Therapists looking to the published literature to assist in making a clinical decision about whether to spend time performing MLD for their lymphoedema clients, can be forgiven for coming away confused and overwhelmed. Conflicting results, indistinct methodology and biased interpretation of the results abound.
One way to overcome this is to look to systematic reviews (SR) and meta-analyses (MA) for answers. A systematic review uses strict searching and selection criteria to make sure that all relevant studies are included in the review. This reduces the selection bias of the reviewing authors, but if only a descriptive analysis is given of the pooled results, the review may still be subject to interpretation bias. A meta-analysis is a statistical re-analysis of pooled data from similar studies to produce a result as if from a much larger study, and is a good way to reduce bias in the reporting of pooled results.
Does MLD improve volume reduction?
A recent SR and MA on standard therapy (compression without or without exercise and skin-care), compared to standard therapy with MLD, concluded that MLD did improve the volume reduction in the lymphoedema arm of women with breast cancer-related lymphoedema (BCRL). The article is available online at https://onlinelibrary.wiley.com/doi/abs/10.1111/ecc.12517. The full reference and a copy of the abstract are available at the end of this post.
But even such painstaking reviews still have their faults. One major drawback in comparing or combining study results is the lack of detailed description about what technique was performed during the intervention. The SR and MA by Shao and Zhong (2017) describes MLD as ...a massage technique which helps to stimulate excess fluid reflux by mimicking pumping action of lymphatic vessels. This seems to infer the Dr Vodder method, but selection criteria for the studies did not specify only Vodder MLD, nor is this description given an accurate representation of the physiological effect of Vodder's MLD.
Why does it matter what technique was used?
The very precise stretching and torquing of the skin - MLD - as taught by the Vodder and Foldi schools has a direct action on the lymphatic smooth muscle, which responds by increasing the rate and force of lymph-motoricity ('pumping' of the lymph collector vessels). This creates a suction effect at the distal vessels and more fluid enters the lymphatic system from the surrounding tissue.
This effect is created through stimulation of the stretch-receptor reflex, a part of the sympathetic nervous system that control the lymphatic smooth muscle. The stimulation is passed through spinal reflexes and the vessels in the contralateral limb also respond with increased lymph-motoricity. If the technique is performed for about 15 minutes or longer a systemic effect is created whereby all the lymph vessels in the body begin to work harder. This effect may then be sustained well after the treatment has concluded.
MLD is performed by stretching and releasing the skin without sliding
Most other schools teach lymphatic effleurage - which should not be called MLD as manual lymph drainage is the name the Vodders gave their very non-effleurage technique to differentiate it from other forms of massage. Lymphatic effleurage uses a retrograde stroke along the length of the collector vessel, emptying the vessel and allowing it to fill up from more distal areas. It does not create the same contralateral effect as MLD and is not sustained once the stroke is finished.
Lymphatic Effleurage uses retrograde stroking to empty lymph vessels
That's not to say lymphatic effleurage does not work. Even Vodder trained therapists will teach people with lymphoedema to do their own self-massage using lymphatic effleurage.
Because the client can use this form of self-treatment regularly and frequently at home this frequent clearing of the lymphatic vessels has a cumulative effect, it is also easy to perform. However, if use by a therapist at a single session will be less effective than MLD.
What does the literature tell us?
If we are looking to the literature to guide our clinical practice, the results of any published study that does not define the technique applied cannot be used to determine whether or not 'MLD' is a beneficial part of comprehensive lymphoedema therapy. This lack of distinction about the method invalidates most of the published studies on the effectiveness of 'MLD'. The good news is that as a result of more rigorous guidelines for reporting clinical trials, future studies should more clearly state the exact techniques used. But as therapists, we will still need to be discerning about how we read published articles.
The abstracts of a selection of articles that specify the Dr Vodder method are pasted below.
De Groote M, Jonnart C, Puissant F, Buisset J, Schlikker E. Lymphoscintigraphic evaluation of the efficiency of manual lymphatic drainage. European Journal of Lymphology and Related Problems. 1992;3(11):85-7.
