**8. Manual lymphatic drainage**

There are four recognized techniques of MLD: the Földi [121], Vodder [122], Casley-Smith [123] and Leduc [124].

The four methods of MLD show some differences, but the major basic principles are very similar. In short, the maneuvers should be applied softly (with specific exceptions), should consist of a skin-stretching form of massage (not sliding), should comply with the direction of lymph flow, should be done using the entire hand or exceptionally with fingers, and should begin at the proximal regions of the extremity [122–126].

MLD is used as a conservative treatment of lymphedema, independently of the specific method [127]. In the case of the Leduc method, MLD consists of a skin-stretching [127] form of massage that applies low pressure (<40 mm Hg) to the underlying tissues [124] along the anatomical distribution of the superficial lymphatic vessels and ganglions, stimulating lymph flow [128, 129] and the reabsorption of interstitial fluid and macromolecules through the lymphatic circulation [124, 128, 129]. At the lower extremity, the call-up maneuver, a technique belonging to the Leduc method initiates with inciting (or call-up) maneuvers in the inguinal region (ganglionar stimulation) and then progresses distally along the lower extremity down to the edematous region, again employing call-up maneuvers, in order to stimulate lymph flow by enhancing the contractility of lymphagions of lymph collectors, [128, 129]. The reabsorption maneuver, another Leduc technique, is then applied over the edema to drain the interstitial fluid and soluble macromolecules through the lymphatic circulation [128–130] by stretching the leak filaments (connections between connective tissue to endothelial cell of lymphatic capillaries) when the skin is mobilized [128–130]. The whole procedure ends with a second round of call-up maneuvers, which are then applied in the reverse direction, ending at the groin region, in the case of the lower limb [128, 129]. Technically, the call-up maneuver initiates with the most proximal part of the hand and ends with the hands touching the skin while producing skin-stretching and is applied to promote the increase of lymph flow [128, 129]. The reabsorption maneuver initiates with the most distal part of hand and ends with hands touching the skin while applying skin-stretching [128, 129].

#### **8.1. Contraindications/Precautions**

literature, like ligation, stripping and venous phlebectomy, subfascial endoscopic perforator

In CVD, compression, like that provided by stockings, is recommended as a primary treatment, except when patients are candidates for vein ablation, in which case compression is also suggested as an adjuvant treatment, particularly to prevent ulcer recurrence [33]. Compression therapy is recommended as a complement to surgery (like stripping), and to venoactive drug treatment, in order to control edema and pain, and to enhance venous ulcer healing [33].

The severity of the disease is related with the difficulty of the peripheral venous system to evacuate the venous blood from the periphery in the direction of the heart [33], resulting in venous stasis [33, 115]. Furthermore, it is assumed that there is a strict relation between blood flow velocity and secondary deep vein thrombosis [114]. The prevention of stasis is a main goal in CVD treatment and decisive in preventing venous complications and is frequently done through conservative approaches. Conservative CVD treatment might include intermittent pneumatic compression [116], compression stockings and bandages [77, 117, 118], and muscle pump activation using electrical muscle stimulation [77, 119], transcutaneous electrical nerve stimulation [119], or active and passive movements [103, 119]. In this regard, MLD maneuvers may be an alternative treatment to enhance venous flow [21–23]. Nevertheless, this intervention needs specialized professionals and could be an expensive health care treatment. Teaching caregivers or patients simple lymphatic drainage, despite the lower efficacy showed in the treatment of lymphedema, when compared with MLD applied by profession-

The important role played by the ankle range of motion and calf muscle strength in the efficacy of CMPF is now widely recognized [30, 36, 43, 45, 90]. Likewise, altered CMPF seems to play a key role in the physiopathology of CVD [30, 36, 43, 45]. Physical exercise is nowadays widely recommended for CVD management [90, 120]. In previously conducted randomized controlled trials, exercise training in patients with CVD [90] or with post-thrombotic syndrome [120] was shown to improve calf muscles' peak torque at slow (60º/s) and fast (120º/s) speeds [90], maximal heel rise repetitions [120], CMPF [90], and HRQL [120]. However, the role of physical exercise in ameliorating the measures of clinical severity of CVD or in improving few performance features, such as joint range of motion or work and power ability of

