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Treatment Outcomes of Manual Lymphatic Drainage in Pediatric
Lymphedema
Kausar Ali MD , Rami Dibbs BA , Catherine Dougherty PT, DPT ,
Ionela Iacobas MD , Renata Maricevich MD
PII: S0890-5096(21)00563-X
DOI: https://doi.org/10.1016/j.avsg.2021.06.021
Reference: AVSG 5897
To appear in: Annals of Vascular Surgery
Received date: May 5, 2021
Revised date: June 10, 2021
Accepted date: June 11, 2021
Please cite this article as: Kausar Ali MD , Rami Dibbs BA , Catherine Dougherty PT, DPT ,
Ionela Iacobas MD , Renata Maricevich MD , Treatment Outcomes of Manual Lym-
phatic Drainage in Pediatric Lymphedema, Annals of Vascular Surgery (2021), doi:
https://doi.org/10.1016/j.avsg.2021.06.021
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https://doi.org/10.1016/j.avsg.2021.06.021
https://doi.org/10.1016/j.avsg.2021.06.021
 1 
Treatment Outcomes of Manual Lymphatic Drainage in Pediatric Lymphedema 1 
Kausar Ali MD
1
, Rami P. Dibbs BA
1
, Catherine Dougherty PT, DPT
2
, Ionela Iacobas MD
2
, 2 
Renata S. Maricevich MD
1,2
 3 
1
Division of Plastic Surgery, Baylor College of Medicine, Houston, TX, USA 4 
2
Division of Hematology/Oncology, Texas Children’s Hospital, Houston, TX, USA 5 
Corresponding Author 6 
Renata Souza Maricevich, MD 7 
6701 Fannin St. Suite 610.00 8 
Houston, TX. 77030 9 
Phone: (832) 822-3180 10 
Fax: (832) 825-3192 11 
renata.maricevich@bcm.edu 12 
 13 
Short running title: Pediatric Lymphedema Manual Lymphatic Drainage 14 
 15 
Financial Disclosures / Commercial Associations: none 16 
Sources of Support: none 17 
Products / Devices / Drugs: none 18 
Declaration of Interest: none 19 
 20 
 21 
 22 
 23 
 
 2 
Abstract 24 
Background: Pediatric lymphedema can result in irreversible, debilitating limb swelling, 25 
tissue fibrosis, skin ulcers, infection, and impaired limb function in children at an early age. 26 
Manual lymphatic drainage (MLD) is a noninvasive technique, which is a part of intensive 27 
decongestive therapy to reroute lymphatic flow to healthy channels used to manage 28 
lymphedema. Outcomes of this treatment option in children have not been studied. We 29 
evaluated the effect of decongestive therapy involving MLD in pediatric patients with 30 
complex lymphatic anomalies by measuring treatment progress and functional outcomes via 31 
changes in limb circumference, limb functionality, dexterity, skin quality, and pain. 32 
Methods: A single-institution retrospective study on a cohort of eight pediatric patients with 33 
lymphatic anomalies who completed a course of MLD was conducted from 2015 to 2017 to 34 
investigate the role MLD plays in their lymphedema reduction. Pain scores were measured 35 
on a scale of 0-10, with 0 being no pain and 10 being the worst pain imaginable. The 36 
functional performance was measured by the Canadian Occupational Performance 37 
Measurement questionnaire. 38 
Results: Among all patients, there were four cases affecting the upper extremities, four 39 
affecting the lower extremities, and three affecting the truncal region. 5 of 8 patients 40 
demonstrated a reduction in lymphedema with an average girth reduction of 8.2% in the 41 
lower extremities, 3.0% in the upper extremities, and 7.4% in the truncal regions. In 42 
unilateral cases, the difference in limb circumference between the affected and normal 43 
extremity decreased by an average of 25.6%. Four patients completed the Canadian 44 
Occupational Performance Measurement questionnaire with an average improvement of 45 
30% in daily task performance. Three patients reported complete resolution of pain. 46 
 