Using lymphoscintigraphic techniques, thirteen women with lower limbs swelling have been studied before and after treatment (manual lymphatic drainage according to Vodder's Method, 20 x 30 minutes, ten weeks). Using T- Student test for paired values, all scintigraphic parameters (time to reach lymph node, nodal uptake of the tracer and residual activity in lymph vessels) were demonstrated to be improved after treatment (p < 0.01). The results demonstrate in clinical conditions the efficiency of manual lymphatic drainage on lymphatic system.
Johansson K, Lie E, Ekdahl C, Lindfeldt J. A randomized study comparing manual lymph drainage with sequential pneumatic compression for treatment of postoperative arm lymphedema. Lymphology. 1998;31(2):56-64.
We compared manual lymph drainage (MLD) with sequential pneumatic compression (SPC) for treatment of unilateral arm lymphedema in 28 women previously treated for breast cancer. After 2 weeks of therapy with a standard compression sleeve (Part I) with maintenance of a steady arm volume, each patient was randomly assigned to either one of two treatment regimens (Part II). MLD was performed according to the Vodder technique for 45 min/day and SPC was performed with a pressure of 40-60 mmHg for 2 hours/day. Both treatments were carried out for 2 weeks. Arm volume was measured by water displacement. Arm mobility, strength, and subjective assessments were also determined. Lymphedema was reduced by 49 ml (7% reduction) (p = 0.01) in the total group during Part I. During Part II, the MLD group decreased by 75 ml (15% reduction) (p < 0.001) and the SPC group by 28 ml (7% reduction) (p = 0.03). The total group reported a decrease of tension (p = 0.004) and heaviness (p = 0.01) during Part I. During Part II, only the MLD group reported a further decrease of tension (p = 0.01) and heaviness (p = 0.008). MLD and SPC each significantly decreased arm volume but no significant difference was detected between the two treatment methods.
Koul R, Dufan T, Russell C, Guenther W, Nugent Z, Sun X, et al. Efficacy of complete decongestive therapy and manual lymphatic drainage on treatment-related lymphedema in breast cancer. International Journal of Radiation Oncology Biology Physics. 2007;67(3):841-6.
Objective: To evaluate the results of combined decongestive therapy and manual lymphatic drainage in patients with breast cancer-related lymphedema. Methods and Materials: The data from 250 patients were reviewed. The pre- and posttreatment volumetric measurements were compared, and the correlation with age, body mass index, and type of surgery, chemotherapy, and radiotherapy was determined. The Spearman correlation coefficients and Wilcoxon two-sample test were used for statistical analysis. Results: Of the 250 patients, 138 were included in the final analysis. The mean age at presentation was 54.3 years. Patients were stratified on the basis of the treatment modality used for breast cancer management. Lymphedema was managed with combined decongestive therapy in 55%, manual lymphatic drainage alone in 32%, and the home program in 13%. The mean pretreatment volume of the affected and normal arms was 2929 and 2531 mL. At the end of 1 year, the posttreatment volume of the affected arm was 2741 mL. The absolute volume of the affected arm was reduced by a mean of 188 mL (p < 0.0001). The type of surgery (p = 0.0142), age (p = 0.0354), and body mass index (p < 0.0001) were related to the severity of lymphedema. Conclusion: Combined decongestive therapy and manual lymphatic drainage with exercises were associated with a significant reduction in the lymphedema volume.
SHAO Y. & ZHONG D.-S. (2017) European Journal of Cancer Care 26, e12517, doi:0.1111/ecc.12517 Manual lymphatic drainage for breast cancer-related lymphoedema Breast cancer-related lymphoedema (BCRL) is a common sequela of surgical or radiation therapy of breast cancer. Although being an important part of conservative therapy, the role of manual lymphatic drainage (MLD) on BCRL is still debating. The objective of the current systematic review and meta-analysis was to determine whether the addition of MLD to the standard therapy (ST) could manage BCRL more effectively.
We searched PubMed, EMBASE and Cochrane Library for related randomised clinical trials to compare the volume reduction, improvement of symptoms and arm function between groups with or without MLD. Four randomised controlled trials, with 234 patients, were included.
Results showed there was a significant difference in volume reduction between MLD plus routine treatment and sole routine treatment. Current trials show that adding MLD to the ST could enhance the effectiveness of treating volume reduction of lymphoedema, but might not improve subjective symptoms or arm function.