Manual lymphatic drainage (MLD) is a special massage technique that primarily has the goal of improving lymph flow in the body and loosening hardened tissue. As opposed to conventional massages, MLD focuses on the lymphatic system which plays an important role during the “detoxification” of the body. This medical massage is performed by specifically trained lymphatic therapists, usually physiotherapists with an additional qualification. By making gentle, circular and pumping movements, excess fluid is removed from the tissue, and drainage of lymph is promoted. In addition to the reduction of swelling, it is also used for pain alleviation and relaxation.
Manual lymphatic drainage is a specialist physiotherapy technique or medical form of massage that stimulates the lymphatic system. After the cardiovascular system, the lymphatic system is the most important transport system in the human body. It consists of lymphatic organs and vessels that are tasked with the removal of waste substances. The individual lymphatic pathways run through the whole body and end in the lymph nodes where the lymph is filtered. A lot of lymph nodes can be found in the neck area, in the armpits and around the groin. Others are located deeper within the body, e.g. in the abdomen. MLD is often used to treat lymphoedema, i.e. excessive accumulation of lymphatic fluid. Treatment consists of various techniques. Using gentle, rhythmical and circular hand movements on the skin, the fluid in the lymphatic pathways is stimulated to drain. MLD has a decongesting effect and reduces pain caused by tension. Manual lymphatic drainage can also be beneficial in cases of lipoedema. Lipoedema is a painful fat distribution disorder in the legs or arms. MLD cannot reduce fat cells in number or size but it can alleviate pain and make the tissue a little softer.
During manual lymphatic drainage, the patient lies comfortably on a treatment bed. The lymphatic therapist uses special hand techniques with gentle movements to stimulate lymph flow. The therapist follows the natural direction of the lymph vessels in the body to loosen blockages and to direct the fluid towards the lymph nodes where it is filtered and moved on. This technique requires dexterity and precision to get ideal results.
Manual lymphatic drainage: upper body
Before treatment starts, the doctor takes a thorough medical history including pre-existing conditions and problems. During MLD, the therapist systematically clears the drainage pathways. During this process, several areas of the body are always treated to activate different parts of the lymphatic system. Lymphatic drainage starts with clearing the lymphatic fluid’s central drainage pathways. This stimulates lymph flow. The skin is moved in circular motions in turn in the following areas: the clavicular fossae, below the ear lobes, under the armpits, in the area of the diaphragm, the abdominal region and the groin. That is where key drainage pathways are located, which are cleared during this process. This generates a suction effect that can reach all the way into the extremities. This is followed by the areas of the body that actually have to be treated, such as the legs or arms.
First, the tissue is prepared by carrying out gentle, circular movements and exerting pressure rhythmically on the lymphatic pathways. This makes removal of fluid from the affected area easier. Afterwards, the lymph nodes are stimulated intentionally to achieve increased drainage of the tissue. Specific hand techniques are used for this, which can be adapted as required.
The three main methods of MLD are based on Asdonk, Vodder, and Földi. The four primary terms for hand movements coined by Dr. Emil Vodder are pump, rotary, stationary circle, and scoop. They must all be performed gently and in a mainly circular motions. This stretches the skin. We differentiate between a pushing phase in the direction of the desired drainage and a passive decongestion phase. The movements are adapted to the relevant body part.
In cases of a hardened (manifest) lymphoedema, further movements are required, such as the ring-shaped oedema movement, the comprehensive loosening movement and the comprehensive shifting movement. When these hand techniques are performed, treatment is adapted to the consistency of the tissue – the firmer the oedema, the higher the pressure.
These hand movements activate lymphatic drainage by improving the pumping performance of the lymph vessels. This creates a stimulus for a higher pumping frequency of the smooth muscle cells in the lymphatic pathways. Repeating the movements several times results in an increased flow rate.
Generally speaking, oedemas can develop in any tissue of the body. The arms and legs are affected most often. Therefore, they are the most common target areas in manual lymphatic drainage. However, swelling can also occur in the area of the torso, neck and head as well as the genitals, all of which can be treated with MLD.
