O R I G I N A L A R T I C L E

Manual lymph drainage

therapy using light
massage for
fibromyalgia sufferers:
a pilot study
Ragnar Asplund

Fibromyalgia is a syndrome characterised by chronic wide-spread pain, stiffness,

disturbed sleep and sleepiness. Medication with analgesics and antidepressants and also
physiotherapy, are often prescribed and give some relief. Patients’ experiences of
symptom relief from manual lymph drainage therapy (MLDT) by the Vodder method
were examined. Seventeen women aged 49.0 ± 8.7 (mean ± SD) years who had had
fibromyalgia for 16.9 ± 10.1 years were treated with light massage with the MLDT
technique for 1 h on 12 occasions during a 4-week period. Symptoms were evaluated
using visual analogue scales (VAS). Pain, stiffness, sleep, sleepiness and well-being all
improved during the treatment period. Two months after treatment cessation,
significant improvement remained in pain (P < 0:001), stiffness (P < 0:01), sleepiness
(P < 0:01) and well-being (P < 0:001), but not in sleep, and after 5 months in pain
(P < 0:05) and sleepiness (P < 0:01). Preliminary results indicate that MLDT can be
a valuable alternative treatment for patients with fibromyalgia. Controlled studies
are needed.

c 2003 Elsevier Ltd. All rights reserved.

Editor’s comment
Pilot or small-scale studies are useful forerunners to larger more conclusive research. Any research into relieving the
debilitating symptoms of fibromyalgia sufferers must be encouraged.
PD

KEY WORDS: fibromyalgia, manual lymph drainage therapy, pain, stiffness, sleep, well-being

INTRODUCTION post-operative X-ray radiation therapy (Johans-

Ragnar Asplund MD, PhD
Family Medicine Stockholm,
Karolinska Institute, Huddinge,
Sweden.
Correspondence to:
Ragnar Asplund, Tallv€agen
3, S-833 34 Str€omsund,
Sweden.
Tel.: +46-670-100-07;
Fax: +46-63-16-56-26;
E-mail: ragnar.asplund@jll.se
Journal of Orthopaedic Nursing (2003) 7, 192–196 ª 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/j.joon.2003.09.001
Manual lymph drainage therapy (MLDT) has
been proven effective in mobilising fluid in dif-
ferent conditions with lymph-oedema. The de-
velopment of lymph therapy by the method of
Vodder for oedema in cancer treatment, which
started in Germany in the 1960s, has recently
been described (Kasseroller 1998). In Sweden
MLDT has become common in the treatment of
lymph-oedema after breast cancer surgery and
son et al. 1998, Johansson et al. 1999). MLDT is
also useful in post-operative oedema mobilisa-
tion after fractures of the distal radius (H€ar
en
et al. 2000).
In a lymph therapy clinic in the County of
J€
amtland, Sweden, a number of patients were
treated with MLDT for different conditions with
oedema in the period 1999–2000. Unexpectedly,
patients with soft-tissue pain experienced signif-
icant relief, and some of them considered the

