Two months ago, we began a series on contraindications to MLD. This post will continue that topic, citing a few more contraindications.
According to Ai, MLD in patients with severe hypertension can increase vascular pressure and potentially trigger hypertensive crises. (I would partly disagree.) MLD commonly lowers blood pressure due to the stimulation of the parasympathetic nervous system. So, MLD would actually benefit patients with hypertension. However, there are a couple considerations.
First, blood pressure should be monitored before and after MLD to ensure it doesn’t drop too low. Second, MLD should be a gentle, light massage. Too much pressure can contribute to vascular damage. This is particularly important in cases of atherosclerosis or vascular disease impacting arteries. Hardened deposits of fat, cholesterol, and other substances that accumulate in the walls of arteries create arterial plaques. These can potentially become unstable (leading to a blood clot) or dislodge and cause emboli. Emboli can block arterial blood flow (leading to problems like a stroke or PE). The neck is frequently used in MLD sequences. Given the location of the carotid arteries, caution should be used.
Conditions like arthritis or autoimmune diseases (in an acute phase), or other inflammatory processes like gout or bursitis, can benefit from MLD. But not in the acute phase of a flare up. The manual manipulation of the tissues could intensify the inflammatory response or exacerbate pain and swelling. MLD should only be considered after the acute phase of inflammation has resolved. (Otherwise, there is risk of an exacerbation period before improvement.)
I would add, these inflammatory conditions can also benefit greatly from MLD. The benefits include (among others):
Manual Lymph Drainage is a powerful therapeutic tool, but it must be applied carefully and selectively. The above contraindications aren’t comprehensive (there are other precautions including those specific to certain body areas). Understanding the contraindications ensures that patients receive appropriate care and prevents unintended complications. Clinicians should always conduct a thorough assessment of the patient’s health history and current condition to determine whether MLD is suitable. By respecting these contraindications, therapists can help ensure that MLD remains a safe and effective intervention for lymphatic and fluid management.
Generated by Ai (with edits by author)
References
Foldi’s Textbook of Lymphology
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Last month, we began a series on contraindications to MLD. This post will continue that topic, citing a few more contraindications.
Patients with heart failure are at risk for fluid overload, and MLD could further strain their cardiovascular system. The technique’s effects on fluid mobilization may overwhelm the heart’s ability to manage the increased fluid load. Foldi underscores the importance of careful evaluation of a patient’s cardiac function before initiating MLD, especially in those with advanced heart conditions. MLD is not appropriate if heart failure isn’t controlled. And it’s not appropriate if the sole reason for swelling is heart failure as that is a medical condition requiring medical intervention (not lymphedema). Patients with combined edema (from heart failure or other organ dysfunction) and lymphedema require extra caution.
Patients suffering from severe renal insufficiency or kidney failure may experience difficulties in fluid regulation. In such cases, MLD could cause fluid retention and exacerbate symptoms like edema or ascites (according to Ai). (My position is that MLD increases lymphatic flow & ultimately cardiovascular return & renal load. But MLD is primarily not done as it would be of no benefit because lymph vessels are already working at maximum capacity due to the dynamic nature of the edema.) Patients with impaired kidney function should be closely monitored, and MLD should be avoided or used with extreme caution in individuals with compromised renal status. Again, patients with combined edema (from renal disease or other organ dysfunction) and lymphedema require extra caution.
Deep vein thrombosis (DVT) or other thromboembolic disorders are a significant contraindication for MLD. Manual lymph drainage can increase blood and lymphatic flow, potentially dislodging clots and causing a pulmonary embolism (PE) or other complications. Foldi’s Textbook emphasizes the critical importance of excluding thrombosis prior to MLD treatment and recommends that patients with active DVT or a history of thromboembolic events within 6 months not undergo MLD (with some exception). DVTs in the acute phase are at risk of dislodging & creating a PE which can kill a person. In the subacute phase (which occurs over the next several weeks), there is typically pain, redness and swelling. The body begins to break down the clot in a process known as fibrinolysis, where enzymes dissolve fibrin and other clot components. As this process happens, part of the clot is reabsorbed, while the remaining structure becomes more organized and fibrous. In the chronic phase (month 3-6), the clot typically becomes firm and organized (restructured with scar tissue) and has little risk of dislodging by month 6.
The exception to waiting 6 months is if a person has a filter and/or receives anticoagulation medication. After stabilization with anticoagulant therapy, MLD may be safely resumed after a 2 to 4-week period (if the physician approves MLD).
Manual Lymph Drainage (MLD) is a therapeutic technique designed to stimulate the lymphatic system, promoting the movement of lymph and improving the drainage of excess fluid. This technique is widely used for conditions such as lymphedema, post-surgical recovery, and certain inflammatory disorders. However, MLD is not appropriate for all patients. According to Foldi’s Textbook of Lymphology, it is essential to understand specific contraindications to ensure patient safety and prevent complications. Here, we will explore some of these contraindications, providing a deeper understanding of when MLD should be avoided.
One of the primary contraindications to MLD is the presence of acute infections. This includes bacterial, viral, or fungal infections, which could be exacerbated by the increased circulation induced by MLD. The stimulation of lymphatic flow could spread infectious agents through the body, worsening the condition or increasing the risk of sepsis. Conditions such as cellulitis, abscesses, or acute skin infections require medical treatment and should not be treated with MLD until the infection is resolved. Interestingly, the body protects itself against infectious agents by causing lymphangions to spasm. This contraction is part of the body’s attempt to limit the spread of infection or inflammation by slowing down lymph flow and creating a “barrier” effect. When performing MLD properly (which includes gentle, rhythmic strokes), the parasympathetic nervous system (the “rest and digest system”) is reflexively stimulated, causing relaxation and enhancing lymphatic circulation. As a result, these lymphangion spasms can relax, potentially allowing the spread of the infection to other parts of the body.
