The massage therapy profession is moving toward an understanding of the importance of evidence-informed practice, a process that allows us to make statements about the benefits and risks of massage based on objective criteria and not just anecdotal reports. Let’s take this premise and apply it toward understanding the evidence behind various forms of lymphatic work.

Starting with the Research
When we think of “evidence” for an evidence-informed practice, we most often think of scientific research studies. Yes, these are evidence, but the information is only as good as the study’s design. Going a step further, it’s important to look at both meta-analysis and systematic reviews when evaluating evidence to weed out poor research studies and seek common conclusions from higher quality ones.   
In relation to lymphatic techniques, I found three systematic reviews and a meta-analysis of randomized controlled trials (RCTs) related to manual lymphatic drainage (MLD):
1. “Systematic Review of Efficacy for Manual Lymphatic Drainage Techniques in Sports Medicine and Rehabilitation: An Evidence-Based Practice Approach,” by G. Vairo et al., published in The Journal of Manual & Manipulative Therapy in 2009.1
2. “Effects of Manual Lymphatic Drainage on Breast Cancer-Related Lymphedema: A Systematic Review and Meta-Analysis of Randomized Controlled Trials,” by T. W. Huang et al., published in the World Journal of Surgical Oncology in 2013.2
3. “Conservative Interventions for Preventing Clinically Detectable Upper-Limb Lymphoedema in Patients Who Are At Risk of Developing Lymphoedema After Breast Cancer Therapy,” by M. M. Stuiver et al., published in the Cochrane Database of Systematic Reviews, 2015.3
4. “Manual Lymphatic Drainage for Lymphedema Following Breast Cancer Treatment,” by J. Ezzo et al., published in the Cochrane Database of Systematic Reviews, 2015.4

While results varied, none of these reviews offered conclusive support for manual lymphatic drainage, and individual studies justifying the use of massage for lymphatic movement are few in number and also inconclusive. This means that other forms of evidence need to be used to justify massage benefits related to the lymphatic system.  
Expert opinion consensus is the primary type of evidence that currently supports the manual movement of tissue fluid and lymph. The foundation for this type of evidence needs to be based on known anatomy and physiology, changes that occur with pathology, and the ability to support normal function based on logical approaches that mimic normal function. When making statements related to the possibility of massage therapy, performed in a specific way, with the intent to influence lymphatic movement in the body, we need to provide a logical explanation or rationale (a “justification”) and to explain to clients that although the methods appear to be clinically effective, research, as yet, is unable to prove the outcomes.
Let’s use our evidence to explore the possibility that massage can influence the lymphatic system in a beneficial manner and create a justification process for that possibility.

Justification Step 1—Understand Normal Function of the Lymphatic System
The lymphatic system includes the spleen; thymus; lymph nodes and lymph nodules; the lymph capillaries, vessels, trunks, and ducts; and lymph and lymphocytes. It is a one-way system that begins in the tissues and ends when it reaches the blood vessels. The system helps the body maintain homeostasis by collecting accumulated tissue fluid around the cells and returning it to the bloodstream.
The lymphatic system is an open-ended system, beginning in the interstitial spaces. The fluid located around the cells is called interstitial fluid. As fluid pressure increases between the cells, the cells move apart, pulling on the microfilaments that connect the endothelial cells of the lymph capillaries to tissue cells. The pull on the microfilaments causes the lymph capillaries to open like flaps, allowing interstitial fluid to enter the lymph capillaries. The moment interstitial fluid enters a lymph capillary a flap valve prevents it from returning to the interstitial space. Lymph capillaries join to form larger lymph vessels that resemble veins but have thinner, more transparent walls. Like veins, they have valves to prevent backflow. The large vessels continue to merge and eventually become two main ducts called the right lymphatic duct and the thoracic duct (left lymphatic duct) (Image 1). The right lymphatic duct drains the upper right half of the body and empties into the right subclavian vein. The thoracic duct drains the rest of the body and empties into the left subclavian vein.
The lymph nodes play an active part in the immune defenses of the body by filtering out and destroying foreign substances and microorganisms. Interstitial fluid comes from blood plasma that seeps through capillaries. Interstitial fluid becomes lymph when it moves into the lymph capillaries, which are tiny, open-ended channels located in tissue spaces throughout the body. Lymph contains proteins and other cell by-products, as well as pathogens and cell debris. As lymph travels through lymph vessels, it is filtered by lymph nodes that remove the pathogens and cell debris, before traveling to the bloodstream and once again becoming plasma.

