New Developments in MLD Techniques

New Developments in MLD Techniques

This article is taken from the Winter 2019 issue of LymphLine, the LSN’s quarterly newsletter available to all LSN members. For details of how to become a member, click here.

The LSN is receiving an increasing number of enquiries regarding advances in lymphatic drainage massage that are being made as a result of Fluoroscopy imaging. The LSN requested the following articles which explain how and why things are changing, their influence on the way many MLD practitioners are carrying out massage, and how these new developments might benefit you.

First, Jane Wigg, Nurse Consultant at LymphVision and Director/ Trainer of the Lymphoedema Training Academy shares her expertise on developments in MLD. 

Jane Wigg


Manual Lymphatic Drainage, or MLD, is a specialist form of massage carried out by trained therapists and used to stimulate the lymphatic system. Unfortunately, for a variety of reasons, MLD is not widely available on the NHS. In the late 1980s, partly in response to this but also to allow people to carry out more frequent treatments for themselves to maintain their condition between clinic appointments, pioneers of lymphoedema management such as Caroline Badger and Eunice Jeffs introduced Simple Lymphatic Drainage, (now called Self Lymphatic Drainage), SLD. In SLD individuals carry out a simplified version of the massage for themselves.

Why is SLD changing?

Techniques have developed somewhat over the years due to science, our common sense and greater understanding but have basically stayed the same. However, recent developments in our ability to map how lymphatics are working in individuals in ‘real time’ have led to some significant changes in how therapists who use this technique work and in the advice that they offer to patients.

New assessment tools for lymphoedema are always evolving. I have been working with the imaging tool of lymphofluoroscopy or ICG fluorescent imaging for the last 5 years. This imaging technique allows us to see lymphatics moving in ‘real time’. A small amount of tracer is injected under the skin and a specialist camera is used to show where the lymphatics are working or failing (Fig 1). Lymphofluoroscopy Imaging has allowed us to evaluate many treatments and products used in lymphoedema therapy. One such treatment is Manual Lymphatic Drainage and our new knowledge has led us to develop a new technique of MLD which has in turn led to changes in Self Lymphatic Drainage (SLD). The MLD technique that we have developed is called Fluoroscopy Guided MLD (FG-MLD®) or ‘Fill&Flush’.

FG-MLD® was pioneered by Professor Belgrado from Brussels and is internationally recognised as a method of MLD taught in many countries by the Lymphoedema Training Academy (LTA).

This article will discuss some of the changes that have taken place due to the new understanding that we have gained from lymphofluoroscopy. It will outline some of the advice that is provided to the groups of patients I see at LymphVision and that we teach to our students (often your therapist) through the Lymphoedema Training Academy (LTA).

Often those living with lymphoedema are discharged from clinics on a regimen of what is called maintenance therapy, consisting of skin care, exercise, compression and SLD. All of these things are very important but I firmly believe that most people want to see an improvement in their swelling rather than to maintain it. Certainly where SLD is concerned we want to achieve a reduction in the swelling and this might mean changing what you do and how often you do it! The frequency of SLD might need to be increased to 4-6 times per day. I suggest you imagine you have a ‘pot’ of fluid, for example 500mls and when you carry out your SLD you remove 50mls, then it comes back throughout the day, and you remove it again in the evening… only to return overnight! If you increase the frequency of your SLD, you are much more likely to reduce the oedema, reducing the long-term involvement later. Of course, all lymphoedemas are different and therefore the filtration or filling of your lymphoedema will be different to someone else’s. So they may need SLD 4 times a day to manage their lymphoedema and you may need it just twice a month for top up.

Because of this change in how we think about SLD, we now prefer to call SLD ‘Movement and Drainage’.

Figure 1.

‘With ‘Movement and Drainage’, “the more you drain, the more you gain!” emptying the nodes frequently and often. If you can do this, you are usually onto a winner and gain some improvement.’

We now also understand that the lymphatic system will drain in its own unique way and that we have little influence over it. We can, however, force the fluid to where it drains normally, in an attempt to improve that drainage. We have learnt that one area of focus that is important is the emptying of lymph nodes. Generally, lymph nodes only empty if you are moving, especially moving the areas the nodes are in! Remember that your nodes are in places that naturally empty with movement – so as you move your arms and legs, the more the nodes empty and therefore the more drainage is possible. When you don’t move, or have a static job, the nodes do not empty, and you get a backlog of fluid, maintaining (or not improving) the swelling.

With ‘Movement and Drainage’, “the more you drain, the more you gain!” emptying the nodes frequently and often. If you can do this, you are usually onto a winner and gain some improvement.

Lymphofluoroscopy imaging has allowed us to take the guess work out of MLD and to improve outcomes by informing our knowledge about where fluid drains and how it is processed. An example of this is that we are often told that our legs drain to our axilla (armpits) when in fact very few people (7%) drain their bodies this way and you actually gain more from your SLD by emptying the groin nodes than you do by trying to drain fluid to the arm pit. However, if you have swelling to the level of the belly button you have an increased chance of draining this way. I have seen this drainage route in only 5 people I have mapped and only one person who did not have a genital lymphoedema.