 3 
Conclusions: MLD can be used as a reliable noninvasive method for decongestion and 47 
analgesia to delay the onset of lymphedema-associated fibrosis and long-term disability in 48 
children with complex lymphatic malformations. 49 
Keywords: pediatric, lymphedema, manual lymphatic drainage, outcomes, noninvasive 50 
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 4 
Introduction 70 
Lymphedema is an abnormal collection of lymphatic fluid in the interstitial space, 71 
resulting in protein and long-chain fatty acid accumulation, limb swelling, poor 72 
immunologic responses, and eventually tissue fibrosis and impaired extremity function.
1
 In 73 
the pediatric population, the majority of patients have primary lymphedema, usually due to 74 
congenital lymphatic malformations or dysplasia of the lymphatic system.
1-2
 Some children 75 
have limb swelling from lymphedema or complex, mixed vascular anomalies associated 76 
with congenital syndromes like Milroy disease and Klippel-Trenaunay syndrome. 77 
Decongestive therapy should be employed as early as possible to delay the onset of 78 
the debilitating effects of lymphedema, such as tissue fibrosis, skin ulcers, infections, 79 
functional disabilities, immobility, and psychosocial impairment.
3
 A wide array of 80 
modalities are implemented in decongestive programs to treat lymphedema. Noninvasive 81 
options include manual lymphatic drainage (MLD), decongestive exercises, compression 82 
bandage, Kinesio Tape, lymphatic pumps, sclerotherapy, and sirolimus for lymphatic 83 
anomalies.
1
 Invasive options include lymphovenous bypass surgery and autologous lymph 84 
node transplantation.
4-5
 85 
MLD is an established technique to treat lymphedema through superficial manual 86 
therapy, which stimulates smooth muscle contractility of the lymphatic channels and 87 
redirects lymphatic fluid towards existing healthy drainage tracts.
1
 This form of 88 
decongestive therapy opens up collateral lymphatic routes, enhances reabsorption of 89 
lymphatic load, and promotes lymphatic contractility for improved lymphatic outflow. The 90 
Vodder technique is one of several methods to perform MLD and is performed five times 91 
per week spanning about 4-6 weeks depending on the extremity affected and bilateral and/or 92 
 
 5 
truncal involvement.
6
 This method involves a constant change in pressure and stretching of 93 
the skin along the affected limb in order to promote lymphangiomotricity and soften 94 
fibrosis. Decongestion and softening of tissue through this MLD technique alleviates pain, 95 
relaxes muscles, and over time improves limb dexterity and overall function.
6
 96 
Few studies have described the use of MLD in children with lymphatic disease. 97 
Pereira de Godoy et al. describe using their own manual drainage technique in a 16 year-old 98 
female with primary lymphedema, achieving successful and stable edema reduction.
7
 99 
Lasinksi et al. and Lopera et al. describe the benefits of combined MLD and compression 100 
garment therapy for decongestion, but these studies were performed in adults.
8,9
 In our 101 
study, we evaluate the effect of decongestive therapy involving MLD in pediatric patients 102 
with complex lymphatic anomalies by measuring treatment progress and functional 103 
outcomes through changes in limb circumference, limb functionality, dexterity, skin quality, 104 
and pain. By exploring outcomes, MLD has great potential in being a part of intensive 105 
decongestive therapy courses for reducing lymphedema and has possible long-term 106 
sustainability, as the techniquecan be learned and performed at home for maintenance 107 
therapy. 108 
 109 
Material and Methods 110 
Patient population 111 
An Institutional Review Board-approved retrospective chart review was performed 112 
to look at outcomes of an intensive decongestive therapy course that included MLD for 113 
lymphedema management in pediatric patients. Chart review was performed on all pediatric 114 
patients with lymphedema who were referred to the outpatient Vascular Anomalies Center at 115 
 