There are four recognized techniques of MLD: the Földi [121], Vodder [122], Casley-Smith

The four methods of MLD show some differences, but the major basic principles are very similar. In short, the maneuvers should be applied softly (with specific exceptions), should consist of a skin-stretching form of massage (not sliding), should comply with the direction of lymph flow, should be done using the entire hand or exceptionally with fingers, and should

ankle plantarflexors could not be clearly demonstrated [90, 120].

begin at the proximal regions of the extremity [122–126].

surgery or valve reconstruction [66].

160 Clinical Physical Therapy

als [25], could be an alternative.

**8. Manual lymphatic drainage**

[123] and Leduc [124].

There are several contraindications and precautions for MLD and decongestive lymphatic therapy. It is suggested that cardiac, pulmonary and renal functions should be monitored because of temporary increase in blood flow and circulatory loading [73]. As for the contraindications, the literature describes erysipelas, lymphatic systemic infection and lymphangitis, meaning inflammation of the lymphatic system, as absolute contraindications for MLD and decongestive lymphatic therapy [131]. Severe renal and heart failure are also contraindications for the use of multilayer bandages and intermittent pneumatic compression [132], whereas caution should be enforced when employing MLD in patients with severe cardiac insufficiency [128, 131, 132]. Unstable hypertension, thyroid dysfunction, hepatic cirrhosis with abdominal fluid (ascites), superior vena cava obstruction, untreated tuberculosis or malaria, are also contraindications for physical treatment [131, 132]. If swelling occurs for a long time after initial breast surgery, medical examination should be sought and any physical treatment will be stopped if inflammation occurs [132]. Also, Crohn disease, recent surgery, and diabetes are some additional clinical conditions that may be monitored for precaution [73].

#### **8.2. Manual Lymphatic Drainage in Lymph edema**

There are several indications for the use of MLD other than lymphedema, like CVD, postthrombotic syndrome, chronic wounds, traumatic edema (iatrogenic, postsurgical, and musculoskeletal injury), complex regional pain syndrome, and lymphedema [73].

The evidence of MLD for the treatment of edema (related to cancer or traumatic during sport activity, or other orthopedic injuries) [25, 26, 133] and in improving functional status (related to total knee arthroplasty) [24] is unclear but has been considered somehow effective, but more research is needed. Nevertheless, MLD might have an important role in CVD by improving HRQL, symptoms [134, 135], and range of motion [24] when edema/lymphedema is present. In palliative treatment, MLD improves pain and dyspnea [25].

Based on a systematic review, the importance of MLD for preventing the incidence of lymphedema is unclear [25]. A meta-analysis shows that MLD does not provide further therapeutic benefit in reducing lymphedema related to breast cancer, when compared to the standard treatment or with compression therapy [25], but another study has demonstrated a benefit when employing MLD in these cases [136]. However, the small benefit of MLD must be evaluated together with its cost in terms of time and money spent by patients and health care systems and such cost-benefit evaluation favours the option for compression therapy by using multilayer bandages or compression hosiers and adding MLD only if the response to treatment is unsatisfactory [136].

Lymphatic drainage employing a simpler sequence, but using the same principles as MLD, in a way that can be applied by patients as a self-drainage [137, 138] is less effective than MLD in reducing limb volume or lymphedema related to breast cancer but can be used as a more economical MLD option [25].

It has been also suggested that MLD, despite the augmentation of lymph flow (increasing lymphagion contraction and lymphatic reabsorption), might also be responsible for increasing arteriolar blood flow, redirection of flow toward collateral vessels, anastomoses, and perhaps stimulating angionesis, but these hypothetical effects of MLD need scientific evidence [73].