Lymphatic circulation is separated into two layers:
• The superficial circulation, which constitutes 60–70 percent of lymph circulation, is located just under the skin in the junction between the superficial fascia and the dermis. The superficial circulation is not stimulated directly by exercise but is influenced by the stretching and pulling of the skin and superficial fascia during movement.
• Deep muscular and visceral circulation, below the fascia, is activated by muscular contraction, peristalsis, and respiration.
The movement of lymph is known as lymphatic drainage. The lymphatic system does not have a central pump like the heart, so various factors assist the transport of lymph through the lymphatic vessels. During inhalation, the thoracic duct is squeezed, which pushes fluid forward and creates a vacuum in the duct. During exhalation, fluid is pulled from the lymphatics into the thoracic duct to fill the partial vacuum. The main mechanism of opening lymph capillary vessels (called collectors) is from the pull of the skin and fascia during movement. Movement of lymph fluid in the lymph vessels is assisted by the pressure exerted by the compression of skeletal muscles against the vessels during physical movement and by changes in internal pressure during respiration. Major lymph plexuses are found on the soles and the palms, possibly because the rhythmic pumping of walking and grasping facilitates lymphatic flow. The lymph vessels themselves may have an intrinsic pumping action.

Justification Step 2—Understand What Happens When Function is Not Normal
When the influx of fluid into the tissue is more than can be drained by the lymphatic system, edema occurs. Simple edema can be related to variations in fluid and salt intake or hormonal changes.  Common causes of edema are congestive heart failure, kidney disease, liver disease, and medications, including steroids, hormones, and chemotherapy for cancer, which may cause edema as a side effect. Localized edema occurs with inflammation and lymphatic obstruction, and scar tissue and muscle tension can cause obstructive edema by restricting lymph vessels.
Additionally, both a lack of movement and an increase in exercise can result in edema. A decrease in movement interrupts the normal pumping action of fluid, while an increase in exercise can strain the lymph system by causing blood capillary permeability, resulting in an increase in fluid movement into the interstitial spaces. This may be one cause of the delayed onset of muscle soreness when there is an increase in physical activity. With injury, increased blood flow to an injured area and the release of vasodilators, which are part of the inflammatory response, can also contribute to edema.
The more severe condition of lymphedema occurs with an increase in tissue fluid caused by inflammation or obstruction by scar tissue, parasites, or trauma. Lymphedema can be life threatening because the interstitial fluid is contaminated, injuries to the skin do not heal, and even small abrasions and sores can become infected.

Justification Step 3—Understand Current Methods for Lymphatic Treatment
Methods used to support lymph drainage include medication (diuretics) and decongestive therapy. The primary medical treatment for generalized edema is the cautious use of diuretics to remove the fluid. Complete/complex decongestive therapy (CDT) is an intensive program that combines bandages, compression garments, external pumping sleeves that rhythmically compress the area, manual lymphatic drainage, exercise, and self-care. MLD methods use a gentle technique designed to move the skin in specific directions based on the underlying structure and physiology of the lymphatic system. The intent of the various interventions is draining lymph already in the lymph vessels (collectors) and stimulating the formation of lymph by increasing the flow of interstitial fluid to the lymphatic capillaries (initial lymphatics). The working hypothesis for manual methods is to support more normal fluid flow by creating spaces in the tissues and then massaging fluid into these spaces by external tissue compression.
There are different types of MLD techniques, including those advanced by Emil Vodder, Albert Leduc, Bruno Chikly, the Földi College, Judith Casley-Smith, and José Maria Pereira de Godoy. Most of the methods have a foundation based on the work by Vodder and the Dr. Vodder Akademie in Austria.
There is a long history of manual methods in osteopathic medicine that target the lymphatic system. Taylor Still, DO, proposed the initial principles of manual lymphatic drainage techniques with the advent of osteopathic manipulative techniques in the late 1800s. The osteopathic medical profession has designed a set of osteopathic manipulative techniques, called lymphatic pump techniques, to enhance the flow of lymph through the lymphatic system.