While MLD can be beneficial for some cancer-related issues, it is contraindicated in active cancer or in cases where the patient has metastatic disease. Foldi emphasizes that manual drainage may inadvertently promote the spread of cancer cells, particularly in individuals with untreated or advanced malignancy. The stimulation of lymph flow could potentially facilitate the movement of cancerous cells, thus accelerating metastasis. MLD should not be performed over the affected areas in such cases unless specifically approved by an oncologist.
cancer cells
There is some debate about this in recent times by newer graduating lymphedema therapists. The debate centers around the fact that cancer cells choose whether or not to turn on or off. So, MLD isn’t “causing cancer.” But the caution is that cancer cells spread through one of two ways: blood flow or lymph flow. The concern with MLD during active cancer (particularly over the site of cancer) is that you speed up potential spread of cancer cells by stimulating lymph flow. I always disclose these facts to patients. I require patients with active cancer to sign a waiver if they wish to receive MLD. (Gloves should be worn if chemo is being administered.) In terminal cancer cases, the massage can be especially calming & comforting.
Researchers at Yale are studying the lymphatics discovered in the meningeal dura mater. Anne Eichmann, Professor of Medicine said, “Meningeal lymphatic vessels are potential targets to treat brain diseases.”1 This includes causes of intracranial hypertension like brain injury or stroke according to Foldi.2
Years before Yale’s 2022 research, Foldi had written about this in the Foldi Textbook of Lymphology. In the chapter on lymphostatic diseases, Foldi notes lymphostatic failure can occur in the body’s organs – including the brain. Many people might consider this “lymphedema.” But lymphedema is referring to the lymphostatic condition that affects the skin & tissues. When it’s elsewhere in the body, it’s simply called “lymphostatic failure.” If it affects the nerves, it’s called, “lymphostatic neuropathy.” If it affects the brain, it’s called, “lymphostatic encephalopathy.” Etc. Foldi states, “Any organ requiring lymphatic drainage develops a lymphostatic disease under circumstances of low-output failure or combined [high & low output] failure.”2
What can give rise to congestion surrounding nerves? Inflammation, as occurs in trigeminal neuralgia (cranial nerve V is affected) & Bell’s Palsy (the facial nerve, cranial nerve 7, is affected). Cranial nerve V runs through the dural venous sinus (the cavernous sinus). Cranial nerve 7 passes through the temporal bone. There’s a head & neck MLD sequence that can address this.
On the right is the facial nerve involved in Bells’ Palsy. The picture shows it passing through the temporal bone. The nerve can swell, causing it to be compressed. This leads to the symptoms people experience.
It’s important to be aware that dural venous sinuses don’t have valves or muscle like regular veins do.As a result, blood can flow backwards. In fact, most brain veins (except for the larger pial veins) don’t have valves or muscle.3 (Spinal veins are also valveless & muscleless.4)
The Noted Anatomist describes the dural venous sinuses at minute 5 in this video.
The missing valves & muscle in these veins allows them to expand if intracranial pressure rises. But, as The Noted Anatomist states, “Veins that drain the eyes or nasal pages could flow backwards, back into the orbit or nasal area. This could transport infection into the brain.” That’s the downside. MLD may be able to help this backflow caused by congestion.
Foldi notes that, “Immune deficiency develops in lymphedematous areas. This fact plays an important role in the pathophysiology of lymphostatic diseases.”5 In lymphedema, as inflammation continues, we see the changes characteristic of lymphedema tissue as the disease progresses (skin thickening, fat growth, scarring or fibrosis, skin papules & hyperkeratosis, etc.). Complete decongestive therapy (with MLD being one of the components of CDT) improves this condition by decongesting the tissue. It’s a proven fact that proper MLD speeds up lymphatic flow.6,7,8 Check out the below video of a person receiving leg MLD. It shows the movement of lymph fluid before & after MLD.
If MLD can increase lymph transport, it stands to reason that it could reduce swelling around nerves or congestion in the brain given what we’ve learned about anatomy. Foldi has already suggested that it does. Wolf Lüdemann (physician) treated patients with intracranial pressure due to brain injury using MLD. And the pressure reduced.9 (It’s important to note position can also play a role in intracranial pressure.)
Foldi highlighted patients with recurrent inflammatory nasal congestion & primary lymphedema (which caused dysplasia of the jaw & paranasal sinuses) who were treated with MLD. Their tonsils were often enlarged, leading to mouth-breathing. The kids often have trouble staying awake & concentrating in school. Colds were a common occurrence. MLD improved their symptoms.10
It’s interesting to note that Dr. Emil Vodder (credited with being the founder of MLD) got his start in the south of France treating patients with colds, migraines & sinus problems.11
MLD has potential to help nerve inflammation & conditions causing intracranial pressure through head & neck MLD. In fact, “Földi’s concept of lymphostatic encephalopathy provides both a possible explanation of the wide spectrum of symptoms after these accidents [causing increased brain pressure] and a way to help heal the problems by using MLD.”12
1 https://www.frankenthalerfoundation.org
