This document provides information on manual lymph drainage for treating lymphedema. It describes the lymphatic system and causes of lymphedema, stages of lymphedema, and complete decongestive physiotherapy. It details techniques for manual lymph drainage including direction of strokes, basic movements like pumps and circles, sequence of treatment, and truncal and extremity drainage patterns. The goal is to encourage lymph flow and reduce swelling through light skin stretching and movement toward lymph nodes.

1. 淋巴水腫之物理治療
楊靜蘭
臺大醫院復健部物理治療技術科
台大物理治療學系兼任講師

2. Lymphedema
 Abnormal accumulation of tissue
proteins, edema, and chronic
inflammation within an extremity

3. Primary lymphedema
 Malformation or malfunction of the
lymphatic system
- hypoplasia
- hyperplasia: too large collector,
valve not working properly
- aplasia

4. Secondary lymphedema
 Surgery- lymph node removed
 Radiotherapy- scar tissue
 Trauma
 Infection
 Filariasis
 Paralysis or immobility
 Chronic venous insufficiency

5. Stages of lymphedema
 Stage I: edema is pitting and reversible
 Stage II: spontaneous irreversible
proliferation of connective
tissues, hardening of the extremity
 Stage III: elephantiasis, papilloma
cartilage-like hardening

6. 完整之減腫脹物理治療法
 Complete decongestive physiotherapy
 Complex physical therapy
 Complex lymphedema therapy
 Decongestive lymphatic therapy

7. Complex physical therapy
 Intensive phase: 4 wks
 Maintaining phase: 6-9 months
- enlarging collateral lymphatics
linking obstructed lymphotomes to
normal ones
- connective tissue, loose skin
remodel

8. 完整之減腫脹物理治療法
 Manual lymph drainage
 Bandaging
 Exercise
 Skin care
(International society of lymphology, 1997)

9. Manual lymph drainage (1)
 Purpose: mechanically move fluid into
initial lymphatic; cause collateral
lymphatics that cross the watershed
become larger

10. initial
lymphatic
precollector
collecting vessel
Superficial
lymphatic
system
Deep
lymphatic
system
16: perforating lymphatics

12. Watersheds
 Sagittal,horizontal- four quadrant
(lymphotome), each section consisting of a
limb and the adjacent quadrant of the trunk
(Fig)
 Boundaries between the areas of lymph
drainage, the direction in which lymph drains
 Linear area on the skin and contain few lymph
collectors
 Some lymph fluid may cross the watershed via
lymph capillaries (initial lymphatic plexus)

14. Horizontal Watersheds
 Upper horizontal watershed: a line from the
jugular notch (manubrium) to the aromion,
and continues posterior to the vertebral
levels between C7 and T2;separates the
neck and shoulder territory from the
territories of the arm and thorax
 Lower horizontal watershed: start at the
umbilicus and follows the caudal limitation
of the rib cage to the vertebral column

15. Anastomoses
 small lymphatic vessel
 anterior axillo-axillary, P-A-A
 anterior inter-inguinal, P-I-I
 axillo-inguinal (Fig)

17. Manual lymph drainage (2)
 Skin movement：outer 0.3mm of the skin
 Rich bed of lymph capillaries in the
superficial tissues
 Stretches the microfilaments just below the
skin which control opening to the initial
lymphatic, thus allowing interstitial fluid to
enter the lymphatic system while also
stimulating lymph vessels to contract

18. Lymph collectors
 Lymph angion: 6-20 mm, up to 10cm
 Lymph transportation

19. Manual lymph drainage (3)
 Pressure: very light, gentle; the softer
the tissue, the lighter the pressure, as
trying to move one Kleenex over the
surface of another Kleenex
 30~40mmHg
 1.5~8 ounces/square inch (pressure
found in the collecting lymphatics)

20. Manual lymph drainage (4)
 40-90 mins on consecutive days
 Direction: toward the lymph node
 Speed: the greater the amount of fluid, the
slower the movement
 Rhythm: maintain connection with the
same area for at least a minute, repeating
the stroke with the same pressure,
direction, and speed

