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Its never too early to start MLD

Updated: May 17, 2023

There are an increasing number of systematic reviews (SR) on lymphoedema management and MLD, and a quick search on Google Scholar returned 211 results since 2020.

Many reviews try to differentiate the benefits of comprehensive lymphoedema treatment with or without MLD, or in comparison to compression devices. But almost all of them fail to deliver any truly conclusive results, other than that we need more and better quality research.

They all suffer from three main problems

  1. The heterogeneous nature of lymphoedema makes large scale studies difficult - SRs work best when they amalgamate many large scale RCTs on heterogenous subjects. Variation in the quality and methodology of studies exacerbates this and frequently prevents meta analysis

  2. Poor description of MLD techniques without sub-analysis on the technique used - not all MLD techniques create the same physiological responses in the body, and MLD techniques used for fibrosis are rarely included.

  3. Selection criteria limit the inclusion of studies which have not measured changes in limb size, and therefore often fail to capture other outcomes of interest such as fibrotic induration, frequency of cellulitis infection etc.

Despite these problems, many SRs will report an additional benefit of MLD on a secondary outcome such as pain or patient reported symptoms. Or in a subgroup, such as was reported in two recent reviews which included studies clearly identified as the Dr Vodder method or one of its many derivatives (therefore suffering less from problem number 2). The report by Liang et al (1) showed that MLD did have added benefit for people younger than 60, and the review by Thompson et al (2) found some evidence for MLD to prevent onset in early breast cancer patients, and to reduce arm volume in early stage lymphoedema compared to moderate or later stages.

The finding by Thompson et al is particularly interesting in light of what we know about lymphoedema onset and progression, and why we vary the application of MLD for different stages.
Change in lymph vessels as lymphoedema progresses

Since lymphedema begins with an accumulation of excess free fluid, an increase in lymphatic pumping - such as is induced by the shearing forced applied during MLD - can easily suction out this freely moving fluid. But as lymphoedema progresses the excess fluid is replaced by fibrous and fatty deposits and even the lymph vessels themselves become fibrosed. Simply increasing the suction effect of the lymph system may have little effect in volume reduction. So its not surprising that when results are reported by stage, as in the Thompson et al review (2), there is better evidence for the use of MLD to reduce limb volume in the earlier stages, but less so in the later stsges. The finding by Liang and colleagues (1) that MLD benefits a younger age group, may also be an indication that MLD has a better effect in earlier lymphoedema. Unfortunately they did not present results by stage, but it is possible that younger participants may also have had milder disease.

What neither review has captured is the way that we adapt how MLD is applied as lymphoedema progresses

the middle and latter stages we need to focus more on addressing fibrosis and maintaining good skin integrity. In these stages compression is required to reduce and maintain limb size, and it's not surprising that the addition of MLD doesn't add significantly to the volume stats. But that doesn't mean that we don't still need the MLD, and what is frequently reported in SRs are significant improvements in secondary outcomes such as pain, range of movement, and quality of life. Since these outcome measures are not usually the primary outcome under investigation by the review, they tend to be buried in the results and not well highlighted in the conclusions.

If only there was a vaccine against lymphoedema!

Prevention is better then cure is one of the most recognised sayings in regards to our health, and lymphoedema is a classic example. We have a brief but crucial window of opportunity during the first few months after surgery or other traumatic tissue injury, to support and stimulate repair of the lymphatic system. This also applies to scarring, and over a longer timeframe to neural repair, so MLD plays an important role in this early treatment phase.

The earlier you provide frequent systemic support to the lymphatic, venous and nervous systems, the better things heal and the less likely there will be long term consequences.

The one thing consistently reported in systematic reviews is that more and better quality research is needed. I'd like to qualify that and suggest that the research needs to be on specific aspects of lymphatic therapy, on each stage of lymphoedema, and including more nuanced outcome measures. This would give us much better guidance in our clinical practice and allow us to tease out which therapies will have the most benefit at each stage of disease.