The effects of MLD are caused by generating pressure in the tissue, stretching the skin and alternating between pressure and suction. Treatment has the following positive effects:
Manual lymphatic drainage has many benefits. In addition to the reduction of swelling and water accumulation, it can also contribute to pain alleviation, detoxification and improvement of the skin. Furthermore, it promotes the patients’ relaxation and well-being, which can have a positive effect on the whole body and mind. Manual lymphatic drainage is therefore a comprehensive treatment method that offers physical as well as mental relaxation and alleviation.
* This effect, however, has not been medically substantiated.
Manual lymphatic drainage is an important element of both phases of complex manual decongestive therapy (CDT) – of the decongestive and the maintenance phase. CDT includes four basic principles:
Compression therapy
By applying special lymphological compression wraps (e.g. Juzo SoftCompress, combined with short-stretch compression wraps) or adjustable compression wraps (e.g. Juzo ACS Light or Juzo Compression Wrap), lymphatic drainage is supported during the decongestion phase, and the outcome of the decongestion is secured.
During the maintenance phase, medical compression garments are used (e.g. Juzo Expert).
Decongesting movement exercises
Targeted exercises promote lymph flow. A combination ofcompression and movement is ideal.
Skin care
Proper skin care is key to preventing infections.
Manual lymphatic drainage
This special form of massage has been designed to remove accumulated fluid from the tissue. It can be performed in the area of the legs, arms, face and torso.
These four components of CDT are only possible with a fair amount of self-management.
Manual lymphatic drainage has proven very effective when treating lymphoedema. Lymphoedema can have various causes, such as injuries, surgery and even congenital impairments of the lymphatic system. Lymphoedema occurs when the lymphatic drainage is impaired based on a chronic, inflammatory condition of the interstitium (spaces between cells, tissues, organs), resulting in fluid retention in the tissues. This causes restrictions in movements and an increased risk of infection. The increased lymphatic load can seriously damage the vessels in the long term. MLD stimulates lymph flow. It therefore helps to reduce swelling,improve metabolism and strengthen the immune system.
Read more about the subject of lymphoedema on our “Well-informed” page: Lymphoedema.
During the treatment of lipoedema problems, manual lymphatic drainage has also proven effective. In addition to the reduction of swelling and fluid retention, it can also be used for pain alleviation. During the procedure, pain receptors in the skin, also known as C-fibres, are stimulated. This can increase the pain threshold and reduce pain. Following treatment, lipoedema patients are pleased with how light their legs feel and how soft their tissue is. Since the majority of lipoedema patients are also affected by obesity and therefore by the risk of suffering from obesity-related lymphoedema, MLD can treat several conditions at the same time.
Further information about this condition can be found on the “Well-informed” page: Lipoedema.
There are many reasons why manual lymphatic drainage is useful after surgery. First, surgery usually involves cutting the skin. Based on the position of the lymphatic pathways directly under the skin, they are practically always severed during surgery. This causes fluid to build up which can be reduced with MLD. Furthermore, this treatment encourages regeneration of lymph vessels in the severed tissue. Mobility is often restricted after a procedure. The doctor may also prescribe rest and recovery phases at this stage to safeguard the surgical outcome. This means that the muscle pumps are significantly less effective in transporting fluid. Therefore, manual lymphatic drainage is recommended after surgery. In scar therapy, MLD ensures better mobility of the scar. It can also reduce pain and promote healing.
The decision when MLD can be performed after surgery depends on various factors, such as the type of surgery, the individual patient situation and the doctor’s recommendations. The phases of wound healing also play a role.
Before surgery, too, manual lymphatic drainage can be beneficial because it reduces swelling caused by an injury or an illness, thus making the procedure easier.
Useful information about this topic can also be found on the “Well-informed” page: Scars.
During pregnancy, lymphatic fluid accumulates in the tissue of some women because of changed hormone levels. This results in oedema in the legs and feet, and sometimes in the arms and hands. These problems can be alleviated with manual lymphatic drainage and compression stockings. Deep lymphatic drainage in the abdominal and pelvic areas is not recommended.
You can find further information about this topic in our article “Successful duo: pregnancy and compression”.