21. Manual lymph drainage (5)
 Direction: stretching the lymphatics
longitudinally, horizontally, and
diagonally; toward the lymph node
(neck, axilla, and groin)
 Does not include long strokes, heavy
pressure, rapid movements (ex:
percussion)

22. Direction
 Upper body: between the
waist and clavicle;
between the waist and
spine of the scapula on the
dorsum of the trunk
 R’t axillary nodes: right
arm and right side of the
trunk
 L’t axillary nodes: left arm
and left side of the trunk
 Neck: medial side of each
breast, along the sternum

23. Direction
 Lower body:
 Inguinal nodes in front:
superficial lymphatics in the
buttocks drain laterally
around the body to the
inguinal nodes in front
 Lateral area of the posterior
thigh draining laterally
around the leg
 Medial area of the posterior
thigh draining medially
around the leg

24. Lymph node
 Function: produce lymphocyte/filter
lymph
 Do not regenerate
 Sensitive to radiotherapy
 Lymph circulation slows down at the
lymph nodes, prone to congestion

25. Factors influence lymph move
 Do not have a central pump like the heart of the
blood circulatory system
 Lymph angion
-Random spontaneous contraction of the smooth
muscle wall of the lymph vessel
-Stretch reflex of the angions, start and stop
depending on whether the pressure inside the
lymphatics exceeds or falls
 Pumping of the arterial system
 Pumping of the skeletal muscles during
activity(Fig)
 Pressure changes in the thorax during breathing

26. Factors influence lymph move
 Low amplitude body movement, ex:
walking 40 paces/min, tend to empty
lymphatics in the chest and abdomen
 External mechanical factor: manual
lymphatic massage

27. Basic movements
• Stationary circle
• Thumb walk, thumb circle
• Pump, pump-chase
• Scoop
• “J” strokes, “Jay walk”
• Flat hand push: only stretches the
lymphatics in one direction
• Figure 8

28. Stationary circle
• Working phase: Straight stretch-
oval-shaped stretching of the skin;
slight compression at the beginning
of the movement, stretch of the
tissues at the end of the movement
• Zero phase

29. Thumb walk, thumb circle
• Applied with the palmer surface of
the thumb
• Primarily on the hand and foot, face,
bony protuberance

30. Pump
• on the extremities, gently compress
the tissues and scoop or stretch the
skin toward the appropriate lymph
node
• Working phase: the hand is placed on
the skin with ulnar deviation and
wrist flexion, finger extended, thumb
in opposition to the fingers, transit
to radial deviation and wrist
extension

31. Scoop
• Applied on distal extremities, spiral
shaped movement
• Working phase: hand in ulnar
deviation and pronation
(perpendicular to the pathway of
lymph collectors), web space between
the index finger and thumb is in
contact with the skin, gliding over the
skin in a spiral like movement

32. Rotary, “J” strokes, “Jay walk”
• on the back of the torso, thigh
• Hand in an elevated position and
parallel to the pathway of lymph
collectors, wrist in flexion, all finger
tips in contact with the skin
• Palm placed on the skin in an elliptical
movement (over the ulnar side)

33. Fibrosis technique
• Kneading: the fibrotic tissue is lifted
softly from the underlying tissue in
an S-shape
• Fibrotic tissue fold is lifted and the
other hand pressing down on it
• Contraindicated in the area of
radiation fibrosis

34. Sequence
• Begin on the well side first: massage
lymph node and trunk quadrant
opposite to the edematous side
• Clearing across the watersheds
• Clearance of deep truncal areas
• Massage the lymph nodes and trunk
quadrant closest to the edematous
limb
• Massage the proximal area of the
edematous limb
• Massage the distal area of the
edematous limb
• Lymph node

35. Truncal decongestion
for unilateral secondary U/E lymphedema
• Terminus
• Lateral neck lymph node (20 circles, 6-10 cirs/s)
• Anterior thorax on the contralateral side
– Axillary lymph node
– Thoracic breathing
• Activation and utilization of the AAA/PAA/AI
anastomosis
• Inguinal lymph nodes on the ipsilateral,
affected side
• Intercostal and parasternal techniques on the
affected trunk quadrant to utilize deep
drainage pathway