Justification Step 4—Evaluate Current Interventions in Relation to Massage Therapy
The fourth step in the justification process is to evaluate currently used lymphatic interventions in relation to the application of massage therapy. During this evaluation, indications, contraindications, and cautions are identified, and contrasts and comparisons are drawn between the methods used and massage.
Scope of practice is an important consideration here. Much of what is being used for lymph-related treatments is part of the osteopathic medicine scope of practice, including the prescription of medications. There is specific advanced training in decongestive therapy, and these methods are often used by physical therapists and nurses.
The massage-like skin stretching used in MLD and the rhythmic rocking and compression used in the osteopathic approach are also part of therapeutic massage. The management of simple edema as part of a general massage seems to be within scope of practice; however, if pathology does exist, focused treatment by a massage therapist without direct supervision by a physician, nurse, or physical therapist may be outside an MT’s scope of practice.

Justification Step 5—Answer the Question
The fifth step is to answer the question we began with: Can massage targeting general fluid movement and lymphatic function be justified?
If massage does indeed affect the movement of fluid (including lymph) in the body, then somehow massage would need to mimic the natural mechanism of fluid and lymph movement.
The pressure and tissue movement provided by massage mimics the tissue sliding and compressive forces of movement and respiration, and can move the skin to open the lymph capillaries, allowing interstitial fluid to flow into lymph vessels.
Simple muscle tension and connective tissue stiffness puts pressure on the lymph vessels and may block them, interfering with efficient drainage. Massage may normalize this muscle tension and increase connective tissue pliability. As the muscles relax and the tissues soften, the lymph vessels open and drainage becomes more efficient. Massage therapists should work on the areas of muscle and connective tension first, using appropriate massage methods such as gliding and kneading with moderate pressure, and then finish the area with skin drag methods.
Moving the skin moves the lymphatics. Stretching the lymphatics longitudinally, horizontally, and diagonally stimulates them to contract. The pressure gradient from high pressure to low pressure is supported by creating low-pressure areas in the vessels proximal to the area to be drained. Massage that uses light pressure to drag the skin has the potential to increase superficial uptake of interstitial fluid into the lymphatic capillaries. The focus of the initial pressure and finishing strokes is in the dermis, just below the surface layer of skin, and the layer of tissue just beneath the skin and above the muscles. This is the superficial fascial layer, which contains 60–70 percent of the lymphatic circulation in the extremities. Not much pressure is required to contact the area. If too much pressure is applied, the capillaries are pressed closed; this nullifies any effect on the more superficial vessels. Generally, light pressure is indicated initially, which increases to a moderate level (including kneading, compression, and gliding) during repeated application to the area to reach the deep lymphatic vessels. The technique then returns to lighter pressure over the area. Rhythmic, gentle, passive, and active joint movement and rhythmic muscle contraction reproduce the way the body normally pumps lymph, especially in the deep lymphatic circulation.
During massage, the practitioner can stimulate this process by using rhythmic compression with enough depth to compress the muscle tissue in general with rhythmic pumping of the thorax including the abdomen. The client helps the process by breathing slowly and deeply, which stimulates lymph flow.
The depth of pressure, speed and frequency, direction, rhythm, duration, and drag are adjusted to support the lymphatic system and fluid flow in general:
• Depth of pressure. This pressure is just enough to move the skin. The lymphatics are located mostly in superficial tissues, in the outer 0.3 millimeters of the skin, and surface edema occurs in those superficial tissues, not in the deep tissue. Because lymph capillary plexuses are present on the bottoms of the feet, rhythmic compression on the soles may also enhance lymph flow.
• Speed and frequency. The greater the amount of fluid in the tissue, the slower the massage movements. Massage strokes are repeated at a rate of approximately 10 per minute in an area, the approximate rate at which the peripheral lymphatics contract.
• Direction. The lymph is moved toward the closest cluster of lymph nodes, which are located in the neck, axilla, and groin for the most part (Image 2). Massage near nodes first, and then move fluid toward them, working proximally from the swollen area toward the nodes. Massage the unaffected side first, then the obstructed side. For instance, if the right arm is swollen because of scar tissue from a muscle tear, massage the left arm first. When possible, position the area being massaged above the heart so that gravity can assist the lymph flow.
• Rhythm. Slow, rhythmic repetition of the massage movements stimulates a wave in the lymph fluid similar to intestinal peristalsis (e.g., a pump).
• Duration. Full-body lymphatic drainage massage lasts about 45 minutes. Focus on local areas for about 5–15 minutes.
• Drag. Drag on the tissue pulls open the terminal ends of the lymphatic capillaries (flap), allowing interstitial fluid to enter. Drag moves the superficial tissues (skin and superficial fascia) into and out of bind.      

