MLD Archives - Lymphedema Therapy Source

July 1, 2026 By Rebecca Summers, OT, CLT-LANA, CSR

Rethinking MLD Pressure (part 2)

Last month, we started a discussion about MLD pressure. Foldi always taught light pressure. Newer research indicates lymph vessels aren’t occluded until 86 mmHg. We’re continuing that topic this month.

**Why This Does Not Mean “Deeper Pressure Is Better”**

One of the most important conclusions from the study is often overlooked:

The researchers specifically noted that manual lymph drainage pressures applied by the hand are typically under 10 mm Hg, which remains well below lymphatic occlusion thresholds. (Sage Journals)

That matters because MLD is not intended to “force fluid through pipes.” Instead, it works by:

stimulating lymphatic vessel activity,
improving lymphangion filling,
enhancing rerouting through collateral pathways,
and supporting natural lymphatic pumping.

The study supports the idea that properly performed gentle MLD does not collapse lymphatics. In other words, Foldi’s gentle-pressure philosophy remains physiologically sound.

The Difference Between Compression and MLD

The study also helps clarify confusion between:

manual lymph drainage pressure, and
compression therapy pressure.

Compression garments and pneumatic compression devices may use substantially higher pressures than hands-on MLD. The researchers warned that if compression pressures exceed lymphatic occlusion pressure, collectors and initial lymphatics could temporarily collapse during inflation phases. (Sage Journals)

This distinction is critical in clinical practice.

Foldi-based Complete Decongestive Therapy (CDT) has always emphasized that:

MLD prepares and stimulates lymphatic pathways,
compression maintains fluid reduction,
exercise activates the muscle and lymphatic pumps,
and skin care protects vulnerable tissues.

The therapies work together — but they do not work the same way.

What This Means for Therapists Today

The 2016 findings encourage a more evidence-based discussion around lymphatic pressure without abandoning traditional lymphology principles.

For certified lymphedema therapists, the takeaway is not to use heavier pressure. Instead, the study reinforces several clinical ideas:

1. Gentle Pressure Can Still Be Effective – MLD does not require deep force to stimulate lymphatic transport.

2. Vessel Filling Matters – Lymphatic flow is intermittent. Proper sequencing and preparation techniques — central clearing, proximal-to-distal preparation, and rhythmic repetition — may improve lymphatic filling and flow.

3. Precision Matters More Than Intensity – Direction, sequencing, stretch, and rhythm likely influence outcomes more than raw pressure.

4. Compression Must Be Individualized – Higher pressure is not automatically better, especially in compromised or fibrotic tissues.

Modern Imaging Is Validating Traditional Lymphology

One of the most fascinating aspects of this research is how modern imaging technology is beginning to visually confirm concepts long taught in Foldi-based education.

The lymphatic system is dynamic, contractile, and responsive — not passive.

Near-infrared fluorescence imaging allows researchers to watch lymphangions contract and observe fluid movement in real time, offering a new scientific window into therapies that were previously understood mostly through clinical outcomes and practitioner experience. (Sage Journals)

As lymphatic science evolves, the future of lymphedema care will likely combine:

traditional clinical wisdom,
advanced imaging,
individualized pressure strategies,
and deeper understanding of lymphatic biomechanics.

The Foldi principles are not being replaced. They are being explained more clearly than ever before.

References
¹ Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 526. Germany: Urban and Fisher.
² Belgrado, J.-P., Vandermeeren, L., Vankerckhove, S., Valsamis, J.-B., Malloizel-Delaunay, J., Moraine, J.-J., & Liebens, F. (2016). Near-infrared fluorescence lymphatic imaging to reconsider occlusion pressure of superficial lymphatic collectors in upper extremities of healthy volunteers. Lymphatic Research and Biology, 14(2), 70–77. https://doi.org/10.1089/lrb.2015.0040

June 1, 2026 By Rebecca Summers, OT, CLT-LANA, CSR

Rethinking MLD Pressure (part 1)

What Foldi’s Principles and New Lymphatic Research Tell Us

For decades, manual lymph drainage (MLD) has been guided by one central principle from the Foldi school of lymphedema treatment: lymphatic vessels are delicate, superficial, and highly responsive to pressure.¹ Therapists are taught to use slow, rhythmic, skin-stretching movements rather than deep tissue force. Now, modern imaging research is helping explain why that approach works — and where MLD pressure thresholds may actually lie.

A landmark 2016 study published in Lymphatic Research and Biology used near-infrared fluorescence lymphatic imaging (NIRFLI) to directly observe lymphatic flow in real time.² The researchers discovered that superficial lymphatic collectors tolerated much higher occlusion pressures than previously believed, with an average occlusion pressure of approximately 86 mm Hg in healthy subjects. (Sage Journals). At first glance, that finding may seem to contradict traditional Foldi-based MLD concepts emphasizing gentleness in applying MLD pressure. In reality, the research actually reinforces many of Foldi’s core principles.