Read more research here

1) Liang, M., Chen, Q., Peng, K., Deng, L., He, L., Hou, Y., . . . Li, L. (2020). Manual lymphatic drainage for lymphedema in patients after breast cancer surgery: A systematic review and meta-analysis of randomized controlled trials. Medicine, 99(49), e23192. doi:10.1097/md.0000000000023192

Background: Studies have shown that manual lymphatic drainage (MLD) has a beneficial effect on lymphedema related to breast cancer surgery. However, whether MLD reduces the risk of lymphedema is still debated. The purpose of this systematic review and meta-analysis was to summarize the current evidence to assess the effectiveness of MLD in preventing and treating lymphedema in patients after breast cancer surgery. Methods: From inception to May 2019, PubMed, EMBASE, and Cochrane Library databases were systematically searched without language restriction. We included randomized controlled trials (RCTs) that compared the treatment and prevention effect of MLD with a control group on lymphedema in breast cancer patients. A random-effects model was used for all analyses. Results: A total of 17 RCTs involving 1911 patients were included. A meta-analysis of 8 RCTs, including 338 patients, revealed that MLD did not significantly reduce lymphedema compared with the control group (standardized mean difference (SMD): −0.09, 95% confidence interval (CI): [−0.85 to 0.67]). Subgroup analysis was basically consistent with the main analysis according to the research region, the publication year, the sample size, the type of surgery, the statistical analysis method, the mean age, and the intervention time. However, we found that MLD could significantly reduce lymphedema in patients under the age of 60 years (SMD: −1.77, 95% CI: [−2.23 to −1.31]) and an intervention time of 1 month (SMD: −1.77, 95% CI: [−2.23 to −1.30]). Meanwhile, 4 RCTs including, 1364 patients, revealed that MLD could not significantly prevent the risk of lymphedema (risk ratio (RR): 0.61, 95% CI: [0.29–1.26]) for patients having breast cancer surgery. Conclusions: Overall, this meta-analysis of 12 RCTs showed that MLD cannot significantly reduce or prevent lymphedema in patients after breast cancer surgery. However, well-designed RCTs with a larger sample size are required, especially in patients under the age of 60 years or an intervention time of 1 month.

2) Thompson, B., Gaitatzis, K., Janse de Jonge, X., Blackwell, R., & Koelmeyer, L. A. (2020). Manual lymphatic drainage treatment for lymphedema: a systematic review of the literature. Journal of Cancer Survivorship. doi:10.1007/s11764-020-00928-1

Abstract Purpose Manual lymphatic drainage (MLD) massage is widely accepted as a conservative treatment for lymphedema. This systematic review aims to examine the methodologies used in recent research and evaluate the effectiveness ofMLD for those atrisk of or living with lymphedema. Methods The electronic databases Embase, PubMed, CINAHL Complete and Cochrane Central Register of Controlled Trials were searched using relevant terms. Studies comparing MLD with another intervention or control in patients at-risk of or with lymphedema were included. Studies were critically appraised with the PEDro scale. Results Seventeen studies with a total of 867 female and two male participants were included. Only studies examining breast cancer-related lymphedema were identified. Some studies reported positive effects ofMLD on volume reduction, quality of life and symptom-related outcomes compared with other treatments, while other studies reported no additional benefit ofMLD as a component ofcomplex decongestive therapy. In patients at-risk, MLDwas reported to reduce incidence oflymphedema in some studies, while others reported no such benefits. Conclusions The reviewed articles reported conflicting findings and were often limited by methodological issues. This review highlights the need for further experimental studies on the effectiveness ofMLD in lymphedema. Implications for Cancer Survivors There is some evidence that MLD in early stages following breast cancer surgery may help prevent progression to clinical lymphedema. MLD may also provide additional benefits in volume reduction for mild lymphedema. However, in moderate to severe lymphedema, MLD may not provide additional benefit when combined with complex decongestive therapy.


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