From our experience and the feedback from lymphofluoroscopy we now know common pathways that the lymphatics drain and this allows us to advise on the most effective ways to use massage to help yourself. For example, get into the habit of emptying your nodes several times throughout the day, particularly if you are not very active or have an inactive job. It is not as complicated as it sounds – simply take a soft sponge ball or even a clean ball of socks, pop it in the nodal area that is appropriate for you, behind the knee, in your groin, under your armpit, (Figures 2–4 below) then move the limb to squeeze the ball, do this 4-5 times.

You can see how to carry out this movement with drainage technique by visiting our Facebook page Lymphoedema Training Academy @lymphtraining and you can find a therapist who has had training in the technique by visiting our website

All lymphoedema is different so what works for one, may not work for another. Generally, what we know now is different from what we knew 20 years ago but it is not one rule for all. Lymphofluoroscopy mapping has allowed us to improve our knowledge and by passing this on to you we hope it will enhance the treatments that you can provide for yourself. By making these small but important changes, emptying your nodes more frequently, and carrying out SLD more often for a few weeks, you may well improve some of your swelling. And of course, by not having to spend time draining places that we know we don’t drain to, means it’s a win-win and you get more of your life back too. You do not need to have individual mapping to be able to use the knowledge that we have gained but if you would like to be individually mapped, we’re happy to help you with that too.

The second article is written by Jeanne Everett, Chair of the Macmillan Lymphoedema Association (MLA), who has also shared her experience.

The Macmillan Lymphoedema Education Project was led by Dr Jacquelyne Todd with the aim of standardising teaching across the UK of the Casley-Smith method of Manual Lymphatic Drainage and Multi-Layer Lymphoedema Bandaging. Following completion of this programme, the Macmillan Lymphoedema Association was formed over 10 years ago.

The Macmillan Lymphoedema Association offer standardised courses – accredited and non-accredited – throughout the UK. Accredited courses are delivered at degree and masters level providing students the opportunity to gain an academic qualification alongside specialist skills.

The team at MLA

The courses are open to nurses, physios and other healthcare professionals as well as fully qualified Vodder therapists who want to learn an alternative approach to Manual Lymphatic Drainage, a specialist massage technique used in the treatment of lymphoedema.

The Macmillan Lymphoedema Association meets annually to consolidate, evaluate and develop their own skills and knowledge. Teaching materials are updated regularly in response to research and development in the treatment of lymphoedema – allowing the MLA to continue to offer standardised, informative and high quality education for specialist lymphoedema management.

We use our expertise to develop training materials and teach hundreds of health care professionals across the UK about the management of lymphoedema.

We are part of the Casley-Smith International group of educators and clinicians aiming to improve the standard of lymphoedema care internationally.

Our high-quality teaching is used to deliver accredited university courses, as well as non-accredited courses which do not involve academic work leading to higher education points but do include listing as a Casley-Smith MLD practitioner.

The Casley-Smith technique is based on the Földi method
and follows the principles of re-direction within a compromised lymphatic system which provides more flexibility for treating patients.

It provides a systematic approach to the clearance of lymphatic drainage regions, comprising of hand manoeuvres, effleurage strokes and breathing exercises. Delivered in a slow, rhythmical fashion using gentle pressures, MLD is usually
provided within a programme of physical therapies including exercise and skin care.

When MLD is used to treat severe or complicated lymphoedema (such as body swelling alongside limb swelling) it is usually given on a daily basis over two to three weeks. Time spent each day will depend on the site and size of the swollen area, but always includes treatment of the main drainage routes in the body. Some of the specific techniques can be simplified into
a slow effleurage movement over the skin which the patient or carer can learn as Simple Lymph Drainage (SLD). This can be used for self-management.

As a network of Casley-Smith MLD teachers, the MLA has been delighted to see the recent research into Manual Lymphatic Drainage (MLD) with the use of video fluoroscopy imaging. It is encouraging to see the benefits of this new imaging evidence, and the MLA has welcomed the opportunity to explore the Casley-Smith method using the Fluoptic Fluorescence Imaging System themselves.

In May 2017, we met together to acquire evidence using this new system, and made a video of our experience, and the results. We were delighted to partner with PocketMedic to develop this film, who also have other films available about lymphoedema and its management.

We know that MLD treatment improves lymphoedema and patients report positive outcomes. At the annual peer review of the Casley-Smith lymphoedema teachers, where all teaching materials are reviewed and updated, discussions around current and new evidence have led to changes and updating of MLA teaching materials and of the Casley-Smith MLD technique also.

The new evidence from video fluoroscopy has underlined the effectiveness of the Casley-Smith technique, especially in its emphasis on breathing and exercise, which have been further emphasized by modifications now made to the technique. Incorporating new patient activities has enabled greater participation by patients themselves, leading to improved outcomes from their MLD treatment. This brings with it an exciting time
in lymphoedema management, with patients now more able to become partners in their own care; incorporating the new MLD techniques into their own SLD regime gives them greater control of their lymphoedema.

For more information see the MLA website