WHAT ARE THE MAIN FUNCTIONS OF MANUAL LYMPHATIC DRAINAGE (MLD)? - Why is Manual Lymphatic Drainage so Important? - What is the contribution of MLD to Complete Decongestive Therapy (CDT)? - Organic Lymphatic Vascular Disease - Pediatric and Primary Lymphedema - Secondary Lymphedema - Lymphostatic Elephantiasis - Lymphatic Filariasis/Podoconiosis - Best Practices Management Clinical Guideline / Treatment Protocol / Patient Care Pathway

To understand the principal functions of Manual Lymphatic Drainage (MLD) as a fundamental component of conservative treatment, it is important to review the basic notions regarding what is the lymphatic circulatory system, and what is Complete Decongestive Therapy (CDT).

WHAT IS THE LYMPHATIC CIRCULATORY SYSTEM?

The Lymphatic system is part of the immune system and it helps to cope with infections. It is made up of a network of vessels that transport lymph (a clear fluid that transports nutrients and waste) and lymph glands (nodes) that filter the lymph fluid. Other lymphatic organs are the tonsils, liver, and spleen.

Although the body’s blood and lymph circulation are totally different hemodynamic mechanisms, they are mutually dependent and complementary circulatory systems. Whilst the blood circulation is pumped through the body by the heart, the lymphatic fluid is moved by the rhythmic contractions of the muscular walls of lymphangions, which are segmented portions of the lymph vessels separated by a valve on either side. The sequential, segment-to-segment contractions of the lymphangions are under the control of the autonomic nervous system but can be augmented by external stimuli on the lymphatics. When damage occurs to the lymphatic system, drainage of interstitial fluid may become compromised, and the resulting lymph stasis causes chronic inflammation and the build-up of interstitial fluid known as Lymphedema.

WHAT IS THE FUNCTION OF THE LYMPHATIC SYSTEM?

The lymphatic vascular system has many essential physiological functions, including maintenance of tissue fluid homeostasis by returning interstitial fluid to the blood, distributing nutrients and absorption of dietary lipids through mesenteric lymphatics, and filtering and destroying invading micro-organisms. The waste products are then expelled from the body via the urinary system. Dysfunction of the lymphatic system (Organic Lymphatic Vascular Disease) can lead to severe infections, disability, disfigurement, and loss of Quality of life (QoL) as can be assessed with the ICF model (International Classification of Functioning, Disability, and Health). Read more information about the signs, symptoms, and complications of lymphoedema HERE.

WHAT IS COMPLETE DECONGESTIVE THERAPY (CDT)?

Complete decongestive therapy (CDT) is the most effective non-surgical treatment for lymphedema, as it reduces the symptoms and improves patients’ functionality, mobility, and quality of life. CDT is the conservative multimodal treatment for lymphatic dysfunction.

Complete Decongestive Therapy (CDT) involves a two-phase intervention. In Phase 1 (intensive or reduction phase), which lasts two to four weeks, the goal is to improve skin integrity and reduce the amount of edema through compression bandaging and Manual Lymphatic Drainage (MLD). The therapist also instructs the patient on good skin care practices and prescribes decongestive exercises. In Phase 2 (maintenance phase), after the limb is sufficiently reduced in volume, the patient is then fitted with a compression garment, and the goal is to maintain the volume reductions achieved in Phase 1 through self-care strategies, lymph-reducing exercises, and the permanent use of compression garments.

Complete Decongestive Therapy (CDT) is a combination of the following components:

• Skincare,
• Manual Lymphatic Drainage (MLD,
• Multilayer Bandaging/Compression Garments (Compression Therapy),
• Decongestive exercises.
• Patient education ( patient basic self-help notions)

• Compression Pumps (this is an optional adjuvant, and must be accompanied by Manual Lymph Drainage (MLD) conducted by therapists at the specialist level).

It must be made clear that treatment without Manual Lymphatic Drainage (MLD) does not represent Complete Decongestive Therapy (CDT). Even though the terms Complete Decongestive Therapy (CDT) and Decongestive Lymphatic Therapy (DLT) are used synonymously in the medical literature, they don't represent the same treatment management focus. Read information about what are the important differences between the two principal lymphedema treatment protocols HERE.

WHAT IS THE ROLE OF COMPRESSION THERAPY IN LYMPHATIC DISEASE?

To be clear on the concepts, Compression Therapy is used to describe the compression part of the therapy, whether it is bandaging, compression pumps, or a custom-fitted garment. The maximum reduction of edema volume is achieved by compression bandaging. Compression therapy helps reduce interstitial fluid by decreasing its formation and preventing lymph backflow into the interstitial space. Compression also assists the pumping action muscle pump effect of muscles by creating a resistance against which muscles can work. 