36. Extremity
for unilateral secondary U/E lymphedema
• Upper extremity
• Lymph nodes
superficial- supratrochlear (cubital) nodes
deltoideopectoral nodes (Fig)
deep- axillary nodes (Fig)
Lymphatic vessels
superficial- dense plexus of the palm
radial(cephalic vein), medial(median),
ulnar(basilic) forearm bundle (Fig)

37. Extremity
for unilateral secondary
U/E lymphedema Subclavian
trunk
Lateral
upper arm deltoideopectoral
nodes
• Mesothenar territory/Medial
forearm territory/Medial
upper arm territory Medial upper arm
• radial hand territory/radial
forearm territory/axillary,
supraclavicular lymph node
• ulnar hand territory/ulnar
forearm
Mesothenar territory
territory/antecubital lymph
ulnar hand territory
node

38. Pectoralis major muscle
along the clavicle (7 7s
stationary circle
AAA
AI
•Sternum ->
parasternal
•Rib cage (near nodes
the axilla, below
the breast)

39. •Lateral edge of
scapula &
PAA underarm region
of the trunk
IA (thoracic portion)
Thoracic spine

40. Intercostal technique
The intercostal lymph nodes occupy
the posterior parts of the intercostal
spaces, in relation to the intercostal
vessels.
They receive the deep lymphatics from
the postero-lateral aspect of the chest
The efferents of the glands in the lower
four or five spaces unite to form a trunk,
which descends and opens either into the
cisterna chyli or into the commencement
of the thoracic duct.
The efferents of the glands in the upper
spaces of the left side end in the thoracic
duct; those of the corresponding right
Stationary circle with 3
spaces, in the right lymphatic duct
or 4 finger pads, with
pressure working deep
(perforation precollector)

41. Truncal decongestion
for bilateral secondary U/E lymphedema
Supine
• Lateral neck lymph node
• Abdominal treatment/diaphragmatic breathing
• Inguinal lymph nodes on both sides
• Activation and utilization of the AI
anastomosis on both sides (rotary technique
and stationary circle)
• Intercostal and parasternal techniques on the
both affected trunk quadrants to utilize deep
drainage pathway

42. Abdominal treatment
• Superficial abdominal treatment:
Increase lymph transport within the
thoracic duct and larger lymphatic
trunks
• Deep abdominal treatment:Caudal
part of the thoracic duct, the
cisterna chyli, the pelvic and lumbar
lymph node are stimulated

43. Truncal decongestion
for unilateral secondary L/E lymphedema
• Lateral neck lymph node
• Axillary lymph nodes on the ipsilateral,
affected side
• Activation and utilization of the IA
anastomosis on the affected side (rotary
technique and stationary circle)
• Inguinal lymph nodes on the contralateral
side
• Activation and utilization of the AII/PII
anastomosis
• Abdominal treatment/diaphragmatic
breathing
• Paravertebral technique

44. Lumbar area
• Area outlined by the lower
horizontal watershed, horizontal
gluteal fold, and the sagittal
watershed Paravertebral
• Effleurage, starting at the lympn node
posterior sagittal watershed
toward the inguinal LN
• PII
• Paravertebral lymph node
Stationary circle paravertebrally
with the finger pads (working deep)

45. Truncal decongestion
for bilateral secondary L/E lymphedema
Supine
• Lateral neck lymph node
• Abdominal treatment/diaphragmatic
breathing
• axillary lymph nodes on both sides
• Activation and utilization of the IA
anastomosis on both sides (rotary
technique and stationary circle)

46. Practice
• Lower extremity
Lymph nodes- anterior tibial node,
popliteal node, inguinal node (Fig),(Fig)
lymphatic vessels
superficial- medial (great saphenous vein),
lateral (small saphenous vein)
deep- anterior/posterior tibial, peroneal (Fig)

47. Collectors on the L/E
• inguinal node/ pelvic lymph node/ lumbar
lymph node/ lumbar trunk / cisterna chyli/
thoracic duct
• Collectors from the dorsum of the foot/
ventromedial territory/ skin of the lower leg,
except an area in the middle of the calf/
follow the great saphenous vein/ pass behind
the medial condyle of the femur/ superficial
inguinal LN
• Dorsolateral territory/ drain skin in the middle
of the calf/ follow the small saphenous vein/
superficial popliteal LN/ deep popliteal LN/
deep inguinal LN