pain relief more valuable for them than the oe-
dema reduction itself when they described their
impressions of MLDT to their therapist. The
alleviation of pain seemed to be experienced ir-
respective of the treatment diagnosis and also of
the location of treatment.
In order to re-evaluate these experiences of
the patients a pilot study was undertaken in a
group of women with long-standing fibromyal-
gia. The aim was to test whether pain and other
symptoms might be alleviated with MLDT in a
small group of patients and also to become ac-
quainted with the subjects in order to facilitate
planning of a controlled study.
PATIENTS AND METHODS
Women with long-standing soft-tissue pain,
classified as fibromyalgia, were referred by gen-
eral practitioners or specialists in orthopaedics or
rheumatology to the Lymph Clinic in M€ orsil,
J€
amtland. The medical history was taken and a
physical examination was performed by a gen-
eral practitioner engaged in the project.
Inclusion criteria
Women of ages 18–65 years, fulfilling the criteria
of fibromyalgia adopted by the American Col-
lege of Rheumatism 1990 (Wolfe et al. 1990)
qualified for inclusion.
Exclusion criteria
Women were excluded from the study if they
were pregnant or suffered from diabetes, car-
diovascular diseases, neurological diseases, can-
cer, thrombosis or had a known increased risk of
thrombosis, infections, thyrotoxicosis, alcohol or
drug abuse or any other medical conditions lia-
ble to cause difficulties in diagnostic procedures,
treatment or evaluation of results.
Treatment procedure
The treatment was carried out as very light,
completely pain-free, rhythmical translational
movements of the skin in the flow direction of the
lymph vessels (Kasseroller 1998). The whole body
was treated, but most attention was paid to the
face, neck and trunk. The treatment was given
during a 4-week period, in a 1-h session every
week-day (Monday–Friday) during the first week,
every other day during the second week (three
sessions) and twice weekly in weeks three and four.
Each session was followed by a 15-min rest.
Test instruments
A questionnaire with questions on general health
and previous experiences of fibromyalgia was
Manual lymph drainage therapy 193
filled in before the start of the study. A question-
naire concerning the duration of musculo-skeletal
disease, the employment status and the duration
of musculo-skeletal symptoms was answered be-
fore the start of the study, after 2 and 4 weeks of
treatment, and after three and 6 months after
commencement of treatment. The symptom in-
tensity was followed by recordings on 100 mm
long visual analogue scales (VAS) on the same
occasions concerning general well-being, pain,
stiffness, daytime sleepiness and night sleep. The
patients’ perception of the influence of fibrom-
yalgia on their general ability, working ability and
ability for re-creational activities was similarly
recorded. In all VAS scales, the value “0” repre-
sented the absence of the symptom in question or
the most favourable estimation of the influence.
Statistical methods
Standard methods were used for calculating mean
values and standard deviations. Group compari-
sons of non-numerical data were made with the v2
test. Regression analysis (StatView 5.0 for the
Macintosh) was performed. For comparison of
pairs of numerical data, regression analysis was
used. ANOVA was applied for comparing more
than two series of numerical data.
Ethics
The study was approved by the Ethics Commit-
tee of the University of Ume
a and conducted in
accordance with the rules of the Declaration of
Helsinki.
RESULTS
Seventeen women aged 49.0 (8.7) (mean
[SD]) years met the inclusion criteria and were
included. Their symptom duration was 16.9
(10.1) years.
Before the study began two women were
gainfully employed, one had been sick-listed full-
time for less than 6 months, one for 6–12
months, and two for more than one year, and six
women were receiving a disability pension be-
cause of their disease. In four cases the women
were sick-listed to a certain extent and were
partly receiving unemployment benefit.
In six women, the disease had originated from
accidents or some musculo-skeletal trauma,
while eight women believed that their disease had
mental reasons. Three women considered that
both mechanisms were responsible or had no
idea of the cause of their disease.
Twelve women suffered from musculo-skele-
tal pain every day and at all times of the 24-h
period, four of them for part of the 24-h period
every day and one women part of the time at
194 Journal of Orthopaedic Nursing

least on half of the days of every week. None of Sleep and sleepiness
the women had experienced any significant im-
A longer duration of fibromyalgia was associated
provement or symptom relief during the last
with worse baseline estimates of sleep (r2 ¼ 0:28;
year.
P < 0:05), but not with the sleep development
All women completed the treatment pro-
during the treatment period. During the treat-
gramme and there were no reports on side
ment period, sleep improved in parallel with the
effects.
improvement of pain (r2 ¼ 0:45; P < 0:01). The
sleep improvement during the treatment period
Pain and stiffness did not persist after cessation of treatment
(Figure 3).
According to the VAS scores, the pain improved
Sleepiness improved during the treatment
during the 4 weeks of treatment, and the im-
period, and the improvement remained at the
provement still partly remained at the end of
end of the study period (Figure 4). Neither base-
study period (Figure 1). Two months after ces-
line estimates nor changes in sleepiness during
sation of treatment, the VAS-scored pain had
the treatment period were affected by age or the
returned to 74% of the baseline level and 3
duration of fibromyalgia. Higher VAS scores for
months later it had returned to 91% of baseline.
sleep deterioration were associated with higher
A long duration of fibromyalgia was associated
scores for sleepiness (r2 ¼ 0:33; P < 0:0001).
with greater improvement of pain during treat-
ment (r2 ¼ 0:24; P < 0:05). The improvement of
pain was unaffected by age.
Well-being
Higher VAS scores for stiffness were obtained
in women with high initial pain scores Well-being improved during the treatment pe-
(r2 ¼ 0:60; P < 0:0001), but there was no associ- riod, and the improvement was still experienced
ation between stiffness and either age or fi- at 3 months but not at 6 months (Figure 5).
bromyalgia duration. The stiffness decreased Well-being improved with improvement of
during the treatment period, and this improve- pain (r2 ¼ 0:80; P < 0:0001). Changes in well-
ment persisted at 3 months but not at 6 months being were unaffected by age and fibromyalgia
(Figure 2). duration.

mm mm
80 70

70 60 NS
*
NS
60 *
50
***
50
***
*** ***
40
0 2 weeks 4 weeks 3 months 6 months
0 2 weeks 4 weeks 3 months 6 months

Fig. 1 The development of VAS-scored pain as compared Fig. 3 The development of VAS-scored sleep as compared
with the initial level during and 3 and 6 months after with the initial level during and 3 and 6 months after
commencement of MLDT. *, P < 0:05; ***, P < 0:001. commencement of MLDT. *, P < 0:05; ***, P < 0:001; NS,
P P 0:05.

