WHAT ARE THE STRATEGIES FOR DISCREDITING AND DEVALUING MANUAL LYMPHATIC DRAINAGE (MLD)? - The Low-Cost Management Alternatives - Pediatric and Primary Lymphedema - Secondary Lymphedema - Best Practices Management Guideline /Treatment Protocol/Patient Care Pathway

Lymphedema (LE) occurs due to obstruction of normal lymphatic circulation leading to lymphatic fluid stasis. The lymph build-up results in inflammation, followed by fibrosis and sclerosis, then adipose tissue differentiation, and finally progression to chronic irreversible LE.

In recent years, some lymphedema organizations and national health systems have focused their health guidelines and policies on implementing low-budget healthcare management for lymphedema. To achieve this goal, a new treatment concept called “Decongestive Lymphatic Therapy (DLT)” was developed so as to principally exclude Manual Lymphatic Drainage (MLD), and thus include substitute low-cost management options.

In many countries lymphoedema services are sparse, and various strategies have been used to justify and implement low-budget alternatives, including undermining the effectiveness of the conservative treatment or discrediting Manual Lymphatic Drainage (MLD). The resulting management focus emphasizes too the provision of intensive treatment with MLD only for very severe lymphedema (elephantiasis) and complex cases and thus excludes earlier preventive intervention for patients with severe, moderate, and mild, degrees of swelling. 

Even though the terms “Complete Decongestive Physiotherapy (CDT)” and “Decongestive Lymphatic Therapy (DLT)" are used synonymously in the medical literature, they are not equivalent and don't represent the same treatment management focus. Read more about the principal differences between “CDT” and “DLT” HERE.

Paradoxically, some consensus documents, while stating that Manual Lymphatic Drainage (MLD) should only be performed by properly trained professionals, simultaneously detract from MLD and recommend as a good and valid alternative, self-treatment options for the intensive volume reduction phase, even though this has little scientific evidence. 

With regard to the objective of discrediting MLD, there are confusing research studies that focus on demonstrating its unnecessary inclusion as an essential component of treatment, basing the reports only on the results in terms of volumetric reduction measures, but not taking into account the important functions of MLD. Read more about the principal functions of Manual Lymphatic Drainage HERE.

The following is a list with a sample of conclusions and statements concerning volumetric measurements and MLD published in some studies:

• "It is difficult to formulate strong conclusions on the long-term benefits of MLD for volume reduction".
• "Manual lymphatic drainage adds no further volume reduction to Complete Decongestive Therapy".
• "The addition of manual lymphatic drainage (MLD) to the standard therapy does not contribute significantly to reducing edema volume".
• "Manual lymphatic drainage adds no further volume reduction to Complete Decongestive Therapy".
• "There is no statistically significant difference in the reduction in limb volume between the MLD groups and the non-MLD groups".
• "The efficacy of MLD to other therapist interventions needs to be demonstrated, not least because MLD requires specialized training and is labor-intensive compared to other treatments for lymphoedema".
• "MLD was not associated with any more benefits to standard physiotherapy in lymphedema volume reduction".
• "Compression Bandaging, with or without MLD, is an effective intervention in reducing arm lymphedema volume".
• "Compression Bandaging on its own without MLD should be considered as a primary treatment option in reducing lymphedema volume".

The following are a sample of statements included in some studies to justify the implementation of patient self-treatment instead of clinical management:

• "Self-management strategies yielded smaller volume reductions but demonstrated that they are more beneficial than doing nothing at all".
• "Patient self-management may be useful when health professional-based therapies are not accessible or economically viable".
• "Self-maintenance demonstrated a positive impact on “subjective” limb complaints and quality of life issues".
• "Low-budget management can be initiated by a health professional or patient with the anticipation of some benefit, even though the evidence to support them is, in some instances, poor".

The following are a sample of comparison trials that are made to justify the suppression of treatment with Manual Lymphatic Drainage (MLD) from treatment protocols:

• MLD + standard physiotherapy versus standard physiotherapy alone.
• MLD + compression bandaging versus compression bandaging alone.
• MLD+ compression therapy versus non MLD treatment + compression therapy.
• MLD + compression bandaging versus SLD + compression bandaging.
• MLD + Compression Garments versus Compression Garments + pneumatic pump.
• MLD + Compression Garments versus Compression Garment + self-drainage (SLD).
• MLD + Compression Garments versus Compression bandaging + self-administered simple lymphatic drainage (SLD).

These studies and trials don't mention the potentially serious and irreversible adverse effects that may arise in the short or long term, such as the possibility of lymph displacement to previously unaffected areas, if manual lymphatic drainage (MLD) is not included prior to the application of compression therapy in the process of reducing the volume of the edematous limb. 

Many lymphedema-related healthcare management studies are only cost-saving non-investment strategy tools. It should be borne in mind that the annual health expenditure for the maintenance treatment of lymphoedema adds far less in comparison to the cost of treatment for many chronic diseases, and even so, many national health systems do not treat or are undertreating lymphedema. 

Early detection and preventive treatment (Preventive Healthcare) can reduce overall costs by maintaining affected limbs at minimal volumes and treating other comorbidities and complications before they become chronic. Read more about what is the best treatment option for lymphedema HERE.

For the purposes of the above discussion, some basic and important concepts relating to the treatment of lymphoedema are detailed below:

• Manual Lymphatic Drainage (MLD) is part of the conservative treatment known as Complex Decongestive Therapy (CDT). The five components of the Initial Phase I are skin care, manual lymphatic drainage (MLD), multilayer compression bandaging, decongestive exercises, and patient education.

• It must be taken into account that the isolated application of individual components is not recommended and, that treatment without Manual Lymphatic Drainage (MLD) does not represent "Complex Decongestive Therapy (CDT).

• There is a big difference between the terms “ Complex Decongestive Physiotherapy (CDT)” and “Decongestive Lymphatic Therapy (DLT)".

• The term "Compression Therapy” is used to describe the compression part of lymphedema therapy, whether it is bandaging or a custom-fitted garment. Edema volume reduction is principally achieved by compression, and wrapping with a low-stretch bandage is the major component of the intensive volume reduction phase.

• Isolated compression therapy of the extremities, particularly in those with lymphoedema also affecting the quadrants of the trunk, may increase swelling at the root of the extremity and may even lead to genital lymphoedema.

• Manual Lymphatic Drainage (MLD) should always be applied before the compression phase and is not intended to be a stand-alone treatment option. MLD as a stand-alone treatment is used when treating body parts that are not conducive to sustained compression (e.g., face, breast, genitalia, and trunk).

• The main function of Manual Lymphatic Drainage (MLD) is aimed at lymph vessel and lymph node drainage, rerouting of lymph into nonobstructed lymphatics, development of accessory lymph collectors, and improving lymphatic contractility. MLD therapists are trained in the anatomy and physiology of the lymphatic circulatory system.

• It must be kept in mind that the primary role of Manual Lymphatic Drainage (MLD) is not for volumetric reduction.

References:

GERMAN SCIENTIFIC SOCIETY GUIDELINE

THE INTERNATIONAL SOCIETY OF LYMPHOLOGY

LYMPHATIC SYSTEM FLOWS

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