Younger patients, those heavier in weight and higher in body mass index are more likely to show poor lymphedema treatment outcome after intensive decongestive therapy [25]. When an elastic sleeve and multilayer bandaging are associated to MLD, there is a higher chance that the lymphedema treatment is successful [139].

Decongestive lymphatic therapy is the physical treatment for lymphedema by combining MLD with other treatments, like low-stretch bandaging and compression garments, exercise, and skin care, and sometimes also with intermittent pneumatic compression [30, 127, 140]. This method may reveal itself as effective in the treatment of lymphedema of the lower limb as it is for that affecting the upper limb as a result of cancer [135, 141].

Most often, decongestive lymphatic therapy is applied along two phases: the first is the edema reduction and intensive one, and the second one is the maintenance phase [127, 142, 143].

Decongestive lymphatic therapy is often prescribed for patients with venous ulcer and when CVD are associated with mixed edema (lymphatic and venous origin), now combining MLD, compression bandages, and stocking, physical therapy to improve calf muscle performance, and in few cases, intermittent pneumatic compression [16]. In the case of CVD, wearing compression garments is essential for treatment efficacy [16, 143].

#### **8.3. Manual lymphatic drainage in CVD**

#### *8.3.1. The technique*

The evidence of MLD for the treatment of edema (related to cancer or traumatic during sport activity, or other orthopedic injuries) [25, 26, 133] and in improving functional status (related to total knee arthroplasty) [24] is unclear but has been considered somehow effective, but more research is needed. Nevertheless, MLD might have an important role in CVD by improving HRQL, symptoms [134, 135], and range of motion [24] when edema/lymphedema

Based on a systematic review, the importance of MLD for preventing the incidence of lymphedema is unclear [25]. A meta-analysis shows that MLD does not provide further therapeutic benefit in reducing lymphedema related to breast cancer, when compared to the standard treatment or with compression therapy [25], but another study has demonstrated a benefit when employing MLD in these cases [136]. However, the small benefit of MLD must be evaluated together with its cost in terms of time and money spent by patients and health care systems and such cost-benefit evaluation favours the option for compression therapy by using multilayer bandages or compression hosiers and adding MLD only if the response to treat-

Lymphatic drainage employing a simpler sequence, but using the same principles as MLD, in a way that can be applied by patients as a self-drainage [137, 138] is less effective than MLD in reducing limb volume or lymphedema related to breast cancer but can be used as a more

It has been also suggested that MLD, despite the augmentation of lymph flow (increasing lymphagion contraction and lymphatic reabsorption), might also be responsible for increasing arteriolar blood flow, redirection of flow toward collateral vessels, anastomoses, and perhaps stimulating angionesis, but these hypothetical effects of MLD need scientific evi-

Younger patients, those heavier in weight and higher in body mass index are more likely to show poor lymphedema treatment outcome after intensive decongestive therapy [25]. When an elastic sleeve and multilayer bandaging are associated to MLD, there is a higher chance

Decongestive lymphatic therapy is the physical treatment for lymphedema by combining MLD with other treatments, like low-stretch bandaging and compression garments, exercise, and skin care, and sometimes also with intermittent pneumatic compression [30, 127, 140]. This method may reveal itself as effective in the treatment of lymphedema of the lower limb

Most often, decongestive lymphatic therapy is applied along two phases: the first is the edema reduction and intensive one, and the second one is the maintenance phase [127, 142, 143].

Decongestive lymphatic therapy is often prescribed for patients with venous ulcer and when CVD are associated with mixed edema (lymphatic and venous origin), now combining MLD, compression bandages, and stocking, physical therapy to improve calf muscle performance, and in few cases, intermittent pneumatic compression [16]. In the case of CVD, wearing com-

is present. In palliative treatment, MLD improves pain and dyspnea [25].

ment is unsatisfactory [136].

162 Clinical Physical Therapy

economical MLD option [25].

that the lymphedema treatment is successful [139].

as it is for that affecting the upper limb as a result of cancer [135, 141].

pression garments is essential for treatment efficacy [16, 143].

dence [73].

