedema Affecting the Leg … [...]

  • Andrea Hames

    I have lymphedema in both legs and was taught self MLD by my therapist with the inclusion of steps 4 and 5. Can you tell me the reason you do not recommend including them? Also, I will be in the Sebastian area and wondered if there are any talks or programs you will be giving in the next couple of months in the area.

    Thank you.

    • Joachim Zuther

      Your therapist was absolutely correct not to include steps 4 and 5 with lymphedema affecting both legs. The sequence shown here applies to lymphedema affecting one leg.

      • Joachim Zuther

        If you have primary lymphedema (inguinal lymph nodes are present), it would be beneficial to include these steps. If your lymphedema is secondary (inguinal lymph nodes removed and/or radiated), then it is not necessary to include #’s 4/5, but you would not do any harm either.

  • Andrea Hames

    My therapist did include 4 and 5 and I’ve been using those steps. Wondering if I’m doing any harm by including them and what the reason for not doing them is. Does it somehow interrupt the flow or potentially cause the lymph to drain / pool in another area?

  • Sharlane

    In reference to MLD to LE’s I have heard that the rate of return for fluid into the thoracic duct is approx. 125cc/hr. Is this true and are there any citable studies? We are trying to find good basis for contraindications to treatment for CHF or renal failure.

    Thank you.

    • Joachim Zuther

      That is correct – about 20 liters of lymph fluid is returned to the venous blood via the venous angles per day (24 hours). Wikipedia is one source, but I am sure you will be able to find more resources on the subject

  • Abby

    I have LE in both legs, right side and right arm. My PT has me do MLD on my arm every night and alternating on legs every night. (as in right tonight left tomorrow) Is that your recommendation too?

  • Hi Joachim,

    My name is Magda and I’m working for compression hosiery company called Daylong. I’m currently researching information about Lymphoedema and Leg Ulcers. Do you know any publications or magazines that are published in UK that are popular and worth reading,please?

    Thank you
    Best wishes,
    Magda

    • Joachim Zuther

      Most compression garment manufacturers offer custom made stockings. I would recommend seeking the adice of a certified fitter. Most therapists are fitters, so I would recommend using the link “Find a Therapist” on this website to locate a therapist in your area.

  • Rachel Ahnell

    I am at a loss… my mother (84y/o) living in UK has been “diagnosed” with lower extremity lymphedema she also has a diagnosis of cardiac amyloidosis and takes a diuretic and a medication for atrial fibrillation. For the last 6 weeks her legs have been oozing fluid – nurse has been dressing them daily with no improvement- now they are sending her to a clinic for bandaging….. your thoughts please…( she had a wide dissection lumpectomy for breast CA in 2009 with radiation and has had mild lymphedema in the affected arm on and off)

    any thoughts or comments???

    • Joachim Zuther

      The oozing of fluid (lymphorrhea) can only be stopped by removing the excess fluid from the extremity. This can be accomplished with CDT, bandaging the extremity is part of it.

  • I have been doing wraps sice January. Started.with the right leg and now working on the left. Has anyone had numbness in their legs? No trouble with the first one, but the left one is numb on front and sides.

  • Alicia

    I would like to learn as much as possible about treating lymphedema in the legs. My mother has it in both legs for about 6 years now. She had a bad experience with a physical therapist and refuses to go back. Financial issues also play a huge part. Her medical insurance barely covers anything she needs.
    I’m hoping this will help me to help her. It’s hard watching your parent go through this, especially at a young age. If you have any other tips or advice, please e-mail me at aliciatw93@gmail.com. Subject: Lymphedema

    Thank-you.

    • Joachim Zuther

      The Academy of Lymphatic Studies offers Lymphedema Management Seminars. In these classes non-therapists can learn how to treat and manage uncomplicated lymphedema affecting the upper and lower extremities. The number is 1-800-863-5935

  • Pamela Hain

    I believe I have stage I lymphedema. However, my first visit to a hospital so called lymphedema expert was discouraging. It appears there are a number of incorrect ideas in general belief:
    1. there is no pain with lymphedema
    2. pitting edema is not a sign in the early stages
    3. you cannot get lymphedema 7 years after surgery
    4. It cannot affect both arms and both legs.

    I am beginning to think that I will have to do the therapy myself.

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