48. Lower quadrant
• Terminus
• Deep abdomen- lumbar node chain
• Inguinal nodes
• IT band (upper/middle/lower)
• Rectus femoris (upper/middle/lower)
• Gracilis (lower half of the medial thigh)
• Flush knee: thumb scroop
• Lower leg

49. Lower quadrant
• Ankle, metatarsal, lateral malleolus: thumb
scroop；
• center of sacrum, off each side
stretch laterally over waist
• Popliteal lymph nodes
• Gluteal region to knee
• Knee to ankle
• stationary circle between the malleoli and
Achilles tendon tendon
• Dorsum and sole of the feet
• Inguinal node

50. Genital lymphedema
 Usually irreversible without treatment,
tends to become more fibrotic and
increases in size
 Malignant/primary/secondary
 Combined penile and scrotal swelling
 Genital swelling should precede the
sequence for leg lymphedema
 Complications including lymphatic cysts,
fistula, lymphorrhea, bacteria and mycotic
infection

51. Genital lymphedema treatment
 If fistula is present, wearing sterile gloves for
treatment
 Lateral neck lymph node
 axillary lymph nodes on both sides
 Activation and utilization of the IA
anastomosis on both sides
 Inguinal lymph nodes on both sides
 Abdominal treatment/diaphragmatic
breathing
 Treatment of the scrotum

52. Face and neck
• Indication:
• Local injury (bruising and swelling), dental
surgery or cosmetic surgery
• Low energy resulted of stress, overwork,
or depression can depress the immune
system
• Tense facial muscles- MLD not only move
lymph, it is deeply relaxing
• Unhealthy skin-MLD remove toxins

53. Face and neck
• Contraindication:
• open wounds, incisions, scratches and
abrasions should allow to heal
• Local swelling due to allergies,
hormones, steroids, fatigue, infection,
excess salt in the diet

54. neck
• Performed on both sides of the neck and
face
• Supraclavicular nodes: 20 stationary
circles over the sternal and clavicular
attachments of the SCM muscle, 7s /circle,
3 mins
• 20 stationary circles on the area between
the ear and the mastoid process, posterior
and inferior to the ear (parotid and
retroauricular lymph node)

55. neck
• Drain the nodes along the region of
the SCM muscle, stationary circles 7
times,7s/circle, total 3-4 mins
(lateral cervical lymph node)
• 8-10 mins to drain the cervical lymph
nodes

56. Direction
• Face and neck
• Lymph nodes in the neck: lymph from
the superficial lymphatics of the
head
• Occipital nodes: lymph from the top
of the head, back of the head, then
drain toward the cervical nodes
(along the SCM)
• Pre-auricular and mandibular nodes:
lymph from the fascial lymphatics,
then drain into the cervical nodes

57. neck
• Place the flat fingers of both hands under
the neck, 7 7s stationary circles over the
cervical vertebrae, on the sides of the
neck, 7 7s stationary circles
• Two flat fingers inside the triangle formed
by the SCM, the clavicle, and the scalene
muscle, 7 7s stationary circles
• Under the chin, under the jaw line (midway
between the chin and the angle of the jaw),
under the ear (submandibular LN)

58. neck
• Thyroid cartilage
• Depression between the cartilage and
the SCM muscle

59. Posterior neck and
occipital area
• Deep lateral cervical lymph node
• Occipital and parietal region,
retroauricular lymph node and
parotid LN
• Upper trapezius m (in the direction
of the supraclavicular fossa)
• Paravertebral lymph node

60. face
• Pretreatment: lateral neck
• In the direction of the angle of the jaw
• On the chin (below the bottom lip), 7 7s
stationary circle (submental, submendibular
LN)
• Deep lateral cervical LN
• Above the jaw line, over the molar
• Lower and upper jaw
• Bridge of the nose and cheek
• Upper lip/ Corners of mouth