The manual technique of MLD is not usually described in the literature. Nevertheless, based on research [21–23], the hands of the physical therapist must do the maneuvers producing a low pressures form of skin stretching. The pressure applied by the hands onto the skin and underlying soft tissues should be carefully adjusted to remain soft and just enough to stretch the skin for at least 4 s. When both legs are treated, the whole session take approximately 40–45 min [17, 18, 21]. The duration and the number of sessions at the studies assessing the role MLD in CVD patients [17, 18] are similar, during 2–5 weeks, patients should complete 10–14 sessions of MLD.

The sequence of the maneuvers follows that commonly used for lymphedema, first, moving from proximal to distal and, second, moving from distal to proximal [128, 129]. The maneuvers can be applied in the following sequence: inguinal region (10 MLD maneuvers), progressing downwards through the thigh, (30 MLD maneuvers at medial and 30 at lateral aspect of thigh), the popliteal region (10 MLD maneuvers applied immediately above the popliteal fossa and another 10 times maneuvers performed immediately below the popliteal fossa), downwards to the leg (30 MLD maneuvers at medial and lateral aspect of leg), and finishing in the dorsal aspect of the foot 30 MLD maneuvers). Next, the maneuvres should be carried out in the reverse order upwards: 15 maneuvers on the dorsal aspect of the foot, 15 maneuvers both on lateral and medial aspect of the leg, 5 maneuvers both below and above popliteal fossa, 15 maneuvers above both the lateral and above the medial aspect of the thigh, 5 MLD maneuvers on the inguinal region (**Figure 1**)[21]

#### *8.3.2. Physiological effects in venous hemodynamic*

Some studies suggest that MLD has an effect on blood flow in superficial veins, especially through the call-up maneuver [144]. Also the real impact of MLD in hemodynamics has been suggested to be insignificant [128]. One study concluded that 5 to 15 minutes of MLD does not

**Figure 1.** Venous ultrasound assessment at popliteal vein during 1st and 10th calf contraction. Venous ultrasound assessment at popliteal vein during 1st (A) and 10th (B) calf contraction, during tiptoe movement for both control (no CVD) and CVD (C0 –C4 ) groups.

change cardiac output in patients with heart failure despite the near 100% increase in venous return after 5 minutes of MLD [128]. Nevertheless, recent studies reveal that in real-time the blood flow in superficial and deep veins increase, despite the presence or absence of venous pathology [22, 145].

Current concepts regarding MLD indicate that each maneuver should take around 4 s from beginning to end [22, 23, 129]. MLD techniques, which are based on manual stretching of the skin and underlying soft tissues, increase venous blood flow along the superficial veins, as has already been suggested [144], but also along the deep venous system, which course beneath the deep fascia. As commonly taught, the call-up maneuver is applied in a proximal to distal direction and enhances venous blood flow. The reabsorption maneuver instead begins distally and then moves proximally, stimulating lymph flow and fluid reabsorption [129]. One study does not substantiate such differential effects between the two maneuvers [22]. In fact, the two maneuvers enhanced venous blood flow to a similar extent and in both deep (femoral vein) and superficial (great saphenous vein) veins.

The amount of strain applied to the skin and deeper tissues by MLD is not known. Although studies using radiolabelled tracers demonstrate the efficacy of MLD in stimulating lymph flow, the exact mechanisms by which these techniques work are not fully elucidated [121, 130]. Skin and deep fasciae are connected by ligamentous structures at the level of the thigh, knee, popliteal fossa, and leg, which give stability to the skin and act like an anchor during lower limb movements [146]. The skin stretching applied during MLD might produce enough increase in pressure upon underlying structures to enhance venous flow in superficial and deep veins, as occurs during the physiological stretching of the skin during limb movement [147].

MLD must take into account venous anatomy and venous blood flow direction just like the lymphatic anatomy and the lymph flow directions, particularly when applied to larger body segments (like the course of GSV), such as the thigh, to be more effective in increasing venous flow [23, 128, 129, 145, 148].