Compression therapy in Phase 1 is done using a specialized bandaging technique with low-stretch bandages called multi-layered bandaging, and compression therapy in Phase 2, is designed to maintain the volume reductions from the first phase, which is achieved by the use of a compression custom-fitted garment that is worn during the day. In some cases, compression bandages are worn at night.

Due to the possibility of lymph fluid displacement during treatment, it is important to take into account that compression therapy alone without Manual Lymphatic drainage (MLD), or performed incorrectly, can provoke the shift of fluid to adjacent previously non-affected areas. 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 lymphedema. Prevention of lymph fluid displacement in upper and lower limbs is something basic and primordial. Only certified therapists at the specialist level should perform MLD in Phase 1(reduction phase). Read more information in the German Scientific  Consensus Document HERE.

WHAT IS THE ROLE OF MANUAL LYMPHATIC DRAINAGE (MLD) IN RELATION TO COMPRESSIVE THERAPY?

Lymphedema is a disease of the skin due to lymphatic valve incompetence (Organic Lymphatic Vascular Disease) which causes inflammation and lymph fluid buildup. Whatever type of compression is applied to lymphatic edema, will have a consequent impact regarding volume and circumference reduction. Lymphatic volumetric reduction is primarily achieved by compression, and this compression is chiefly achieved with multi-layer bandaging. 

The volume reduction produced by compression is mainly due to a reduction in the water content of the tissues, with a proportionally lower elimination of proteins. Isolated application of compression is not recommended because of the risk of draining the liquid and not proteins, reducing the volume but increasing the concentration of proteins with the consequent risk of generating Fibrosis.

An important question is what happens to lymph fluid when it is submitted to compression; does it evaporate, is it absorbed by the bandages, or does it simply disappear? It is important to bear in mind that when Lymphatic edema is summited to compression the lymph fluid is displaced, and that is the precise reason why Manual Lymphatic drainage (MLD) is so important. If lymphedema is summited to compression without MLD, the consequent shift of fluid can provoke a lymph fluid buildup in a previously non-affected area.

According to the German Scientific Society Guidelines, isolated application of single components is not recommended, and Complex Decongestive Therapy (CDT) should be used in its entirety. Isolated compression therapy of the extremities may increase swelling at the root of the extremity and may even lead to genital lymphoedema.

WHAT IS THE PRINCIPAL FUNCTION OF MANUAL LYMPHATIC DRAINAGE (MLD)?

Unlike blood circulation, the lymphatic system has no central pump, such as the heart, to move fluid to the lymph glands, instead, it uses a combination of pressure differences, muscle contractions, and one-way valves to move the fluid. This is why Manual Lymphatic Drainage (MLD) is essential in the treatment of a non-functional lymphatic system.

Manual Lymphatic Drainage (MLD) should be applied prior to compression therapy (multilayer bandages/compression pumps) and is one of the principal components of the conservative Gold Standard treatment plan known as Complete Decongestive Therapy (CDT). MLD is a specialized medical massage technique centered on the anatomy of the lymphatic system that helps promote lymphatic drainage. It should not be confused with a traditional common massage. MLD helps prevent fibrosis and the displacement of lymph fluid to adjunct areas when lymphatic edema is submitted to compression therapy (bandages or compression pumps) for volumetric reduction.

Manual Lymphatic drainage (MLD) is a specific hands-on therapy focused on the lymph vessels to help the flow of lymphatic fluid to move away from the swollen area. Therapy starts in the areas of the non-swollen parts of the body adjacent to the section that includes the affected limb or body part to open the well-working lymph nodes, making it possible for the fluid to move out of the affected area inducing a suction effect. The therapist continues with MLD in the swollen body parts to direct the fluid to the open lymph collectors and redirect lymph fluid toward functioning lymphatic territories. After proximal areas have been gently massaged, a more rhythmic massage is performed from the distal to the proximal part of the extremity. The gentle, rhythmic motions on the skin can also help to soften any hardened (fibrosis) tissue.

Manual Lymphatic Drainage (MLD) goes along with compression bandaging to reduce limb volume, and compression garments to help keep the swelling down. MLD is not intended to be a stand-alone treatment option, and treatment with the intent of decongesting a limb should always be followed by compression bandages or garments. MLD is sometimes administered alone, particularly in areas where it is difficult to use compression therapy. Long-lasting therapeutic success depends on the effectiveness of the treatment chain consisting of a specialist doctor, lymph therapist, health care supplier, and the affected patient.