 6 
Texas Children’s Hospital between 2015-2017. The primary outcome of the study was 116 
reduction in lymphedema. Multiple secondary outcomes were also investigated, including 117 
pain level, skin and tissue quality, and functionality and dexterity of the affected limbs. The 118 
patients underwent an intensive MLD course, which entailed 60 to 120-minute sessions 119 
occurring 3-5 times per week for a total of 4-6 weeks administered by a certified 120 
lymphedema therapist (CLT). Selection criteria for patients in the study included at or below 121 
18 years of age, diagnosis of extremity lymphedema and associated syndromes, and 122 
completion of the intensive decongestive therapy program that included MLD. Patients with 123 
deep vein thrombosis, acute infection in affected limb(s), known cardiac conditions causing 124 
edema (i.e. congestive heart failure, severe hypertension, etc.), or other sources of 125 
edematous extremities (i.e. renal failure, liver failure, malignancy) were excluded from the 126 
study. 127 
Data collection and analysis 128 
Age, sex, and lymphedema diagnosis were recorded for each patient. The duration of 129 
each therapy session and total length of the intensive MLD course was noted. Compliance 130 
with the therapy was determined by missed sessions. In addition, the use of any concomitant 131 
therapy during the MLD course, such as compression garments, sirolimus treatments, and 132 
Kinesio Tape, were recognized. 133 
Patients served as their own control with baseline measurements taken prior to 134 
initiation of MLD and final measurements taken immediately upon completion of the 135 
intensive MLD program at the final session. Pre- and post-MLD data points collected 136 
included weight, limb girth of the affected extremity(s) and trunk, pain scores, and 137 
functional limb performance. Limb girth was measured along the extremity distally to 138 
 
 7 
proximally. For example, in patients with upper extremity lymphedema, limb girth was 139 
measured at the distal interphalangeal (DIP) joints, proximal interphalangeal (PIP) joints, 140 
metacarpophalangeal (MCP) joints, wrist (radiocarpal joint), mid-forearm, elbow, mid-arm, 141 
and axilla. In lower extremity lymphedema, limb girth was measured at midtarsal joint, 142 
midfoot at the level of the navicular bone, ankle at the level of the malleoli, mid-calf, knee, 143 
and mid-thigh. Truncal girth was also measured along the nipple line, mid ribs, distal ribs, 144 
umbilicus, and ASIS planes. Pain scores were measured on a scale of 0-10, with 0 being no 145 
pain and 10 being the worst pain imaginable. Functional performance was measured before 146 
and after MLD therapy using the validated Canadian Occupational Performance 147 
Measurement (COPM) questionnaire, which is an individualized measure to detect changes 148 
in perception of performance over time and to quantify functionality and activity 149 
performance of patient identified tasks.
10,11
 Only patients at or above the age of 1 were 150 
eligible to take this validated questionnaire. Patients completed the questionnaires with 151 
assistance from parents if needed. 152 
To evaluate the primary outcome of lymphedema reduction, each patient’s total body 153 
weight and limb circumference of the affected extremities were compared before and after 154 
MLD. The percent change of weight and limb girth measurements from baseline (pre-155 
therapy) to post-therapy were calculated (post-therapy measurement minus pre-therapy 156 
measurement, difference divided by pre-therapy measurement). Positive results indicated an 157 
increase from baseline, while negative results indicated a decrease from baseline. In patients 158 
with unilateral lymphedema, the limb circumference of the affected extremity was also 159 
compared to that of the normal contralateral extremity both before and after MLD. The 160 
difference in normal and affected extremity measurements was compared before and after 161 
 
 8 
therapy as a percent change to understand how similar the treated extremity became to 162 
normal unaffected limb after MLD therapy. In addition, pain scores, self-reported 163 
functionality scaled by the COPM, weight-bearing status, dexterity measured by fine motor 164 
skills, and skin quality (erythema, softening of tissue, and vesicles) were reviewed in clinical 165 
documentation by the CLT as additional secondary measures before and after MLD therapy. 166 
Finally, subsequent treatments provided after completion of the MLD program were noted 167 
for each patient. 168 
 169 
Results 170 
Our study included eight pediatric patients with a diagnosis of extremity swelling 171 
and lymphedema who completed intensive decongestive therapy involving MLD. The 172 
median age of our sample was 9.8 years with a range of five months to 18 years. Each 173 
patient’s demographics, lymphedema diagnosis and associated condition, indication for 174 
referral to the vascular anomalies clinic, and prior lymphedema treatments are described in 175 
Table 1. The details of each patient’s MLD course, such as compliance with sessions and 176 
concomitant therapies, are also shown. 177 
All but two patients (75%) had full compliance with the MLD sessions. One patient 178 
missed a single session each during her upper extremity and lower extremity MLD courses 179 
and thus, had 83 and 97% completion rates, respectively. The second patient had been 180 
admitted to the hospital during her final week of the MLD program and could only complete 181 
88% of the sessions. 182 
There was an average reduction in limb circumference measurements after MLD 183 
compared to baseline (pre-therapy) measurements (Table 2). Average girth decreased by 184 
 
