Manual Lymphatic Mapping (MLM) of the lymphatic circulation
is a gentle, noninvasive method by which trained practitioners
- using only their hands - can identify the specific direction
of the lymphatic circulation on an affected or unaffected
area of the body [1-15].
A recent advancement in manual palpation techniques, Manual
Lymphatic Mapping is a component of Lymph Drainage Therapy
(LDT) [1-2] - a hands-on modality based on the traditional
work of osteopath F.P. Millard (1922)  and Emil Vodder
Manual assessment of the lymphatic rhythm and direction requires
time and dedicated effort. Without previous specific training
it may seem totally impossible to assess this component of
the lymphatic circulation. Once learned, however, Manual Lymphatic
Mapping offers refinements to the therapeutic process that
are an important tool in the management and pre- and postoperative
functional assessment of lymphedema.
Research continues on the method as we seek to demonstrate
the scientific validity and reliability of Manual Lymphatic
Mapping in providing greater benefits to the lymphedema patient.
MLM Reliability Study: Comparison to a Control
Objective: To compare the reliability of MLM between
an experimental population and a control group. Each examiner
maps subjects, addressing an identical nonaffected part of
the body (that has not been previously studied).
Background: Complex Decongestive Physiotherapy (CDP)
is the noninvasive treatment of choice for lymphedema patients
in the USA. It is recognized and reimbursed by a growing number
of national insurance companies. The emphasis of the manual
component of CDP is to create alternative pathways through
which lymph and interstitial fluid can flow. Manual techniques
to accomplish this are used daily in lymphedema clinics.
Manual Lymphatic Mapping (MLM) is a safe and noninvasive
manual technique that may more accurately identify alternate
pathways in lymphedema patients. This can reduce treatment
time and invasiveness of lymphedema treatment. More than 1,500
therapists have been trained in MLM in North America. Many
of those who have treated lymphedema using CDP and MLM at
the same time report faster volume reduction for extremity
lymphedema and the need for fewer visits during the course
of the treatment.
Population: This study compares the results of manual
lymphatic mapping performed by:
1. Control Group: first-day Lymph Drainage Therapy
(LDT) students, without any previous training in MLM.
2. Experimental (Trained) Group: students from Lymph
Drainage Therapy, level-2 seminar, after 4 days of training
in MLM. No previous training in MLM. This trained group
received only an initial training in MLM. It is not a group
of LDT-certified therapists. They will get experience with
their patients and further training in LDT level 3 and Advanced
Approximately 5,200 students have received training to palpate
the superficial lymphatic flow through LDT. More than 1,500
practitioners, including physicians, PTs, OTs, lymphedema
therapists, and massage therapists, have been trained in North
America in MLM.
The area of the body they are asked to map is in physiological
condition (nonaffected area). Before beginning, each population
is asked to complete and sign a questionnaire that includes
two exclusionary questions:
1. "I have/have not been trained to assess the lymph
flow by palpation."
If this question is answered positively by a student of the
control group, he/she will be excluded from the study.
2. "I have/have not seen a complete lymph chart of [body
area] (with watersheds)."*
If this question is answered positively in any group, the
student will be excluded from the study.
*(Complete lymphatic maps of this specific area are difficult
to find in the United States.)
The numbers of completed and signed forms we have at this
time relating to the mapping of a same nonpathological physical
The Chi-square analysis found the results to be highly significant:
X2 = 329.54, p < 0.0000001
The difference in the experimental group and the control
group correct response proportion was highly statistically
significant. It is extremely unlikely that the difference
was due to chance variation.
The odds-ratio (OR) analysis also found the results to be
OR = 60.20, p < 0.0000001 (CI: 31.02 <
OR < 119.87)
Essentially the subjects in the experimental group were
60 times more likely to provide a correct response than those
in the control group.
The experimental group (LDT level-2 students, day 4) has
just learned the MLM technique. Some of these students will
require some time to integrate and practice MLM before they
can master the technique. We could expect a higher number
of correct answers later in their career.
What is Lymphatic Rhythm?