WHO SHOULD PERFORM MANUAL LYMPHATIC DRAINAGE (MLD) IN LYMPHATIC DYSFUNCTION?

In the context of chronic lymphatic dysfunction, it is very important to note that only certified therapists at the specialist level should perform Manual Lymphatic Drainage (MLD). MLD takes many hours of training, and years of hands-on experience to become a skilled lymphedema therapist. MLD therapists are trained in the anatomy and physiology of the lymphatic system to facilitate lymph drainage of the vessels and have a profound knowledge of the disease. Patients should not have other types of massage on the affected lymphedema area.

Manual Lymphatic drainage (MLD) is not suitable for everyone, and there are situations where MLD must not be applied. Contraindications for MLD can be classified as general or region-specific and include acute infection, cardiac edema, malignancies, acute deep vein thrombosis, renal failure, bronchial asthma, and uncontrolled hypertension. Patients must always refer to their healthcare professional first to make sure that MLD is right for them.

It should be noted that Manual Lymphatic Drainage (MLD) and self-drainage (Simple Lymphatic Draingae-SLD) are not the same. The former is performed by a clinical specialist and the latter is applied by the patient. Self-drainage should not replace MLD in Phase 1 (intensive or reduction phase), given that if MLD is not performed correctly and rigorously before compression therapy (bandages or compression pumps), this can cause serious short or long-term side effects for patients such as the shift of edema to adjacent previously unaffected areas. 

SUMMARY OF THE PRINCIPAL FUNCTIONS OF MANUAL LYMPHATIC DRAINAGE (MLD)

• MLD stimulates and opens well-working lymph nodes and increases rhythmic contractions of the lymph vessels to enhance their activity.

• MLD induces a suction 'call up' and 'reabsorption' effect where lymph is absorbed first in the initial lymphatics and then into larger lymph vessels.

• MLD reroutes stagnant lymphatic fluid from the swollen area toward functioning lymphatic territories

• MLD treats first functional and healthy lymph nodes, followed by proximal and contralateral areas and then ipsilateral and lymphoedematus areas.

• MLD emphasizes the treatment of the anterior and posterior trunk in the early phases before the swollen limb is treated.

• MLD helps prevent fibrosis and the displacement of lymph fluid to adjunct areas when lymphatic edema is submitted to compression therapy (bandages or compression pumps) for volumetric reduction.

IMPORTANT NOTICE 

Lymphedema is a serious chronic and progressive disease due to lymphatic dysfunction (Organic Lymphatic Vascular Disease). The clinical treatment of lymphedema is neither a cosmetic nor an aesthetic treatment. The treatment of lymphedema is to control its progression and alleviate the symptoms related to dysfunction of the lymphatic circulatory system. 

To prevent and avoid serious complications associated with treatment, such as the possible displacement of edema to previously unaffected areas when compression therapy is applied for volume reduction, patients should use highly specialized and experienced therapists. 

Professional qualification and instruction delivered remotely online are not the same as live hands-on practical instruction in the clinical training and certification of lymphedema therapists, similar to all other rehabilitation, medical, and surgical training programs, and especially for developing the necessary manual skills to treat a disease as complex as lymphedema. 

Patients should also take special care when choosing a Multidisciplinary Expert Center of Reference for Lymphedema, as not all countries and centers provide the same treatment options. The best choice is a center of reference that provides Complete Decongestive Therapy (CDT), which is recognized as the Gold Standard treatment for lymphedema.

• Read more about what is the best treatment option for Lymphedema HERE.

• Read about what are the principal functions of Manual Lymphatic Drainage HERE.

• Read about what are the main differences between the two principal lymphedema treatment protocols HERE. 

• Read about what are the strategies for the implementation of low-cost treatment options for Lymphedema HERE.

REFERENCES

(Click on the texts to read the research articles)

SCIENTIFIC SOCIETIES

• German Scientific Society Guideline: Diagnostics and Therapy of Lymphoedema.