 9 
8.2% in lower extremities, 3.0% in the upper extremities, and 7.4% in truncal regions after 185 
undergoing MLD (Figure 1). These reductions in average girth resulted in visibly apparent 186 
changes in extremity lymphedema following MLD (Figure 2). Proximal and distal regions 187 
of the upper and lower extremities had an approximately equal percent reduction in girth. 188 
Overall, five out of eight patients demonstrated reduction in lymphedema volume, 189 
which was defined as a decrease in both weight and limb girth following decongestive 190 
therapy with MLD. Interestingly, patient #4 had a 12% increase in weight and girth increase 191 
after MLD, which could be due to her normal growth rate and low absolute weight where 192 
even small increases in weight and girth appear as a large overall percent increase. 193 
In the unilateral lymphedema cases, the difference in limb circumference between 194 
the affected and normal contralateral extremity decreased by an average of 25.6% after 195 
MLD. In other words, the limb circumference of the affected extremity was reduced and 196 
closer to the circumference of the normal side following MLD. However, the affected 197 
extremity did not completely reach the same size as the normal limb at a 1:1 ratio. 198 
Overall, even if a patient did not experience impressive reduction in limb 199 
circumference, MLD provided a variety of secondary clinical benefits for the patients and 200 
were documented in CLT reports (Table 3). For example, Patient #2 did not have a 201 
significant decrease in lymphedema, but she still had palpablesoftening in her soft tissues 202 
with decreased skin folds and improved truncal mobility. Three patients reported being pain-203 
free (score 0) at the completion of MLD. Additionally, patients had improved skin changes, 204 
such as reduced erythema and resolution of lymphatic vesicles, as described in CLT 205 
documentation. Patients who presented with gait impairment due to lower extremity 206 
lymphedema had improved mobility, weight-bearing status, and better fit of shoes. Patients 207 
 
 10 
with upper extremity lymphedema had more refined motor skills (i.e. Patient #3 had 40% 208 
improvement in his keyboard use following MLD therapy). 209 
The COPM questionnaire has been validated for its use in the pediatric 210 
population.
10,11
 When looking at validated COPM questionnaires for a more standard 211 
method to evaluate functional improvement, performance in daily tasks was found to 212 
improve by an average of 30% (Table 4). However, only half of the patients in the study 213 
completed COPM forms - two patients did not submit the post-therapy portion and another 214 
two patients were ineligible to participate due to being under the age limit of 1. Given that 215 
only four patients completed the COPM questionnaire, it is difficult to make definitive 216 
conclusions. However, with greater limb girth reduction, there appeared to be a greater 217 
degree of improvement in functional outcomes (Tables 2, 4). 218 
Of the five patients who had lymphedema reduction following MLD, three still went 219 
on to receive further treatment due to residual or recurring lymphedema. The most common 220 
subsequent therapy provided was sclerotherapy. Patient #6 underwent a lymphovenous 221 
bypass to her external jugular vein five months following MLD in order to improve her 222 
extremity and face/neck lymphedema. 223 
 224 
Discussion 225 
Pediatric lymphedema can result in progressive and debilitating fibrotic changes to 226 
tissue. As the condition worsens over time, patients lose the dexterity to perform essential 227 
motor functions required for activities of daily living.
3
 Poor functional performance 228 
progresses to immobility if lymphedema is not addressed as soon as possible. Thus, manual 229 
drainage techniques have been implemented by vascular anomalies centers to treat pediatric 230 
 