To understand what causes the lymphatic rhythm, we must look
at the anatomy and physiology of the lymphatic system. Elements
of this system include lymph capillaries (or initial lymphatics),
which carry fluid from interstitial spaces to pre-collectors;
these pre-collectors then convey the fluid to larger vessels
called lymph collectors. Collectors are approximately 100
to 600 microns in diameter and consist primarily of chains
of muscular units called lymphangions, which possess two-leaflet
bicuspid valves. Described as little "lymphatic hearts"
(Mislin, 1961), lymphangions work much like the body's heart
pacemakers, contracting regularly throughout the lymphatic
system (lymphangiomotoricity) and moving lymph in peristaltic
waves. From the tunica media to the tunica externa, these
muscular units have extensive sympathetic and parasympathetic
innervation, somewhat similar to the alpha and beta receptors
found in blood vessels.
Clinical Applications of Manual Lymphatic Mapping to Lymphedema
In lymphedema, Manual Lymphatic Mapping (MLM) can be used
during a session to assess the patient's lymph pathways and
help define a specific treatment protocol. The whole treatment
plan must be consistent with the lymph pathways found with
the MLM. This technique can be used to check the proper use
of the compression bandage or garment, i.e., to confirm that
the identified alternative pathways are still working and
have not been misdirected by the compression. Finally, the
pathways identified can suggest effective protocols for bandaging,
TributeŠ or JoVi PakŠ sleeves, Kinesio TapingŠ,
exercise under compression and self-drainage.
It has been noted, for example, that in cases of postmastectomy
upper-extremity lymphedema, lymph flow has some 20 alternate
pathways to choose between for rerouting to an unaffected
lymph territory (lymphotome). These can include anterior and
posterior pathways to the unaffected axilla, inguinals, clavicles,
intercostals, Mascagni's pathway, vasa vasorum and other special
reroutes. It may be difficult for a manual practitioner to
"guess" or assume which pathway will be taken by
the lymph flow. Wrong assumptions can sometimes cause a significant
loss of time and resources. Working on each and every possible
lymph reroute is very time-consuming and may not be the most
efficient way to help the functional lymph pathways.
Information about the direction and contractility of superficial
and deep lymphatic circulation has definite clinical implications:
1. Identification of the specific directions of the lymphatic
circulation and areas of fluid restriction and fibrosis.
ˇ Before the session, mapping is used to make an
initial assessment of the areas of fluid restriction, stagnation
and fibrotic tissue.
ˇ During the session, the therapist can determine
whether the most appropriate work area has been selected
and how efficiently the lymph flow has been stimulated or
ˇ After the session, mapping is used to verify the
results of the technique, to check the areas of initial
restriction, and to fine-tune sites that require further
An advanced therapist does not need to perform MLM on bare
skin, but can actually map through bandaging and other types
of medical compressions to help determine whether the reroute
of fluid under the compression is consistent with the pathway
determined and encouraged by the therapist. If not, the
compression can be reapplied. A proper compression is essential
for optimal effectiveness, comfort and patient compliance.
2. Description of the new "pathological watershed."
3. Identification of the various alternative pathways used
by the lymphatic/interstitial fluid circulation and the
most efficient alternate pathway(s) leading to a healthy
4. Selection of a physical treatment protocol for self-drainage,
bandages and garments, etc.
5. Preventive application (subclinical lymphedema): Evaluation
of functional alternate pathways or areas of stagnation
in latent phases of lymphedema.
6. Preventive Lymph Drainage Therapy with evacuation toward
most efficient alternate lymphatic/interstitial fluid pathway(s)
before a clinical lymphedema takes place.
Can We Use MLM in Prevention of Lymphedema?
It is important to note that being able to assess patients
in the postsurgical phase, before lymphedema takes place (lymphedema
stage 0 or subclinical lymphedema), may help save significant
time, effort and money for patients, therapists and insurance
companies, as well.
Stage-0 lymphedema could also be defined as a patient with
abnormal/nonefficient lymph reroutes but no clinical edema.
For example, in the case of upper-extremity lymphedema, this
would be a nonpathological pathway that avoids the axilla
but cannot efficiently connect all the way to another group
of nodes (inguinals, contralateral axilla, etc.). Assessing
these patients and creating alternate pathways in a nonlymphedematous,
non-fibrotic, extremity may be done in one or two sessions.