PATHOPHYSIOLOGY

• lymphedema.
• Biology of Lymphedema
• Lymph vessels: the forgotten second circulation in health and disease
• Lymphatic Vessel Network Structure and Physiology
• Lymphatic System Flows
• Organ-specific lymphatic vasculature: From development to pathophysiology.
• The lymphatic vascular system: much more than just a sewer.
• The unresolved pathophysiology of lymphedema.
• Lymphedema: A Practical Approach and Clinical Update.
• Coagulation in Lymphatic System.
• Regulation of immune function by the lymphatic system in lymphedema.
• Oxidative stress in chronic lymphoedema.
• Regulatory T Cells Mediate Local Immunosuppression in Lymphedema.
• Hemostatic properties of the lymph: relationships with occlusion and thrombosis.
• Secondary lymphedema: Pathogenesis
• Gastrointestinal Lymphatics in Health and Disease
• Intestinal lymphangiectasia in adults
• Role of the lymphatic vasculature in cardiovascular medicine
• The lymphatic vasculature in disease
• Lymphoscintigraphic abnormalities in the contralateral lower limbs of patients with unilateral lymphedema.
• The Prevalence of Lower Limb and Genital Lymphedema after Prostate Cancer Treatment: A Systematic Review
• Peripheral Edema

CUTANEOUS COMPLICATIONS

• The lymphatic system and the skin. Classification, clinical aspects, and histology.
• Lymphedema and cutaneous diseases.
• Lymphedema and subclinical lymphostasis (microlymphedema) facilitate cutaneous infection, inflammatory dermatoses, and neoplasia: A locus minoris resistentiae.
• Serum Immune Proteins in Limb Lymphedema Reflecting Tissue Processes Caused by Lymph Stasis and Chronic Dermato-lymphangio-adenitis (Cellulitis).
• Lymphedema and subclinical lymphostasis (microlymphedema) facilitate cutaneous infection, inflammatory dermatoses, and neoplasia: A locus minoris resistentiae.

INFECTIOUS COMPLICATIONS

• Lymphatic Flow: A Potential Target in Sepsis.
• Infectious complications of lymphedema.
• Acute inflammatory exacerbations in lymphoedema.
• Inflammatory Manifestations of lymphedema.

CELLULITIS / DERMATOLYMPHANGIOADENITIS

• Cellulitis.
• Clinical features, microbiological epidemiology, and recommendations for the management of cellulitis in extremity lymphedema.
• Challenges of cellulitis in a lymphedematous extremity.
• Diagnosis and management of cellulitis.
• Cellulitis risk factors for patients with primary or secondary lymphedema.
• Oedema as a risk factor for multiple episodes of cellulitis/erysipelas of the lower leg.
• Prevention of dermatolymphangioadenitis by combined physiotherapy.
• Erysipelas: a common potentially dangerous infection.

TUMOURS

• Malignant tumors as complications of lymphedema.
• Lymphedematous areas: Privileged sites for tumors, infections, and immune disorders.
• Lymphedema-related angiogenic tumors and other malignancies.
• Lymphedema: an immunologically vulnerable site for the development of neoplasms.
• Lymph stasis promotes tumor growth
• A retrospective analysis of Stewart-Treves syndrome in the context of chronic lymphedema.
• Stewart-Treves Syndrome

PAIN

• Congenital lymphedema complicated by pain and psychological distress: case report
• Lymphatic Pain in Breast Cancer Survivors
• Does Manual Lymphatic Drainage Have Any Effect on Pain Threshold and Tolerance of Different Body Parts?
• Lymphedema therapy reduces the volume of edema and pain in patients with breast cancer
• Quality of life in patients with primary and secondary lymphedema in the community

TREATMENT

• Treatment of limbs lymphedema.
• Nonoperative treatment of lymphedema.
• Lymphedema: From diagnosis to treatment.
• Lymphedema-clinical picture and therapy.
• Physiotherapeutic rehabilitation of lymphedema: state-of-the-art.
• Diagnosis and management of lymphatic vascular disease
• Effective treatment of lymphedema of the extremities.
• Lymphoscintigraphic aspects of the effects of manual lymphatic drainage.
• Intensive Treatment of Lower-Limb Lymphedema and Variations in Volume.
• Effectiveness and safety of Complete Decongestive Therapy of Phase I.
• Therapeutic Efficacy of Complex Decongestive Therapy in the Treatment of Elephantiasis of the Lower Extremities.
• Effects of Phase I complex decongestive physiotherapy on physical functions and depression levels in breast cancer-related lymph edema.
• Does lymphoedema bandaging reduce the risk of toe ulceration?
• Study of 700 referrals to a Lymphedema Program.
• Worldwide assessment of healthcare personnel dealing with lymphoedema.
• Földi M, Földi E. Földi’s textbook of lymphology for physicians and Lymphoedema therapists.
• Fluid Shifts Induced by Physical Therapy in Lower Limb Lymphedema Patients
• Visualization of Accessory Lymphatic Pathways, before and after Manual Drainage, in Secondary Upper Limb Lymphedema Using Indocyanine Green Lymphography
• The risk of genital edema after external pump compression for lower limb lymphedema.
• The management of genital lymphoedema
• The management of deep vein thrombosis in lymphoedema: a review.
• Lymphedema-associated comorbidities and treatment gap.