 11 
lymphedema. Outcomes-based research on MLD in the pediatric population is scant. This 231 
study hopes to shed light on the beneficial features of MLD in children suffering from 232 
lymphedema in order to combat the debilitating, progressive changes that lead to poor 233 
function and disability. 234 
In this study, MLD was able to promote reduction in lymphedema in 62.5% of 235 
patients with average girth reductions of 8.2% in lower extremities, 3.0% in the upper 236 
extremities, and 7.4% in truncal regions. Changes in limb circumference hold more value in 237 
determining lymphedema reduction than weight, since weight changes tended to be 238 
unreliable in infants and pubertal patients undergoing normal growth spurts. 239 
MLD via the Vodder technique incorporates superficial manual therapy sequentially 240 
from the trunk, then from proximal to distal regions of the extremity, and lastly back up to 241 
the proximal regions.
6
 By beginning in proximal and truncal areas, this technique can recruit 242 
large healthy accessory tracts in central areas to absorb lymphatic fluid. Subsequently, when 243 
massaging the distal areas of the limb, lymphatic load can be pumped out proximally into 244 
these recruited healthy lymphatic tracts for a reduction in both proximal and distal 245 
lymphedema. Our study corroborates this report by showing approximately equal reductive 246 
effects in proximal and distal limb girth after MLD. 247 
MLD can also contribute to pronounced clinical improvements even if girth itself is 248 
not significantly changed. Such improvements include palpable softening of soft tissue, 249 
resolution of skin erythema and lymphatic vesicles, and analgesia.
6
 Through decongestion 250 
and rerouting of lymphatic fluid to healthy outflow tracts, patients can gain dexterity with 251 
enhanced gait, weight-bearing status, and clinical function, which was seen in our patient 252 
population as demonstrated by improved validated functional performance scores after MLD 253 
 
 12 
therapy.
6
 In our study, one of the patients who did not have impressive reduction in limb 254 
circumference did have clinically improved soft tissue softening and truncal mobility. Based 255 
on these findings, this study highlights how MLD may improve a patient’s functional status 256 
even if the actual absolute amount of lymphedema is not substantially reduced. Additionally, 257 
despite varying levels of reduced limb girth following MLD therapy, functional 258 
improvement was evident in all patients who completed the COPM questionnaires. 259 
The underlying diagnosis and etiology of lymphedema plays a role in how extensive 260 
and progressive lymphedema becomes. As Greives et al. reports, most diagnoses of pediatric 261 
primary lymphedema involve abnormal lymphatic channels due to malformations or 262 
dysplasia, though they can also involve poor contractility of lymphatic smooth musculature.
2
 263 
However, MLD techniques may not be able to completely overcome significant lymphatic 264 
accumulation in pediatric patients with widespread abnormal lymphatic anatomy and 265 
dysfunctional vessels due to their underlying condition.
9,12
 Lack of girth reduction after 266 
MLD was seen in three patients in our study diagnosed with generalized lymphatic anomaly, 267 
CLOVES syndrome, and thigh malformation. These patients may have had less pronounced 268 
improvements in limb girth and skin quality as a result of missing or dysfunctional 269 
lymphatic channels.
 9,12
 270 
Despite decongestive therapy involving MLD, subsequent therapy may be necessary 271 
to treat residual lymphedema or to address recurring lymphedema in severe cases.
9
 In our 272 
study, 60% of patients with lymphedema reduction after MLD still received subsequent 273 
lymphedema therapy. Long-term data on maintenance of girth reduction was unable to be 274 
obtained due to missed appointments after completion of the MLD program. MLD may 275 
improve lymphedema temporarily and provide favorable outcomes for patients, but it is not 276 
 