The increased blood flow in the superficial veins would result in higher blood flow across perforating veins and into the deep veins, thereby raising blood flow in the deep venous system as well. In addition, the pressure applied to the skin, as said before, would probably reach the muscles underneath, and pressure would also increase in deep seated structures including veins, further stimulating blood flow. Also, muscle tone might increase during the time MLD techniques are being applied, induced by the manual stimulation, or in response to the movement of the lower extremity, which could have contributed to the observed increase in venous blood flow.

#### *8.3.3. Therapeutic efficacy of manual lymphatic drainage for treatment of patients with chronic venous disease*

MLD has also been used as a conservative treatment for CVD, [16], mostly when venous lymphedema is present [19, 20]. MLD applied before surgery in patients with CVD improves the clinical class of CEAP classification, HRQL, depression, anxiety, edema, and symptoms [17, 18, 21]. Nevertheless, foot volumetry and reflux volume index only improve when MLD is associated to surgery and compression stockings [17, 18].

change cardiac output in patients with heart failure despite the near 100% increase in venous return after 5 minutes of MLD [128]. Nevertheless, recent studies reveal that in real-time the blood flow in superficial and deep veins increase, despite the presence or absence of venous

Current concepts regarding MLD indicate that each maneuver should take around 4 s from beginning to end [22, 23, 129]. MLD techniques, which are based on manual stretching of the skin and underlying soft tissues, increase venous blood flow along the superficial veins, as has already been suggested [144], but also along the deep venous system, which course beneath the deep fascia. As commonly taught, the call-up maneuver is applied in a proximal to distal direction and enhances venous blood flow. The reabsorption maneuver instead begins distally and then moves proximally, stimulating lymph flow and fluid reabsorption [129]. One study does not substantiate such differential effects between the two maneuvers [22]. In fact, the two maneuvers enhanced venous blood flow to a similar extent and in both

The amount of strain applied to the skin and deeper tissues by MLD is not known. Although studies using radiolabelled tracers demonstrate the efficacy of MLD in stimulating lymph flow, the exact mechanisms by which these techniques work are not fully elucidated [121, 130]. Skin and deep fasciae are connected by ligamentous structures at the level of the thigh, knee, popliteal fossa, and leg, which give stability to the skin and act like an anchor during lower limb movements [146]. The skin stretching applied during MLD might produce enough increase in pressure upon underlying structures to enhance venous flow in superficial and deep veins, as

MLD must take into account venous anatomy and venous blood flow direction just like the lymphatic anatomy and the lymph flow directions, particularly when applied to larger body segments (like the course of GSV), such as the thigh, to be more effective in increasing venous

The increased blood flow in the superficial veins would result in higher blood flow across perforating veins and into the deep veins, thereby raising blood flow in the deep venous system as well. In addition, the pressure applied to the skin, as said before, would probably reach the muscles underneath, and pressure would also increase in deep seated structures including veins, further stimulating blood flow. Also, muscle tone might increase during the time MLD techniques are being applied, induced by the manual stimulation, or in response to the movement of the lower extremity, which could have contributed to the observed increase

*8.3.3. Therapeutic efficacy of manual lymphatic drainage for treatment of patients with chronic* 

MLD has also been used as a conservative treatment for CVD, [16], mostly when venous lymphedema is present [19, 20]. MLD applied before surgery in patients with CVD improves the clinical class of CEAP classification, HRQL, depression, anxiety, edema, and symptoms

occurs during the physiological stretching of the skin during limb movement [147].

deep (femoral vein) and superficial (great saphenous vein) veins.

pathology [22, 145].

164 Clinical Physical Therapy

flow [23, 128, 129, 145, 148].

in venous blood flow.