The Foldi Philosophy: Pressure Is Not the Goal

The Foldi method, developed by Michael Földi and Ethel Földi, teaches that successful lymphatic treatment depends on:

stimulating superficial lymphatic vessels,
encouraging lymphangion contraction,
reducing tissue congestion,
and redirecting fluid toward healthy drainage territories.

The emphasis has always been on precision over force.

Traditional Foldi training warns against aggressive massage because excessive pressure may:

collapse superficial lymphatics,
increase capillary filtration,
irritate tissues,
or worsen inflammation and fibrosis.

The 2016 NIRFLI study adds important nuance to this understanding.

What the 2016 Study Actually Found

Researchers observed lymph flow in healthy volunteers using fluorescent imaging while gradually increasing pressure with a transparent cuff. They combined this with a specialized MLD approach called the “Fill & Flush Drainage Method” to keep lymphatic vessels actively filled during testing. (Sage Journals)

Their findings included:

Mean lymphatic occlusion pressure: 86 mm Hg
No significant differences between age, gender, or side of the body
Previous studies may have underestimated occlusion pressure due to imaging limitations and insufficient vessel filling during testing (Sage Journals)

Earlier estimates had suggested lymphatic occlusion occurred around 24–40 mm Hg. This new research challenged that assumption. (Sage Journals)

This doesn’t mean deeper or more pressure is better. Find out why in the next blog…

June 1, 2025 By Rebecca Summers, OT, CLT-LANA, CSR

MLD and a Woman’s Menstrual Cycle (part 2)

Last month, we looked at what happens during a woman’s period. This month, we’ll talk about how MLD can help.

Symptoms MLD May Help

In the second half of a cycle (the luteal phase), all kinds of unwelcomed symptoms can emerge. These can include bloating, cramps, weight gain, mood swings, fatigue, constipation, headaches & food cravings. These symptoms are caused by the rise & sudden, sharp drop of progesterone (& estrogen) when there is no egg fertilization (i.e. pregnancy). This hormone shift can affect brain chemistry, especially serotonin, which influences mood and emotion.

Bloating & Water Retention – Progesterone affects fluid balance by acting on the kidneys and blood vessels. Its drop can cause fluid to accumulate, leading to bloating, breast tenderness, and mild weight gain.
Cramps (Dysmenorrhea) – As hormone levels fall, the body produces prostaglandins to help shed the uterine lining. These chemicals cause the uterus to contract, which can lead to pain and cramping. Higher prostaglandin levels = more intense cramps.
Constipation – High progesterone (& estrogen) slows down smooth muscle contractions in the digestive tract (motility). This can lead to slower digestion and constipation, especially in the days following ovulation.
Headaches – Estrogen influences how blood vessels expand and contract and affects neurotransmitters like serotonin. When estrogen drops, it can trigger headaches or migraines, especially in those sensitive to hormonal changes.
Fatigue – The body goes through energy-intensive changes during the luteal phase, and the falling hormones can also impact thyroid function and serotonin, leading to tiredness or sleep disruption.
Food Cravings – Estrogen and progesterone influence insulin sensitivity and appetite-regulating neurotransmitters like dopamine and serotonin. The drop can cause cravings (especially for sugar and carbs), which temporarily boost serotonin and make you feel better — at least short-term.
Mood Swings & Irritability – Estrogen and progesterone affect brain chemistry, including: Serotonin (mood), GABA (calmness and anxiety) & Dopamine (pleasure and motivation). When these hormones drop, serotonin levels can dip, contributing to irritability, anxiety, sadness, or mood swings. Sensitivity to this drop varies. Some women experience mild PMS while others experience more severe PMS.

How MLD May Help

MLD increases lymphangiomotion (lymph pumping). By doing so, inflammatory particles & excess fluid are removed. In addition, proper MLD has a very relaxing effect on the body. So, it could help mood. Unfortunately, I’m not aware of any impact on food cravings!

Bloating and Water Retention – MLD gently stimulates the lymphatic system, which is responsible for removing excess fluid and waste from tissues. By improving lymph flow, it can reduce puffiness, bloating, and that heavy, swollen feeling often reported in the days before menstruation.
Breast Tenderness – Swollen, tender breasts are often caused by fluid buildup and hormonal shifts. MLD around the neck, armpits, and chest area can reduce this fluid accumulation and ease discomfort.
Headaches (from fluid pressure) – If headaches are partially due to congestion in the head and neck, MLD may help by encouraging drainage and reducing pressure.
Fatigue (mild benefit) – Some women report feeling more energized after MLD, likely due to improved circulation and detoxification, though this effect varies from person to person.
Constipation – After ovulation, progesterone levels rise before dropping. During this rise, progesterone has a relaxing effect on smooth muscle, including the muscles of the gastrointestinal (GI) tract. This causes slower gut motility (i.e. food moves more slowly through the intestines) which can lead to harder stools, less frequent bowel movements and bloating and gas. Gentle abdominal MLD techniques may improve circulation of lymphatic fluid around the intestines and abdominal organs, reducing congestion, inflammation, or sluggish movement. It can also help reduce fluid retention and bloating in the abdomen, which can make constipation feel worse. With less abdominal pressure, the bowel may move more freely.³
Mood – While MLD may not directly affect mood, it can help with reducing stress and tension, which may indirectly support better mood regulation & feelings of well-being.