 13 
enough to permanently cure the disease. In addition, MLD may benefit as a noninvasive 277 
strategy to treat limb swelling and lymphedema temporarily, but the time and financial 278 
burden of frequent MLD sessions as well as maintenance therapy at home may be difficult 279 
to manage for some children and families. 280 
Two CLTs treated all patients in the study, which eliminated variability in MLD 281 
techniques used. Due to the retrospective design of the study, there are certain limitations to 282 
account for. A large issue in lymphedema treatment outcomes research is poor patient 283 
compliance and high dropout rates. For this reason, our study had a lack of power with a 284 
small sample size as we found few patients who 1) qualified for MLD and 2) completed all 285 
sessions with appropriate measurements taken. Additionally, it is difficult to ascertain the 286 
effectiveness of MLD in one patient over another when the severity of lymphedema varied 287 
between patients. Patients with more advanced-stage lymphedema may not have as 288 
noticeable results from MLD due to their more significantly abnormal lymphatic anatomy 289 
and dysfunction with potentially irreversible lymphedema changes in skin and soft tissue. 290 
Lastly, it is important to note that while all patients had simultaneous compression garment 291 
therapy during their MLD sessions, some also had concomitant sirolimus or a lymphatic292 
pump. These concomitant therapies can be included as part of the overall decongestive plan 293 
for an additive or synergistic effect in lymphedema reduction by preventing re-accumulation 294 
of fluid in tissues and pumping lymphatic preload towards healthy collateral drainage tracts 295 
recruited by MLD.
7
 Thus, while measurements compared in this study were pre- and post-296 
MLD, the reduction in lymphedema cannot be attributed to MLD alone because 297 
simultaneous compression bandage therapy, sirolimus, or lymphatic pump, may have 298 
contributed towards reduction in girth. 299 
 
 14 
Large, prospective studies are needed to further evaluate the effectiveness of MLD 300 
and determine MLD’s long-term sustainability for lymphedema reduction in children. 301 
Overall, MLD is a reliable noninvasive technique that can be taught to parents or guardians 302 
for maintenance therapy at home after completion of the outpatient intensive decongestive 303 
therapy program. Continued maintenance self-therapy at home with MLD and compression 304 
garment usage allows for more independence for the family and may improve the stability of 305 
lymphedema reduction long-term in children with chronic lymphedema; however, the long-306 
term effects and sustainability of MLD is currently still unknown and difficult to assess. 307 
Selection of patients who would benefit would depend on the underlying condition and 308 
etiology of limb swelling, severity of the disease, and feasibility for children and families to 309 
participate in frequent MLD sessions as part of their overall intensive decongestive therapy 310 
program. 311 
 312 
Conclusion 313 
Manual lymphatic drainage is not a cure, but it can provide decongestion to help 314 
ameliorate manifestations of progressive lymphedema, such as limb swelling, pain, impaired 315 
limb function and dexterity, tissue fibrosis, skin ulcers, and infection. While it may not be 316 
successful for all patients, MLD can attempt to counteract the debilitating effects of fibrosis 317 
secondary to lymphedema at an early age and help preserve activity performance and limb 318 
functionality before these effects become irreversible. It can also be performed at home for 319 
maintenance therapy at the convenience of the patient and families. Overall, MLD, while not 320 
a definitive cure, provides a bridge in treatment until more permanent solutions are widely 321 
available. 322 
 
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References 328 
1. Damstra RJ, Mortimer PS. Diagnosis and therapy in children with lymphedema. 329 
Phlebology 2008;23(6):276-286 330 
2. Greives MR, Aldrich MB, Sevick-Muraca EM, Rasmussen JC. Near-Infrared 331 
fluorescence lymphatic imaging of a toddler with congenital lymphedema. 332 
Pediatrics 2017;139(4): e20154456 333 
3. Greene A, Meskell P. The impact of lower limb chronic oedema on patients’ 334 
quality of life. Int Wound J 2017;14(3):561-568 335 
4. Hadamitzky C, Pabst R, Gordon K, Vogt PM. Surgical procedures in lymphedema 336 
management. J Vasc Surg Venous Lymphat Disord 2014;2(4):461-468 337 
5. Mehrara BJ, Zampell JC, Suami H, Chang DW. Surgical management of 338 
lymphedema: Past, present, and future. Lymphat Res Biol, 2011;9(3):159-67 339 
6. Kasseroller RG. The Vodder school: the Vodder method. Cancer 1998;83(12 Suppl 340 
American):2840-2842 341 
7. Pereira de Godoy LM, Pereira de Godoy Capeletto P, de Fátima Guerreiro Godoy 342 
M, Pereira de Godoy JM. Lymphatic drainage of legs reduces edema of the arms in 343 
children with lymphedema. Case Rep Pediatr 2018:6038907 344 
 