MLM (a component of CDP) may help create efficient reroutes
before the lymphedema takes place. These reroutes are equivalent
to the reroutes created at the end of a phase of CDP for clinical
lymphedema patients. Bandaging is not necessary in subclinical
lymphedema. In a certain number of cases, "shunting"
of the lymph circulation before any pathology occurs may be
enough to prevent lymphedema from ever occurring. All the
other precautions for lymphedema (good hygiene and skin care,
avoidance of increased weight and temperature, etc.) may still
Other Scientific Studies With Manual Lymphatic Mapping
1. Long-term evolution of patients with stage-0 (subclinical)
lymphedema that has been "rerouted" efficiently.
Assessment of the extremity volume (development of lymphedema)
and complications over time.
2. Compare the results of MLM and lymphangioscintigraphy
(LAS). This study continues an investigation that began at
the Nuclear Medicine Center Rene Huguenin in Paris (Dr. Alain
Pecking). Due to unfortunate technical problems and the fact
that the study has to be done in France, we agreed to publish
only the feasibility of the study and delayed the study for
a later date.
3. Long-term study in lymphedema centers comparing limb-volume
decrease in lymphedema patients treated by therapists using
MLM and therapists not using this technique.
The probability that the trained group can palpate the
MLM not due to random chance in comparison to the control
group is > 99.9999999%.
If more studies confirm the efficiency of Manual Lymphatic
Mapping, this technique may offer lymphedema therapists an
important tool for CDP management of stage-0 (subclinical)
to stage-3 (spontaneously irreversible) lymphedema.
1. Chikly B., Silent
Waves, Theory and Practice of Lymph Drainage Therapy,
I.H.H. Publ., Scottsdale, AZ, USA, 2001.
2. Chikly B. "Who Discovered the Lymphatic System?"
Lymphology, 30:4 (Dec. 1997), 186.
3. Millard F.P. "Applied Anatomy of the Lymphatics,"
A.G. Walmstey, Ed. International Lymphatic Research Society,
4. Vodder E. "Le drainage lymphatique, une nouvelle mActhode
thAcrapeutique," SantAc pour tous, Paris, 1936.
Lymphatic vessel contractility in animals and humans:
5. Florey H. "Observations on the Contractility of Lacteals
- Part I," J. Physiol., 62 (1927) 267.
6. Heller A. "Uber Selbstandige Rhythmische Kontraktionen
bei Saugetieren," Z. Med. Wiss., 7 (1869), 545.
7. Hewson W. "In the Works of William Hewson," G.
Gulliver, Sydenham Soc.,
8. Lieben S., "Uber die Fortbewegung der Lymphe in den
Physiol., 24 (1910), 112.
9. Kinmonth J.B., Taylor G.W. "Spontaneous Rhythmic Contractility
Lymphatics," J. Physiol. (London), 133 (1956),
10. Engeset A., Olszewski W.L., Jaeger P.M., et al. "Twenty-Four
Variation in Flow and Composition of Leg Lymph in Normal Man,"
Scand., 99 (1976), 140.
11. Olszewski W.L., Kruszewski S., et al. "Observations
of Movements of Lymph
Vessels in Patients with Lymphedema of Limbs," Pol. Tyg.
L., 23 (1968), 1345.
12. Olszewski W.L. "Collection and Physiological Measurements
of Lymph and
Interstitial Fluid in Man," Lymphology, 10 (1977), 137.
13. Olszewski W.L., Engeset A. "Intrinsic Contractility
of Leg Lymphatics in
Man: Preliminary Communication," Lymphology, 12 (1979),
14. Olszewski W.L., Engeset A. "Intrinsic Contractility
of Prenodal Lymph
Vessels and Lymph Flow in Human Leg," Am. J. Physiol.,
239 (1980), 775-783.
15. Chikly B. "Lymph Drainage Therapy (LDT): Manual lymphatic
Its Clinical Application to Lymphedema," Lymph Link,
Network (NLN), 13:3 (Sept. 2000), 1-3, 6-7.
Bruno Chikly, M.D.
Laureat of the Medical Faculty of Paris
Member of the International Society of Lymphology (I.S.L.)
Associate Member of the American Academy of Osteopathy and
Director of Lymph Drainage Therapy seminars
28607 N. 152nd Street
Scottsdale, AZ 85262-6939 USA