A Justified Statement
Now, we have an answer to our question. Massage can be adapted to generally support normal fluid movement and lymphatic function and effectively manage simple edema. Massage can incorporate many of the principles from the various schools of manual lymphatic drainage and osteopathic manipulation techniques without infringement of scope of practice, so long as pathology is not present.

Put Into Practice: Application of Massage to Support Lymphatic Drainage
Having justified the work, here is a protocol for a 50-minute lymphatic system-targeted massage.
The following sequence combines various methods to support fluid movement in the body. Little, if any, lubricant is used, so the skin can be easily moved. The approach is slow and methodical. The pumping protocol is performed in primarily the supine position, but can be modified for side lying and can be done with clients clothed. The massage protocol must be done on skin and can be done in all positions. Each section of the process can be used separately and is easily combined into general therapeutic massage application.  

Generalized pumping protocol (Total time: 10 minutes)
• Begin the massage session by slow skin-stroking on the anterior cervical area above the clavicles. (60 seconds)
• Place both hands on the anterior surface of the thoracic cage just below the clavicles and apply a firm but gentle rhythmic pumping action on the thorax (Image 3). Repeat this procedure four or five times.
• As the client exhales completely, allow your hands to passively follow the movements of the thorax. When the client starts to inhale, resist the movement of the thorax with counter pressure for 5–7 seconds. Repeat this procedure four or five times.
• Place both hands on the surface of the abdomen on either side of the umbilicus and apply a firm but gentle rhythmic pumping action toward the thorax (Image 4). Repeat this procedure four or five times.
• Apply a pumping, rhythmic compression on the soles of the feet and palms of the hands.
• Rhythmically rock the body, beginning at the feet, and passively move the joints throughout the massage session (Image 5).

Massage protocol (Total time: 30 minutes)
• The massage application consists of a combination of short, light, pumping, gliding strokes, beginning close to the torso at the node clusters and directed toward the torso.
• The strokes methodically move distally (Image 6). The stroke does not slip, but rather drags the tissue to bind. The phase of applying pressure and drag must be longer than the phase of pressure and drag release. The releasing phase cannot be too short, because the lymph needs time to drain from the distal segment. Therefore, the optimum duration of the pressure and drag phase is 6–7 seconds; for the release phase, it is about 5 seconds.
• This pattern is followed by long, surface, gliding strokes and kneading with a bit more pressure to influence deeper lymph vessels. The direction is toward the drainage points.
• Repeat in each body segment and limb.
Repeat generalized pumping protocol (Total time: 10 minutes)
To end the session, repeat the same steps as in the opening pumping protocol.

Conclusion
This is an example of how to justify massage adapted to specifically target fluid movement when research evidence is inconclusive or does not exist. Each step of the suggested protocol is based on mimicking normal function. Obviously, all fluid is moved—not just lymph. Also, the connective tissue structures and nervous system are stimulated as well. Regardless of how specific an outcome we intend, massage is just too general and broad in approach and effects to make a specific type of claim.  
However, by using critical thinking and offering full disclosure during the client’s informed consent process, you can safely and ethically offer an adapted massage that is safe for your client’s lymphatic issues.

Contraindications and Cautions for Lymphatic Drainage Massage
If the area in question is swollen, hot, red, and painful, refer the client to a medical professional. If inflammation is present, massage the area only after the reason for the condition has been determined. Here are additional cautions and contraindications:
• Undiagnosed persistent edema should initiate a referral.
• Edematous tissues have poor oxygenation and reduced function, and they heal slowly after injury.
• Chronic edema results in chronic inflammation and fibrosis, which makes the edematous tissue coarse, thicker, and less flexible.
• Massage may lower blood pressure. If the client has low blood pressure, the client may become dizzy upon standing.

