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• Stretching effect on lymph collectors and local smooth muscle, increased the frequency of contraction of lymphangions/
lymph vessels and increased lymphatic transport capacity (Hutzschenreuter and Brümmer, 1988; Hutzschenreuter and
Herpertz, 1993)
• Lymph flow increased (as measured by lymphoscintigraphy) possibly owing to increased rate of contraction of
lymphatics (Francois et al, 1989)
• Variations in interstitial pressures led to enhanced filling and emptying of initial lymphatics (Casley-Smith and Björlin,
1985)
• ‘Call-up’ technique propelled lymph in the collecting lymphatics and exerted a suction effect on distal lymphatics; the
‘reabsorption’ technique moved proteins from a subcutaneous tissue injection site (Leduc, 1988)
• Proximal MLD treatments produced a reduction in distal tissue pressure (Deryden et al, 1994)
• ‘Accessory routes’ within the lymph drainage system appeared to be ‘stimulated’ (Ferrandez et al, 1996)
• Reduction in limb volume occurred, but was not consistent with increased lymph transport as measured by
lymphoscintigraphy (Kafejian-Haddad et al, 2006)
• Blood flow increased in superficial blood circulation and peripheral arteries (Hutzschenreuter et al, 1989)
• Blood flow increased through the femoral vein (Deryden et al, 1994)
• The influence of MLD on the autonomic nervous system produced a calming effect (Hutzschenreuter and Ehlers, 1988)
• Skin circulation improved (Hutzschenreuter et al, 1992)
• Urinary secretion of serotonin, histamine, adrenaline and noradrenaline increased (Kurz et al,1978)
• Breathlessness decreased and sleep improved (Williams et al, 2002)
• Microlymphatic hypertension reduced (Franzeck et al, 1997), although this appeared to be a combined effect of MLD and
compression bandaging
Figure 1: MLD across the back using rotary technique: Vodder to focus on changes in limb volume, using varied or
method poorly defined ways to measure or calculate limb volume,
negating any opportunity for comparison or meta-
analysis. Other outcome measures such as tonometry to
assess changes in skin and tissues (Harris and Piller, 2003),
or measures of symptom changes or quality of life, also
require further validation as a means to evaluate MLD.
Table 4 highlights a sample of studies that have a particular
focus on MLD in breast cancer-related lymphoedema.
Most draw on small samples and some are not randomized
or controlled. Several studies suggest that in some patient
groups, MLD combined with compression bandaging may
be more effective than using compression bandaging alone
(Johansson et al, 1999; McNeeley et al, 2004). However,
specific details of how MLD was used or the effect
measured are often not made clear (Andersen et al, 2000).
Figure 2: Thumb circles to the dorsum of the hand: Vodder Two studies from the UK investigated MLD and
method patient-administered massage (Sitzia et al, 2002; Williams
et al, 2002).Williams et al (2002) undertook a randomized
controlled cross-over study and showed that MLD had
a significant effect in reducing excess limb volume
in women with breast cancer-related lymphoedema
(p=0.013) even without compression bandaging. Similar
results with a trend towards MLD being more effective
were reported by Sitzia et al (2002) although the authors
suggested a larger study sample was required.
Table 4. Evidence: examples of studies of the therapeutic effect of MLD in women with breast
cancer-related lymphoedema
Figure 3. MLD across the midline or ‘watershed’ between two evidence to inform these decisions is limited and as a
skin lymph territories: Casley-Smith method result, it is important that practitioners reflect critically on
their practice in using MLD. Measurement of outcomes
using standardized, valid and reliable methods is crucial,
as is the sharing of results in terms of ‘successes’ and
‘failures’.
It is likely that some patient groups may respond
better to MLD than others. For example, there is some
indication that MLD may be more effective in those with
‘mild’ lymphoedema (McNeeley et al, 2004). Certainly
it is possible that the presence of fibrosclerotic tissues
influences the effect of MLD, rendering it less effective
and indicating that compression therapy in the form of
bandaging may more effective as a first line treatment in
some groups. Equally this may be an indication for early
Figure 4: MLD to the neck: Casley-Smith method intervention with MLD to reverse the changes that may
lead to long-term tissue fibrosis.
While MLD is frequently used in combination with
bandaging, some groups will require MLD as the first-line
treatment. For example, those with oedema of the trunk
and midline are a particular priority for MLD and there
are papers describing the use of MLD in genital oedema
(Katz et al, 2004), breast oedema (Mondry et al, 2002)
and head and neck oedema (Figure 6) (Reiss and Reiss,
2003). Clinical experience suggests that women who have
breast oedema after breast cancer treatment will respond
readily to MLD, with good long-term outcomes. This is
a particular group who may be motivated towards self-
management approaches and may be taught self-massage
of the breast area during a course of MLD. Importantly, the
Figure 5: MLD clearance of superficial inguinal lymph nodes use of MLD in this group may highlight how bodywork
provides a means through which health professionals can
enable people to adjust to and accept changes in their
body after cancer treatment.
The theoretical debate that MLD may somehow promote
metastatic cancer is not substantiated in the minimal
literature (Preisler et al, 1998), nor in clinical practice.
However, this highlights the need for lymphoedema
practitioners to work closely with medical colleagues
to ensure that MLD is appropriately given. It is usually
advisable to delay MLD treatments if someone is receiving
cytotoxic chemotherapy, particularly as the chemotherapy
itself may alleviate an obstructive oedema by reducing
tumour bulk. However, if the focus of care is palliative, it
may not be appropriate to delay lymphoedema treatment,
range of conditions for which MLD may be indicated, as swelling may become poorly controlled. In these
including post-thrombotic syndrome, degenerative situations, MLD can also play an important role in the
nervous system and inflammatory conditions (Asdonk, management of other symptoms such as pain, dyspnoea
1975). Recent papers report on MLD in sports medicine and constipation.
(Vairo et al, 2009), conditions such as fibromyalgia (Ekici While MLD should not be used in the presence of
et al, 2009) and reflex sympathetic dystrophy (Duman acute infection, once antibiotic therapy has begun and
et al, 2009). A potential role for MLD as part of a systemic symptoms have passed, MLD can be considered.
lymphoedema prevention programme is also highlighted MLD is also useful in those with chronic inflammatory
(Torres Lacomba et al, 2010). conditions. If recurrent infection has been a problem,
However, for those using MLD within their daily antibiotic therapy may be indicated during the MLD
practice, a number of questions arise concerning how period as temporary exacerbation of symptoms can
MLD should be used with different groups. As yet, the occur.