Caution

MLD is not a standalone treatment for PMS. It works best when combined with hydration, fiber, movement, and sometimes probiotics or dietary adjustments. Pending a doctor’s approval, NSAIDS like Ibuprofen or heating pads may be helpful for severe cramps. And, in some cases, birth control pills can help regulate a cycle & improve symptoms. With any medication, it’s important to be aware of side effects. And be aware that deep abdominal techniques are contraindicated during menses.

Cycle Idiopathic Edema

While talking about PMS, it’s a good idea to mention another condition: Idiopathic cyclic edema (ICE). ICE is a condition that resembles PMS but is different. Besides similar symptoms, women often have two good weeks followed by two bad weeks of swelling. Oddly, even though considered edema, it is a protein-rich fluid. So, MLD & compression can be helpful.¹ It mostly affects women & causes daily, unpredictable swelling, especially in the legs, hands, face, and sometimes abdomen, with no identifiable underlying disease. (The term “idiopathic” means the exact cause is unknown, and “cyclic” refers to the pattern of swelling that comes and goes, often worsening throughout the day.) Although the cause is not clear, a number of hormones (particularly the luteinizing hormone)¹ are postulated to be involved. Altered vascular permeability and increased lymph formation may also be part of the disorder.²

References
¹ Kasseroller, R. (1998). Compendium of Dr. Vodder’s Manual Lymph Drainage, pg.111. Germany: Huthig GmbH.
² Sabatini S. Hormonal insights into the pathogenesis of cyclic idiopathic edema. Semin Nephrol. 2001;21(3):244-250. doi:10.1053/snep.2001.21651
³ Wittlinger, H., Wittlinger, G. (1998). Textbook of Dr. Vodder’s Manual Lymph Drainage (6^th ed.), pg. 87. Germany: Karl Haug Verlag.

May 1, 2025 By Rebecca Summers, OT, CLT-LANA, CSR

MLD and a Woman’s Menstrual Cycle (part 1)

(Caution: This month’s blog may be a bit awkward for male readers.) A patient recently came into the office seeking relief from symptoms related to her menstrual cycle. Her primary complaints were bloating and weight gain. She had a wedding coming up and wanted to look her best. Can manual lymph drainage (MLD) help with symptoms related to a woman’s period? Let first look at what occurs during a woman’s cycle.

The Cycle

Every month (if things work like they should), a woman goes through a series of steps through which the body prepares for possible pregnancy. The cycle typically lasts 28 days (but the range varies from 21 to 35 days). And it’s regulated by hormones. (If you’ve read past blogs, you may have learned hormones can cause swelling because of how they influence the permeability of the capillary bed, allowing fluid and proteins to escape the blood stream and enter the tissue space.)

Days 1-5: The period. This is when there is active bleeding as the uterine lining sheds. Hormone levels are lower, especially estrogen.

Symptoms: Cramping, bloating, fatigue, mood changes which subside towards the end.

Days 1-13: Follicular Phase. The pituitary gland releases FSH (follicle-stimulating hormone), stimulating the ovaries to produce follicles. One becomes dominant and matures into an egg. Estrogen increases, helping rebuild the uterine lining. Days 8-14 are the best times to get pregnant as there’s an increased chance the sperm will be present when an egg is released (on day 14), but days 8-19 are a conservative window.

Symptoms: Higher energy, mental clarity, clearer/glowing skin, increased sex drive, higher confidence, cervical mucus becomes clearer, stretchier, and more slippery (like egg whites) to help sperm travel easier as ovulation approaches.

Day 14: Ovulation. A few days before ovulation, there’s a surge in LH (luteinizing hormone) triggering the release of the mature egg from the ovary (ovulation) on day 14. This is the most fertile time; sperm can survive up to 5 days, and the egg lives about 24 hours.

Symptoms: Same as the follicular phase. In addition, the breasts and labia may become more sensitive, tender and/or enlarged.

Day 15-28: Luteal Phase. If there is no pregnancy, the empty follicle becomes the corpus luteum (Latin for “yellow body”), which secretes progesterone to thicken the uterine lining for possible pregnancy. If that doesn’t happen, the corpus luteum breaks down, progesterone drops and menstruation begins.

Symptoms: If no pregnancy occurs, PMS symptoms occur (the symptoms women usually want relief from).

PMS Symptoms

PMS stands for Premenstrual Syndrome. But there are numerous acronyms that substitute meaning: “Pass My Snacks,” “Prepare to Meet Satan,” “Pardon My Sensitivity,” “Pizza and Mood Swings,” and “Please Make it Stop” are among the contenders. The symptoms of PMS can include bloating, cramps, weight gain, mood swings, fatigue, constipation, headaches, food cravings. They’re caused by the rise and sudden, sharp drop of progesterone when there is no pregnancy. This hormone shift can affect brain chemistry, especially serotonin, which influences mood and emotion. When the changes are extreme or severe, it’s called Premenstrual Dysphoric Disorder.

How can MLD help? Find out next month!