61. face
• 2nd and 3rd fingers: tip/bridge/root of the nose,
lower eyelids, toward the cheeks, to
supraclavicular fossa
• Medial corner of the eyes, upper eyelid and
eyebrow, to preauricular LN
• Corner of the mouth
• Chin (below the bottom lip)
• Over the region of the molar teeth
• Masseter
• On the region of the TMJ
• Eye sockets (below the eyebrows)
• Forehead toward preauricular LN

62. face
• Temple (temporalis)
• Two fingers in front, two fingers behind
the ear
• Scalp
• TMJ
• Masseter
• Between the ear and mastoid process
• sternal and clavicular attachment of the
SCM

63. Contraindications
 cancer (malignancy): metastasis
 open wounds, rashes, inflamed skin
 fever
 Infection
 heart or kidney disease (CHF, kidney
dialysis)：edema may occur, MLD increasing
blood volume by returning fluid to the blood
circulation
 low blood pressure

64. Contraindications
 Asthma
 Hyperthyroidism, Hypothyroidism
 blood clots and phlebitis:
-avoid massage for two weeks after surgery
-consult physician for patients taking coumadin
-Homan’s test
-warmer, reddened, swollen varicose vein
 organ transplant: immune suppressing medication
 chemotherapy

65. Compression therapy
 Max reduction in 7-10 days
 Tissue looses elasticity, does not
return to original position and shape
even when fluid ↓
 Improve muscle pumping action,
increase total tissue pressure
 Padding

66. Compression therapy
 Bandages
 Special garments

67. Bandage (1)
 first
7-10 days, consecutive day
 short-stretch bandage:low resting p,
high working p
 Graded compression: greater
compression distally and lesser
proximally, amount of pressure
determined by layer of bandages

68. Bandage (2)
 Should not bandage when
- infection
- circulatory, nerve, or arterial
insufficiency problem
- pain or numbness
- recurrence of cancer

69. Special garments
 used when arm size is fairly stable
 Prevent swelling and maintain size of
the limb
 20-40mmHg; 40-50mmHg in severe
case
 During physical activity and exercise

70. Vasopneumatic pump (1)
 Little or no lasting beneficial effects
 Fail to move lymph into different
lymphatic quadrant
 May cause fibrotic ring on the arm
 May damage remaining healthy lymph
vessels

71. Vasopneumatic pump (2)
 Keep the pressure low-never
>35mmHg
 Used with comprehensive tx:self-
massage to the neck and trunk
 Segmental gradient compression
starting at fingers and moving up
toward the shoulder

72. Vasopneumatic pump (3)
 Contraindication
- infection of the limb
- local or proximal malignancy
- anti-coagulant p’t
- DVT
 Palliative pumping – adjunct to pain
control in patient with advanced
carcinoma

73. Exercise
 Wear bandage or compression
garment during ex
 Abdominal breathing exercise
- clearance of deep trunk area
 Lymph drainage exercise
 Stretching and flexibility exercise
 Strengthening exercise
 Aerobic exercise

74. Lymph drainage exercise
• Pelvic tilt
• Partial sit-up with breathing
• Neck rotation
• Head tilt
• Shoulder shrug
• Shoulder rolls
• Shoulder blade squeeze
• Isometric hand press

75. Lymph drainage exercise
• Shoulder rotation
• Elbow bend
• Wrist circle
• Fist clench
• Finger exercise
• breathing

76. Stretching and flexibility ex
 Breast ca: tightness in the pectoral
area or ↓shoulder mobility
 For shoulder joint
cane exercise
door or corner stretch, towel
stretch

77. Strengthening exercise
 Allow to do more activity without
triggering the lymphatic response
 Watch if swelling persist 24 hours
after ex
 Mastectomy: Shoulder blade and
shoulder girdle muscle group of the
arm may weaken; abdominal muscle
(Schmitz, 2009)

78. Aerobic exercise
 Increase lymph flow (coupled with
deep breathing), lose weight
(obesity:higher risk for developing
lymphedema and breast ca)
 Walking or bicycling, swimming when
it’s cool
 UBE

79. Education
 Avoid infection and injury
 Avoid pressure on the involved
extremity
 Avoid constrictive clothing
 Avoid vigorous activity
 Avoid heat
 Keep skin in good condition

80. Education
 Maintain ideal body weight
 Avoid extended use of Diuretics
 Eat healthful foods