COMPRESSION GARMENTS

• A study of the advantages of elastic stockings for leg lymphedema.
• Indications for medical compression stockings in venous and lymphatic disorders: An evidence-based consensus statement.
• Medical compression stockings for chronic venous diseases and lymphedema: Scientific evidence and results of a patient survey on quality of care.
• Impact of Compression Therapy on Cellulitis (ICTOC) in adults with chronic edema: a randomized controlled trial protocol.
• Compression Therapy Is Cost-Saving in the Prevention of Lower Limb Recurrent Cellulitis in Patients with Chronic Edema.
• Occupational leg edema-use of compression stockings.

DISABILITY

• Disability and lymphedema.
• Lymphedema and employability.
• Worse and worse off: the impact of lymphedema on work and career after breast cancer
• Functioning in lymphedema from the patient's perspective using the International Classification of Functioning, Disability and Health (ICF).
• Unilateral upper extremity lymphedema deteriorates the postural stability in breast cancer survivors
• Postural Stability in Patients with Lower Limb Lymphedema
• Disability, psychological distress and quality of life in breast cancer survivors with arm lymphedema

DISFIGUREMENT

• Adjusting to disfigurement: processes involved in dealing with being visibly different
• Quality of Life in Cancer Patients with Disfigurement due to Cancer and its Treatments
• Quality-of-life and body image impairments in patients with lymphedema
• Association of lower extremity lymphedema with pelvic floor functions, sleep quality, kinesiophobia, body image in patients with gynecological cancers

QUALITY OF LIFE

• The impact of lower limb chronic oedema on patients' quality of life
• Quality of life in patients with primary and secondary lymphedema in the community
• Evaluating the effect of upper-body morbidity on quality of life following breast cancer treatment.
• Functionality and quality of life of patients with unilateral lymphedema of a lower limb: a cross-sectional study
• The effect of complete decongestive therapy on the quality of life of patients with peripheral lymphedema

PSYCHOSOCIAL IMPACT

• Psychosocial Impact of Lymphedema.
• Associations between chronic disease, age and physical and mental health status
• A network analysis of psychological flexibility, coping, and stigma in dermatology patients
• 'Abandoned by medicine'? A qualitative study of women's experiences with lymphoedema secondary to cancer, and the implications for care
• People are neglected, not diseases.
• Chronic edema/lymphoedema: under-recognized and under‐treated.
• Lymphatic Medicine: Paradoxically and unnecessarily ignored.
• Medical education: a deficiency or a disgrace.

PEDIATRIC LYMPHEDEMA

• NORD: Rare Disease Database - Lymphedema
• Medical management of lymphedema.
• Primary lymphedema in childhood.
• An approach to familiar lymphedema
• Pediatric Children Lymphedema
• Primary Lymphedema French National Diagnosis and Care Protocol (PNDS).
• Lymphatic filariasis: an infection of childhood.
• Lymphatic filariasis in children: clinical features, infection burdens and future prospects for elimination.

LYMPHATIC FILARIASIS / PODOCONIOSIS

• Podoconiosis: Clinical spectrum and microscopic presentations.
• Podoconiosis: A Possible Cause of Lymphedema in Micronesia.
• A cross-sectional study to evaluate depression and quality of life among patients with lymphoedema due to podoconiosis, lymphatic filariasis, and leprosy.
• The impact of acute adenolymphangitis in podoconiosis on caregivers.
• Neglected tropical diseases and disability-what is the link?
• Locomotor disability in bancroftian filarial lymphoedema patients.
• Neglected patients with a neglected disease?
• Neglected tropical diseases and mental health: a perspective on comorbidity.
• People are neglected, not diseases.
• Addressing Inequity: Neglected Tropical Diseases and Human Rights.
• Neglected Tropical Diseases, Conflict, and the Right To Health.

BLOOD VASCULAR SYSTEM 

• Peripheral Edema
• Phlebolymphedema
• Understanding Chronic Venous Disease: A Critical Overview of Its Pathophysiology and Medical Management
• Role of the lymphatic vasculature in cardiovascular medicine
• Communication between lymphatic and venous systems
• Phlebopathies and occupation
• Phlebopathies and workers
• Evidence of health risks associated with prolonged standing at work and intervention effectiveness
• Leg edema formation and venous blood flow velocity during a simulated long-haul flight