*venous disease*

Previous studies show that MLD (10 sessions in 2 weeks) used in CVD patients who were referred to vascular surgery is effective in diminishing pain and edema and in improving HRQL [17]. When employed for a longer period of time (14 sessions in 5 weeks), MLD also seems to effectively contribute, together with surgery, to improve CVD severity [18]. However, such effect of MLD could be explained by faster recovery during the post-operative time. However, a recent study reveals that MLD (4-weeks period of MLD treatment, comprising ten 40 to 45 min-duration of each of 10 sessions) has a real effect in improving CVD-related symptoms, pain-HRQL and clinical severity (mostly related to venous edema), independently from vascular surgery, with the positive outcomes of MLD persisting after 1 month followup [21]. Nonetheless, MLD seems to be ineffective in changing leg volume, ankle muscles strength, ankle active range of motion, and the physical, social or psychological components of HRQL of CIVIQ [21].

There is no evidence that MLD treatment may significant change ankle muscles performance (either during plantarflexion or during dorsiflexion) and ankle range of motion. However, the role of physical exercise in ameliorating the measures of clinical severity of CVD or in improving some performance features, such as joint range of motion or work and power ability of ankle plantarflexors, could not be clearly demonstrated [90, 120].

However, the possibility that MLD might improve ankle function during more natural activities, such as gait, has not been assessed yet.

MLD increases peripheral venous blood flow in superficial and deep veins in normal limbs and in those with CVD and may be an important conservative treatment for prevent blood stasis and its complications [21–23, 125]. The prevention of stasis, by increase venous return, is a main goal in CVD treatment and decisive in preventing venous complications, and there are several conservative approaches [114]. During the application of the MLD maneuver (with pressure <40 mmHg), the volume of venous blood outflow from deep and superficial veins increases substantially without collapsing the veins [22, 23].

Studies suggested that despite the increase of venous flow during MLD being similar in healthy and CVD groups (C1\_5), in most severe cases of this disease this augmentation might not occur [22, 23]. CVD causes significant damage to the skin and underlying tissues. Persistent inflammation of the skin leads to disease complications such as lipodermatosclerosis, characterized by fibrosis and microcirculatory changes [149], leg edema [27] may interfere with the movement of the skin and underlying soft tissues essential to MLD efficacy.

The adherence to compressive stockings is usually decisive to manage symptoms and complications of CVD and venous stasis [150]. Some studies refer the importance of wearing compression stocking during the application of MLD [17, 18]. In one study, 23 out of the 41 patients did not wear compression stockings and only four participants fully adhere to this treatment, with no influence on MLD efficacy. However two patients in the control group (no MLD treatment) were excluded during the study because they present deep venous thrombosis and coincidently these two participants did not comply with the use of compression stoking [21].

#### **8.4. Recommendations for treating CVD with MLD**

MLD should be applied as a low pressure, manual skin-stretching form of massage applied from distal to proximal throughout the lower limb, with the two hands of the physical therapist placed side by side and respecting the anatomy and flow of venous vessels, in order to increase venous return from the lower limb in subjects with or without CVD (C1\_5).

MLD treatment for CVD should be applied during 2–5 weeks; patients should complete 10–14 sessions (45 min duration for both legs) of MLD. The sequence of MLD maneuvers should be applied proximal to distal, followed by a sequence in reverse direction (i.e., from distal to proximal) such as recommended for lymphedema [124, 128]. Because inflammation may be present in these patients, direct manual skin-stretching should be avoided over the edema, as for local inflammation in lymphedema. Although there is no evidence of the efficacy of MLD in treating venous ulcer (C6 ), it can be applied in these patients as long as no contraindications are present [21].

Despite no evidence that MLD prevent secondary complications associated to venous stasis, like venous thrombosis, the use of MLD may be an option to increase superficial and deep venous flow [23, 104]. In particular, MLD is recommended before venous surgery and should be complemented with compression stockings [17, 18].

It is recommended to use MLD to relief edema, symptoms, severity of disease, and ameliorate HRQL. These effects are more consistent when MLD is used as a coadjutant treatment of compression stocking [17, 18, 21]. When adherence to compression treatment is difficult, MLD can be an option to relief symptoms and improve HRQL in patients with CVD [21].

Compromised muscle pump function, low muscle strength, and limited ankle range of motion can be addressed with other conservative approaches, like physical exercise.