Assessment of Fluid Imbalance
The following information and suggested massage applications may be beneficial for the lymphatic system in general, and for occasional nonpathologic simple edema:
1. Ask the client if the tissue feels taut, distended, fat, or stiff. If the answer is no, palpate to confirm that edema is not present and then proceed with general massage. If the answer is yes, ask for the history and screen for potential referral.
2. Look for decreased muscle definition, bruising, tissue distention, and changes in color. If any of these are found, palpate.
3. Palpate for increased muscle tone, specifically tissue tautness and an increase in fluid (pitting edema) or venous congestion. If these are noted, observe and palpate for signs of inflammation. Palpate for heat and observe for redness. Ask about pain.

Notes
1. Giampietro Vairo et al., “Systematic Review of Efficacy for Manual Lymphatic Drainage Techniques in Sports Medicine and Rehabilitation: An Evidence-Based Practice Approach,” The Journal of Manual & Manipulative Therapy 17, no. 3 (2009): e80–e89.
2. T. W. Huang et al., “Effects of Manual Lymphatic Drainage on Breast Cancer-Related Lymphedema: A Systematic Review and Meta-Analysis of Randomized Controlled Trials,” World Journal of Surgical Oncology 14 (2013).
3. M. M. Stuiver et al., “Conservative Interventions for Preventing Clinically Detectable Upper-Limb Lymphoedema in Patients Who Are At Risk of Developing Lymphoedema After Breast Cancer Therapy,” Cochrane Database of Systematic Reviews (February 2015), accessed December 2015, www.ncbi.nlm.nih.gov/pubmed/25677413.
4. J. Ezzo et al., “Manual Lymphatic Drainage for Lymphedema Following Breast Cancer Treatment,” Cochrane Database of Systematic Reviews (May 2015), accessed December 2015, www.ncbi.nlm.nih.gov/pubmed/25994425.

Resources
Ebert, J. R. et al. “Randomized Trial Investigating the Efficacy of Manual Lymphatic Drainage to Improve Early Outcome After Total Knee Arthroplasty.” Archives of Physical Medicine and Rehabilitation 94, no. 11 (November 2013): 2103–11. Accessed December 2015.     www.movinglymph.com/docs/Misc/Abstract%20RCT%20of%20MLD%20after%20TKA.pdf.
Hodge, L. M. “Osteopathic Lymphatic Pump Techniques to Enhance Immunity and Treat Pneumonia.” International Journal of Osteopathic Medicine 15 (2012): 13–21. Accessed December 2015. www.ncbi.nlm.nih.gov/pmc/articles/PMC3437985.
Knott, E. M. et al. “Increased Lymphatic Flow in the Thoracic Duct During Manipulative Intervention.” Journal of the American Osteopathic Association 105 (2005): 447–56. Accessed December 2015. www.ncbi.nlm.nih.gov/pubmed/16314677.
Pereira de Godoy, J. M. “Godoy & Godoy Technique in the Treatment of Lymphedema for Underprivileged Populations.” International Journal of Medical Sciences 7, no. 2 (2010): 68–71. Accessed December 2015. www.medsci.org/v07p0068.htm.
Pereira de Godoy, J. M. et al. “Cervical Stimulation for Volumetric Reduction of Limbs in the Treatment of Lymphedema.” Indian Journal of Medical Sciences 62, no. 10 (October 2008): 423–5. Accessed December 2015. www.medsci.org/v07p0068.htm.
Schander, A., H. F. Downey, and L. M. Hodge. “Lymphatic Pump Manipulation Mobilizes Inflammatory Mediators into Lymphatic Circulation.” Experimental Biology and Medicine 237, no. 1 (2012): 58–63. Accessed December 2015. www.jaoa.org/content/112/7/413.full.pdf.
Taradaj, J. et al. “Comparison of Efficacy of the Intermittent Pneumatic Compression with a High- and Low-Pressure Application in Reducing the Lower Limbs Phlebolymphedema.” Therapeutics and Clinical Risk Management 11 (2015). Accessed December 2015.     www.ncbi.nlm.nih.gov/pmc/articles/PMC4603726.

Sandy Fritz is the owner and head educator of the Health Enrichment Center School of Therapeutic Massage in Lapeer, Michigan. In massage practice for more than 35 years and actively involved in the global advancement of massage therapy, Fritz is passionate about training the next generation of instructors and leaders. She is the author of Mosby’s Fundamentals of Therapeutic Massage (Mosby, 2012) and Mosby’s Essential Sciences for Therapeutic Massage (Mosby, 2012) and many other textbooks published by Elsevier. Visit www.sandyfritz.info for more details.