Manual Lymphatic Drainage in Physiotherapy

Introduction to Manual Lymphatic Drainage

Manual lymphatic drainage (MLD) constitutes a specialized physiotherapy technique aimed at stimulating lymphatic circulation through gentle, rhythmic, and specific manual maneuvers. Initially developed by Dr. Emil Vodder and his wife Estrid in the 1930s in Denmark, MLD has evolved from an empirical technique to a scientifically validated therapeutic approach, now integrated into standardized lymphedema management protocols.

The lymphatic system constitutes a vascular network parallel to the venous system, composed of lymphatic capillaries, collector vessels, lymph nodes (approximately 600-700 in the human body), and main lymphatic ducts. It fulfills three essential functions: excess interstitial fluid drainage (2-4 liters daily), macromolecular protein transport, and immune surveillance.

Lymphedema, the primary MLD indication, affects approximately 250 million people worldwide. Secondary lymphedema following oncological surgery with lymph node dissection affects 20-30% of breast cancer patients after axillary clearance. MLD, integrated into complex decongestive therapy (CDT), constitutes the reference conservative treatment, recommended by the International Society of Lymphology.

Physiological Principles

MLD relies on deep understanding of lymphatic physiology. Lymphatic capillaries open under increased interstitial pressure and anchoring filament traction. MLD maneuvers create tissue pressure variations favoring initial lymphatic valve opening and excess interstitial fluid uptake.

Collector lymphatic vessels are constituted of functional units called lymphangions, delimited by unidirectional valves with smooth muscle walls capable of autonomous rhythmic contractions (12-15 per minute). MLD pressure (25-40 mmHg) is calibrated to stimulate lymphangion contraction without causing smooth muscle spasm. Maneuver direction strictly follows lymphatic flow from periphery to regional drainage nodes.

The concept of lymphatic territories and drainage basins is fundamental. When a drainage pathway is obstructed, MLD uses derivation pathways (lympho-lymphatic anastomoses) to redirect lymph toward intact drainage territories through interterritorial connections at lymphatic watersheds.

CDT comprises four synergistic components: MLD, multilayer compression bandaging, therapeutic exercises under bandage, and skin care. CDT proceeds in two phases: intensive decongestion (2-4 weeks daily MLD with bandaging), followed by long-term maintenance (elastic compression, exercises, maintenance MLD).

Drainage Techniques

The Vodder method uses four basic maneuvers: stationary circles (circular movements on lymph nodes), pumping technique (alternating pressures along collectors), rotary technique (rotating hand movements with progressive pressure), and scoop technique (cupping movement with ulnar hand border). These maneuvers are characterized by gentleness (25-40 mmHg), slowness (2-3 seconds per complete movement), and regular rhythm.

The Leduc method, developed at Universite libre de Bruxelles, proposes rigorous MLD systematization based on lymphofluoroscopy. It distinguishes call maneuvers (performed upstream of lymphedema on non-obstructed drainage pathways to create a suction effect) from resorption maneuvers (performed on edematous territory to mobilize excess interstitial fluid).

Multilayer compression bandaging, applied after each MLD session, includes tubular jersey, foam or cotton padding, and short-stretch bandages (90-140% extensibility) providing high working pressure and low resting pressure, creating rhythmic pumping during movement. Long-stretch bandages are contraindicated as they compress superficial lymphatic vessels.

Therapeutic exercises under compression exploit muscular pumping effect. Intermittent pneumatic compression can complement MLD in advanced lymphedema, using multi-chamber sleeves inflating sequentially at 30-60 mmHg.

Indications and Clinical Applications

Post-surgical and post-radiation secondary lymphedema is the major oncological indication. CDT including MLD achieves 30-60% volume reductions after intensive phase. Randomized controlled studies demonstrate CDT superiority over compression alone or MLD alone.

Lower limb lymphedema after pelvic oncological surgery follows similar CDT protocol with specific adaptations. Early post-surgical management after breast cancer surgery includes lymphedema prevention through early MLD, shoulder mobilization, and patient education. Surveillance programs enable early detection of subclinical lymphedema.

Primary lymphedema requires long-term management. CDT controls volume, prevents erysipelas episodes, and maintains function and quality of life. Chronic venous edema, lipedema, post-traumatic edema, and compensated heart failure edema constitute complementary indications.

Course of a Treatment Program

The initial lymphedema assessment includes objective volume measurement (circumferential measurements every 4 cm), edema consistency evaluation (ISL staging: stage 0-III), skin assessment, functional evaluation, and quality of life questionnaires (LYMQOL, DASH).

CDT phase I (intensive) lasts two to four weeks with daily MLD sessions (45-60 minutes) followed by multilayer compression bandaging and exercises. MLD follows a sequential protocol: upstream drainage pathway preparation, trunk drainage to open derivation pathways, then member drainage from root to extremity.

Phase II (maintenance) begins after maximum decongestion and continues long-term. It includes daily custom-fitted elastic compression garments (class 2-3), maintenance MLD sessions (progressively spaced), daily exercise program, and patient self-management (self-bandaging, simplified self-MLD, skin surveillance, regular volume measurement).

Patient therapeutic education is fundamental, including simplified self-MLD techniques, self-bandaging, home exercises, daily precautions, and warning signs requiring urgent consultation.

Variants and Complementary Approaches

Lymphatic microsurgery (lymphovenous anastomoses, vascularized lymph node transfer) represents an increasingly accessible surgical option for treatment-resistant lymphedema. Pre and post-surgical physiotherapy rehabilitation is essential. Advanced intermittent pneumatic compression uses multi-compartment devices with programmable pressure algorithms and bio-impedance sensors.

Lymphatic taping uses adhesive elastic bands creating micro-skin lifts facilitating superficial lymphatic drainage. Adapted physical activity, including progressive resistance exercises, has been shown not to increase lymphedema volume while improving strength, function, and quality of life. Aquatherapy offers a particularly favorable environment with hydrostatic pressure providing natural compression.

Contraindications and Precautions

Absolute contraindications include acute infection (erysipelas, cellulitis) requiring prior antibiotic treatment, acute deep vein thrombosis (pulmonary embolism risk), decompensated heart failure (classes III-IV NYHA, volume overload risk), and uncontrolled active neoplasms with untreated lymph node metastases.

Relative contraindications require treatment adaptation: severe renal insufficiency, uncontrolled hyperthyroidism, severe bronchial asthma, and locoregional cancer recurrence (requires oncological discussion). Recurrent erysipelas management is a major issue requiring daily skin care, regular compression, and long-term antibiotic prophylaxis for frequent recurrences.

Lymphedema management in active oncological context requires close coordination with the oncology team. MLD is contraindicated with uncontrolled locoregional recurrence in the drainage territory. With distant metastases and controlled primary tumor, MLD may proceed under medical supervision.