mm
70 mm 80

60
NS 70

50 **
60 **
*** **
***
***
40 ***
0 2 weeks 4 weeks 3 months 6 months 50

0 2 weeks 4 weeks 3 months 6 months

Fig. 2 The development of VAS-scored stiffness as

compared with the initial level during and 3 and 6 months Fig. 4 The development of VAS-scored sleepiness as
after commencement of MLDT. **, P < 0:01; ***, P < 0:001; compared with the initial level during and 3 and 6 months
NS, P P 0:05. after commencement of MLDT. **, P < 0:01; ***, P < 0:001.

mm
80
70
60 NS
***
***
50 ***
0 2 weeks 4 weeks 3 months 6 months
Fig. 5 The development of VAS-scored wellbeing as
compared with the initial level during and 3 and 6 months
after commencement of MLDT. ***, P < 0:01; NS, P P 0:05.
DISCUSSION
One of the main findings in this pilot study of
women with initially severe pain due to long-
standing and incapacitating fibromyalgia was
that they experienced a substantial reduction in
their pains during treatment with very light
massage in accordance with the technique of
manual lymph drainage therapy (Kasseroller
1998). Although the results of the present study
must be interpreted with caution, the extent of
the pain relief was surprising. Previously, it has
been reported in a double-blind study of 48
women with fibromyalgia that connective tissue
massage gives pain relief in one-third of the
treated women (Brattberg 1999).
An important question in the interpretation of
the data concerns the reliability of self-reported
data in an open, uncontrolled study. The pain
reduction and symptom relief may be explained
by the placebo effect. It has been shown that
among patients with tension headache placebo
treatment may be just as effective in pain relief as
conventional pharmacological treatment in some
patients (Murros et al. 2000). The placebo anal-
gesic effect in this case has been attributed to
modulation of endogenous opiates, and the ex-
pectation in association with the treatment of
pain seems to have strong influence on the out-
come (Montgomery and Kirsch 1997, ter Riet
et al. 1998). However, no reports have been
found describing a pain-reducing placebo effect
of more than a few hours’ duration. Thus the
experience of symptom relief in the present study
as long as 5 months after treatment cessation
may therefore support the view that there might
be an effect of treatment apart from the placebo
effect.
The degree of persistent pain relief three and 6
months after the start of the treatment among
the women of the present study (26% and 9%)
was comparable to that in the above-described
report on treatment with connective tissue mas-
sage (30% and 10%) (Brattberg 1999).
The stiffness was more troublesome in women
with high initial pain than in those with less in-
Manual lymph drainage therapy 195
tense pain. The reduction of stiffness also fol-
lowed that of pain relief during the treatment
period and returned in parallel with the return of
pain after the treatment period had ended.
Sleepiness and sleep disturbances were both
common in the women of the present study, and
these symptoms are well-known findings in wo-
men with fibromyalgia (Korszun 2000). A longer
duration of fibromyalgia was also associated
with more profound sleep dissatisfaction. Sleep
improved along with pain reduction during the
study period, but this sleep improvement did not
persist at follow-up.
Well-being improved in parallel with positive
recordings of the other tested variables. One
question of interest is therefore whether there is a
link between the development of the analysed
symptoms and the health characteristics pain
and stiffness, sleepiness, sleep and well-being
during and after the period of MLDT.
Low levels of oxytocin have been found in
women with fibromyalgia with high pain scores
and in children with recurrent abdominal pain of
non-organic origin (Alfven et al. 1994, Ander-
berg and Uvnas-Moberg 2000). In rats, light
stimulation of the skin by stroking the abdomen
and the lateral sides can elevate the levels of
circulating oxytocin (Kurosawa et al. 1995).
Human infants use their hands to stimulate
their mother’s breast during breast-feeding, re-
sulting in an increase in the maternal oxytocin
level (Matthiesen et al. 2001). Oxytocin has an
anti-nociceptive effect (Lundeberg et al. 1994).
The pain reduction during lymph therapy in the
present study may therefore partly be explained
by increased oxytocin release.
The general perception of well-being was low
at the start of the present study, and increased
during MLDT treatment. This development of
the emotional state may be in line with the
finding that low oxytocin levels are associated
with sadness and increasing oxytocin levels are
associated with an increasing feeling of happiness
(Anderberg and Uvnas-Moberg 2000, Turner
et al. 1999).
In conclusion, pain and stiffness, sleep and
sleepiness and well-being all show a favourable
development during a 4-week period with man-
ual lymph drainage therapy in women with long-
standing fibromyalgia. Although this is an open
study, preliminary results indicate that MLDT
can be an alternative and safe treatment for
symptom relief in patients with this disease.
However, this cannot be stated without con-
trolled studies.
ACKNOWLEDGEMENTS
Financial support from the County Council of J€amtland,
Sweden is gratefully acknowledged.
196 Journal of Orthopaedic Nursing
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