Lymphatic drainage – What does the evidence tell us?

May 10, 2021

On Monday 3rd May 2021, prof. dr. Nele Devoogdt presented an overview of the most recent insights regarding manual lymph drainage (MLD) in patients with lymphedema at the 2nd International Conference on Physical Therapy in Oncology (ICPTO).

In a first part, the preventive effect of MLD was elucidated. Based on the more recent findings in research with substantial methodological quality [1], it is currently impossible to draw firm conclusions about the effectiveness of interventions containing MLD in preventing breast cancer-related lymphedema (BCRL). Also in a recent review and meta-analysis [2] was shown that MLD cannot significantly prevent lymphedema in patients after breast cancer surgery. The consequence of these findings imply that, in clinical practice, there is no indication to include preventive MLD in postoperative physical therapy sessions due to its rather small evidence, the fact that it is time consuming and we rather need this time for other essential evidence-based modalities.

In the second part of the talk, emphasis was placed on the treatment effect of MLD. It is known that MLD exerts a physiological effect (in terms of an enhanced lymphatic transport) after a single drainage session. However, an (even more?) important question we should ask as a health care provider might be: does MLD also provides a clinical and long-lasting effect? Does, for example, the lymphatic volume actually decrease, or does the quality of life of my patient improve in the longer term due to this MLD in particular? Based on reviews and meta-analyses published during the last years [3, 4], there is no statistically significant merit of MLD on top of the other modalities of the complex decongestive therapy in reducing lymphedema volume. Also in the recent review and meta-analysis from Liang et al., 2020 [2], it was concluded that MLD has no statistically significant added value in reducing arm volume in patients with BCRL. However, well-designed RCTs with a larger sample size are required, especially in patients under the age of 60 years or with an intervention time of 1 month.

As a respond to this request for further research in well-designed RCTs with a larger sample size, in 2016 our research team started conducting the EFforT-BCRL trial [5]; a double-blind, multi-center RCT in which the aim was to investigate the effectiveness of fluoroscopy-guided MLD (which is hypothesized to be a more optimized type of MLD since, first of all, the hand manoeuvres had been adapted and, secondly, these are based on the patient-specific lymphatic transport) additional to complex decongestive lymphatic therapy, compared to traditional and placebo MLD, for the treatment of BCRL ( identifier: NCT02609724, EudraCT Number 2015-004822-33). The design and first results of this trial were presented by dr. Tessa De Vrieze during a poster presentation on this congress as well. To summarize, this poster presentation revealed that 194 participants with unilateral chronic BCRL were enrolled for this trial in five study centres in Belgium. Participants were randomised into one of three groups, receiving standard complex decongestive therapy (consisting of education, skin care, compression therapy and exercises) either including fluoroscopy-guided MLD (n=63), traditional MLD (n=63) or placebo MLD (n=64). Participants received 14 sessions of physical therapy during a 3-weeks intensive phase and received 17 sessions during a 6-months maintenance phase. On the other days the participants performed self-management. Primary outcomes were: 1) change in excessive volume reduction of the arm/hand, and 2) change in excessive volume accumulation at the shoulder/trunk. Measurements were performed at baseline, after the intensive phase (=primary endpoint), after 1, 3, 6 months of maintenance phase, and after 6 months of follow-up. In all three groups, excessive lymphoedema volume decreased significantly after three weeks of intensive treatment (p<0.001). No significant differences between the fluoroscopy-guided MLD group and the traditional MLD group, or between the fluoroscopy-guided MLD group and the placebo MLD group were found. An increased fluid accumulation at the level of the shoulder/trunk was present in all three treatment groups, however, this was not significantly different between the groups. As the paper elucidating these results is still in publication, more details of this trial will follow later on. Results from secondary outcomes and sub-group analyses, will be presented in due time.  

Taking into account these findings as well, prof. Nele Devoogdt emphasized that in clinical practice, there is no indication to still include time-consuming MLD in the treatment of chronic BCRL. This because there is lack of studies in which the benefit of MLD in addition to the other components of complex decongestive therapy could be demonstrated.

Furthermore, it was stated that randomized trials investigating the treatment effect of MLD in patients with breast oedema or leg oedema are lacking to date.

Despite these perhaps discouraging findings from literature, this power talk fortunately ended on a reassuring and positive note, stating that oedema therapists should definitely not be afraid of losing their job, as there are still many things to do that are crucial in helping and treating our oedema patients. In these, cornerstones should be: education of patients (also regarding self-management), skin care, exercises, compression therapy and evaluation (not only the swelling itself but also problems in functioning and quality of life).

Tessa De Vrieze


1.         Stuiver MM, ten Tusscher MR, Agasi-Idenburg CS, Lucas C, Aaronson NK, Bossuyt PM. Conservative interventions for preventing clinically detectable upper-limb lymphoedema in patients who are at risk of developing lymphoedema after breast cancer therapy. Cochrane Database Syst Rev. 2015(2):Cd009765.

2.         Liang M, Chen Q, Peng K, Deng L, He L, Hou Y, et al. Manual lymphatic drainage for lymphedema in patients after breast cancer surgery: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore). 2020;99(49):e23192.

3.         Ezzo J, Manheimer E, McNeely ML, Howell DM, Weiss R, Johansson KI, et al. Manual lymphatic drainage for lymphedema following breast cancer treatment. Cochrane Database Syst Rev. 2015(5):Cd003475.

4.         Huang TW, Tseng SH, Lin CC, Bai CH, Chen CS, Hung CS, et al. Effects of manual lymphatic drainage on breast cancer-related lymphedema: a systematic review and meta-analysis of randomized controlled trials. World J Surg Oncol. 2013;11:15.

5.         De Vrieze T, Vos L, Gebruers N, Tjalma WAA, Thomis S, Neven P, et al. Protocol of a randomised controlled trial regarding the effectiveness of fluoroscopy-guided manual lymph drainage for the treatment of breast cancer-related lymphoedema (EFforT-BCRL trial). Eur J Obstet Gynecol Reprod Biol. 2017.