Manual lymphatic drainage is a gentle form of treatment that usually does not have any serious side effects. But it must still be performed by qualified therapists to get ideal results. In the case of certain conditions or individual problems, there may be contraindications which must be considered before treatment.
Based on the increased quantity of liquid in the bloodstream, the heart is subjected to additional strain. If the patient is suffering from a weakness (cardiac insufficiency), this treatment may pose a risk. Lymphatic drainage must therefore be considered carefully.
Key contraindications:
Make sure you ask your doctor whether a contraindication relating to manual lymphatic drainage exists for you.
Can manual lymphatic drainage be performed by patients themselves?
During manual lymphatic drainage, the entire body is treated systematically using certain hand manoeuvres while the patient is lying down. Therefore, it is not or only partly suitable for self-treatment. Circular movements around the collarbone, under the armpits or below the ears as well as around the abdomen can be carried out by the patient after proper instruction. Certain techniques can be performed on the arms after proper instruction. Body parts that are difficult to access are less suitable. Legs are hard to self-treat because by flexing at the hip, a bend is caused in the groin area which is key for lymph flow.
The following is possible: stimulating breathing and movement exercises or IPC (intermittent pneumatic compression) as well as IIC (instrument-based intermittent compression) using a lymph drainage machine.
What needs to be considered before manual lymphatic drainage?
What needs to be considered after manual lymphatic drainage?
How long does the effect of manual lymphatic drainage last?
Usually, the effect of lymphatic drainage lasts about 24 hours. During the decongestion phase in particular, treatment should therefore take place every day.
How often and for how long should MLD be performed?
Frequency and duration are very individual and depend on different factors, such as the patient’s condition, symptoms, other treatment measures and lifestyle. People who are regularly active usually need treatment less frequently than inactive patients. Chronic conditions such as primary or secondary lymphoedema or lipoedema require long-term treatment. During pregnancy or following surgery, treatment must continue until the swelling no longer occurs even without treatment.
How is MLD prescribed?
Some of those affected are uncertain about the MLD prescription options. Usually, 6 to 10 treatments are prescribed. In case of chronic conditions, up to 36 sessions can be prescribed for 3 months every quarter.
With certain diagnoses, the “doctor’s budget” is not affected. This includes lymphoedema diagnoses from Stage II. MLD prescriptions for lipoedema patients are “budget-neutral” – this regulation will come to an end by late 2025. In cases of lipoedema, what is known as a special prescription requirement applies; in cases of chronic lymphoedema, what is known as long-term requirement for therapeutic measures applies. Depending on the extent and severity of the oedema, MLD lasts 30, 45 or 60 minutes. This is specified on the prescription.
What must be specified on a prescription for manual lymphatic drainage?
The key information for patients concerning an MLD prescription includes number, frequency (e.g. 1-2 x per week) and duration:
From October 2024, more flexible MLD times will be introduced.
How long is an MLD prescription valid for?
A prescription is generally valid for 28 daysfrom the date of issue. If treatment is urgent, it must be started within 14 days. Treatment must not be disrupted for longer than 14 days without good reason.
Is manual lymphatic drainage paid by your health insurer?
Yes, if MLD has been prescribed by your doctor, the health insurance company will pay for it. Its effects have been substantiated in numerous studies and treatment has been regarded as an effective as well as tried-and-tested method for decades. However, patients are required to make a statutory additional payment – unless they are exempt. This additional payment is 10% of the costs of the therapeutic measures as well as EUR 10 per prescription.
In most diagnosed cases, MLD prescriptions will not affect the doctor’s budget.
Is there a training programme to become a lymphology therapist?
Training and qualification are key for treatment success. Lymphatic therapist is not a classic apprenticeship but involves further education where a certificate is awarded. Usually, physiotherapists or medical massage therapists pursue further education at an approved educational institution with the goal to attain this additional qualification. This training with the relevant final examination generally takes several weeks and involves theoretical expertise relating to the lymphatic system as well as practical skills to perform specific massage techniques. It is only then that manual lymphatic drainage can be offered and performed. In order to keep their expertise up-to-date and to learn new techniques, lymphatic therapists should visit continuing professional development courses regularly.