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8. Lasinski BB, McKillip Thrift K, Squire D, Austin MK, Smith KM, Wanchai A, 345 
Green JM, Stewart BR, Cormier JN, Armer JM. A systematic review of the 346 
evidence for complete decongestive therapy in the treatment of lymphedema from 347 
2004 to 2011. PM R 2012;4(8):580-601 348 
9. Lopera C, Worsley PR, Bader DL, Fenlon D. Investigating the short-term effects of 349 
manual lymphatic drainage and compression garment therapies on lymphatic 350 
function using near-infrared imaging. Lymphat Res Biol 2017;15(3):235-240 351 
10. Verkerk GJQ, van der Molen-Meulmeester L, Alsem MW. How children and 352 
their parents value using the Canadian Occupational Performance Measure 353 
(COPM) with children themselves. J Pediatr Rehabil Med. 2021;14(1):7-17 354 
11. Verkerk GJ, Wolf MJ, Louwers AM, Meester-Delver A, Nollet F. The 355 
reproducibility and validity of the Canadian Occupational Performance Measure 356 
in parents of children with disabilities. Clin Rehabil. 2006 Nov;20(11):980-8 357 
12. Olszewski WL. Contractility patterns of human leg lymphatics in various stages of 358 
obstructive lymphedema. Ann N Y Acad Sci 2008;1131:110-118 359 
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Figure Legends 372 
Figure 1. Mean and range of percent reductions in limb girth for each patient. The left half 373 
of the graph shows cases of upper extremity manual lymphatic drainage, while the right half 374 
shows cases of lower extremity manual lymphatic drainage. 375 
 376 
Figure 2. A patient with bilateral lower extremity lymphedema before manual lymphatic 377 
drainage who has more notable edema, loss of skin folds, and poorly fitting shoes on the 378 
right as compared to the left (left). After manual lymphatic drainage, limb girth has 379 
improved in the right extremity, and the patient continues to wear compression garment for 380 
maintenance of lymphedema reduction (right).381 
 
 18 
 
 
Table 1. Demographics, diagnosis, and the course of lymphedema treatment are described for each patient. 
 Age 
(yrs) 
Sex Diagnosis Area of 
lymphedema 
Indication for 
MLD referral 
Prior treatments MLD sessions Concomitant 
therapy 
Compliance 
1 13 M Left UE capillary-
lympho-venous 
malformation 
Left hand to 
hemithorax, scar 
contractures in 
left digits 
Severe pain, 
lymphatic 
vesicles, impaired 
ROM 
Compression garment, 
sclerotherapy, 
debulking surgeries 
UE: 3 per week 
for 5 weeks 
Compression 
bandage 
100% completion 
2 0.75 F CLOVES syndrome - 
bilateral UE and chest 
lymphatic 
malformations 
Bilateral UE and 
trunk 
Impaired function 
and gross motor 
delay 
Compression garment, 
sirolimus 
UE: 4 per week 
for 6 weeks 
Compression 
bandage 
Missed 3 sessions 
(88% completion) 
3 18 M Blue rubber bleb 
nevus syndrome 
Left hand and 
forearm 
Severe pain, 
impaired hand 
function and fine 
motor skills 
Compression garment, 
sclerotherapy, 
debulking of hand 
venous malformation 
UE: weekly for 6 
weeks 
Compression 
bandage, 
sirolimus 
100% completion 
4 0.4 F Left thigh congenital 
lymphatic 
malformation 
Left LE Impaired ROM None LE: 4 per week 
for 8 weeks 
Kinesio Tape 100% completion 
5 17 F Generalized 
lymphatic anomaly 
Bilateral LE, right 
UE, and abdomen 
Impaired ROM 
and overall 
mobility, fibrotic 
skin 
Compression garment, 
diuretics, sirolimus 
LE: 4 per week 
for 6 weeks 
UE: weekly for 4 
weeks 
Compression 
bandage, 
lymphedema 
pump 
LE and UE: 100% 
completion 
6 6 F Generalized 
lymphatic anomaly 
Bilateral UE and 
LE, neck, and 
abdomen 
Severe pain, 
impaired ROM, 
poor posture 
Compression garment, 
diuretics, sirolimus 
LE: 4 per week 
for 8 weeks 
UE: weekly for 6 
weeks 
Compression 
bandage, 
sirolimus 
LE: missed 1 
session (97% 
completion); UE: 
missed 1 session 
(83% completion) 
7 16 M Left LE lymphatic 
malformation 
Left LE Impaired ROM Compression garment LE: 4 per week 
for 5 weeks 
Compression 
bandage, 
sirolimus 
100% completion 
8 7 M Klippel-Trenaunay 
syndrome 
Right LE 
lymphedema 
Impaired 
function and 
ROM 
Compression garment LE: 3 per week 
for 4 weeksCompressio
n bandage 
100% 
completion 
UE = upper extremity, LE = lower extremity, ROM = range of motion
 
