Elsevier

Physiotherapy

Volume 103, Issue 1, March 2017, Pages 81-89
Physiotherapy

Venous flow during manual lymphatic drainage applied to different regions of the lower extremity in people with and without chronic venous insufficiency: a cross-sectional study

https://doi.org/10.1016/j.physio.2015.12.005Get rights and content

Abstract

Objectives

To evaluate the effect of manual lymphatic drainage (MLD) on venous flow when applied to the medial and lateral aspects of the thigh and leg in patients with chronic venous insufficiency (CVI) and healthy subjects.

Design

Cross-sectional study.

Setting

Participants were assessed in a school-based health community attendant service.

Participants

Fifty-seven subjects participated in this study {mean age: 43 [standard deviation (SD) 14] years, 38 women and 19 men}. Of these, 28 subjects had CVI [mean age 47 (SD 12) years] and 29 subjects did not have CVI [mean age 39 (14) years].

Intervention

MLD was applied by a certificated physical therapist to the medial and lateral aspects of the thigh and leg.

Main outcome measurements

Cross-sectional area; blood flow velocities in the femoral vein, great saphenous vein, popliteal vein and small saphenous vein at baseline and during MLD, measured by duplex ultrasound.

Results

Flow volume in the femoral vein increased from baseline [5.19 (SD 3.25) cm3/second] when MLD was applied to the medial [7.03 (SD 3.65) cm3/second; P  0.001; mean difference −1.69; 95% confidence interval (CI) −2.42 to −0.97] and lateral [6.16 (SD 3.35) cm3/second; P  0.001; mean difference −1.04; 95% CI −1.70 to −0.39] aspects of the thigh. Venous flow augmentation in the femoral vein and great saphenous vein was higher when MLD was applied to the medial aspect of the thigh (P < 0.001), while MLD had a similar effect on venous blood flow regardless of whether it was applied to the medial or the lateral aspect of the leg (P = 0.731).

Conclusions

MLD increases blood flow in deep and superficial veins. MLD should be applied along the route of the venous vessels for improved venous return.

Introduction

Manual lymphatic drainage (MLD) is used as a conservative treatment for chronic venous insufficiency (CVI) [1]. When applied along the course of the great saphenous vein [2] and before surgery [3], [4], MLD appears to improve venous haemodynamics, clinical severity and quality of life [4], [5].

MLD is also a well-known conservative treatment for lymphoedema [6]. It consists of a skin-stretching form of massage that is performed along the anatomical distribution of the superficial lymphatic vessels and ganglions [7], and exerts mild pressure (<40 mmHg) over the underlying soft tissues to stimulate lymph flow and re-absorption of interstitial fluid and macromolecules by the lymphatic system [8], [9].

The real impact of MLD on venous blood flow is unclear, but it has been suggested to be minor [8]. Improving venous return in patients with CVI is important in order to avoid peripheral venous hypertension and consequent luminal hypoxaemia and vein wall distension, which, in turn, impair blood perfusion and cause endothelial hypoxia, leucocyte invasion of the vessel wall, oedema [10] and ongoing damage of skin and subcutaneous tissues (i.e. lipodermosclerosis and skin ulceration) [11].

Although scarce, data show that MLD enhances venous blood flow in distinct deep and superficial veins of the lower extremities in healthy subjects and patients with chronic venous disease [2]. These are important observations given that MLD can be performed not only by therapists, but also by patients and caregivers, if offered proper advice and training [12]. Therefore, MLD may be an interesting alternative for the conservative treatment of CVI [1], [2], [4]. However, the precise mechanisms by which MLD increases venous blood flow are not fully understood. Previous data suggest that MLD increases venous blood flow in superficial and deep veins regardless of the exact technique that is employed [2]. However, in the lower extremities, deep and, particularly, superficial veins have a distinct anatomical distribution that may constrain the efficacy of MLD [2].

Therefore, the aim of this study was to compare the changes in venous blood flow in deep and superficial veins during the application of MLD to the medial and lateral aspects of the thigh and leg. Vascular (cross-sectional area) and haemodynamic (flow velocity and flow volume) changes were assessed in participants with and without CVI in deep (femoral and popliteal) and superficial (great saphenous and small saphenous) veins. Based on the anatomy of the veins in the lower extremity, it was hypothesised that venous blood flow enhancement would be greater when MLD was applied to the medial aspect of the thigh and leg, as the major veins course along this side. Despite the fact that the small saphenous vein runs posteriorly and laterally across the leg [13], and the popliteal vein is deeply and centrally placed within the posterior muscle compartment of the leg [14], higher augmentation of venous flow was expected when MLD was applied to the medial aspect of the leg as this is the path followed by the great saphenous vein.

In addition, it was hypothesised that venous blood flow enhancement caused by MLD would be greater in subjects with CVI due to greater venous pooling in the leg.

Section snippets

Participants

After screening 78 subjects, a convenience sample of 57 participants was recruited to participate in this study, which included 28 participants with CVI (CVI group; 21 women and seven men) and 29 participants without CVI (non-CVI group; 17 women and 12 men). Participants with CVI were recruited from the outpatient clinic of a health school.

The demographic and clinical data of the participants are presented in Table 1. All participants with CVI had venous blood reflux and

Results

The demographic and clinical data of the participants are presented in Table 1. All participants with CVI had pathological venous blood reflux in the lower extremity and had a CEAP classification of C3–5.

No differences in height, weight and body mass index were found between the CVI and non-CVI group. Nevertheless, the CVI group was slightly older than the non-CVI group {mean age 47 [standard deviation (SD) 12] years vs 39 (SD 14) years, P = 0.029}.

Discussion

This study found that MLD, which is based on manual stretching of the skin and underlying soft tissues, increases venous blood flow in superficial and deep veins, and this occurs to a similar extent in participants with and without CVI. The increase in venous flow was higher when MLD was applied to the medial aspect of the thigh, corresponding to the root of the great saphenous vein, compared with when MLD was applied to the lateral aspect of the thigh. However, MLD was found to increase venous

Acknowledgements

The authors wish to thank Aida Paulino, Maria Conceição Branco and Manuel Machado from Unidade Local de Saúde de Castelo Branco for referring patients to this study. The authors also wish to thank Diana Arraia for her help in data collection, and Isabele Salavessa for reviewing the English.
Ethical approval: The study received ethical approval by the review board of the Scientific Council of the Faculty of Human Kinetics, University of Lisbon (Ref. No. Parecer 10/2013).
Funding: This work was

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