 19 
 1 
 2 
Table 2. Aggregate percent change in weight, limb girth, and truncal girth after completion 3 
of manual lymphatic drainage in each patient (calculation: post-therapy measurement minus 4 
pre-therapy measurement, difference divided by pre-therapy measurement). Negative 5 
percent changes illustrate a reduction from baseline, while positive percent changes illustrate 6 
an increase from baseline. Ranges are used for the upper and lower extremities to include 7 
measurements of different levels of the limb measured (i.e. proximal versus distal regions). 8 
 9 
 Weight Proximal 
UE girth 
Distal 
UE girth 
Proximal 
LE girth 
Distal 
LE girth 
Truncal 
girth 
Lymphedema 
reduction 
1 (-) 4% (-) 1-7% (-) 4-10% - - 0% Yes 
2 (-) 2% (+) 2-6% (-) 0-6% - - (-) 4-22% No 
3 (+) 5% (-) 0-10% (-) 0-5% - - - Yes 
4 (+) 12% - - (+) 3-17% (+) 0-6% - No 
5 (-) 19% (-) 0-3% 0% (-) 6-24% (-) 4-20% (-) 7-11% No 
6 (-) 2% - - (-) 13-26% (-) 11-27% (-) 5-20% Yes 
7 0% - - (-) 1-5% (-) 0-5% - Yes 
8 0% - - (-) 4-18% (-) 4-8% - Yes 
UE = upper extremity, LE = lower extremity 10 
 11 
 12 
Table 3. Secondary outcomes of manual lymphatic drainage in each patient. Pain levels are 13 
scaled 0-10, with 0 being no pain and 10 being the worst pain imaginable. 14 
 15 
 Improved 
dexterity 
Skin/tissue 
softening 
Initial 
Pain 
Final 
pain 
Other clinical 
findings 
Subsequent 
therapy 
1 Yes Yes 10/10 0/10 Resolution of skin 
erythema/vesicles 
No 
2 No Yes - - Improved truncal mobility Yes 
3 Yes Yes 4/10 0/10 Improved fine motor 
skills/keyboard use 
Yes 
4 No No - - Unchanged soft tissue bulk, 
but more weight bearing 
Yes 
5 No No - - Improved lower extremities, 
not upper extremities 
Yes 
6 Yes Yes 4/10 0/10 Improved motor strength Yes 
7 Yes Yes - - Improved range of motion No 
8 Yes Yes - - Improved gait and fit of shoes Yes 
 16 
 17 
 18 
 19 
Table 4. Percent changes in performance ratings of self-identified tasks in the Canadian 20 
Occupational Performance Measurement questionnaire after MLD. 21 
 22 
 Patient #1 Patient #3 Patient #7 Patient #8 
Total performance 
scores 
48%  72% 20%  38% 75%  87.5% 30%  90% 
 
 20 
Percent 
improvement 
24% 18% 12.5% 60% 
Identified Tasks 
Pincer grasp, zipper 
closure and 
grabbing food with 
left hand, gripping 
blade and lever 
when mowing lawn, 
keyboard typing 
Picking up a pencil 
and sandwich, 
turning doorknob, 
carrying a box, 
using Xbox 
controller 
Walking > 1 
block, running, 
lifting heavy 
object, running, 
taking shower or 
bath on own, 
completing 
chores around 
the house 
Taking pants and 
socks on/off, 
jumping, picking 
up things from 
floor, running 
without leaning to 
the side, running 
endurance in 
soccer 
 23 
 24 
 25 
 26 
 27