Systematic Review on MLD for BCRL


The Cochrane Library of Systematic Reviews has accepted only 4 reviews on management of lymphoedema – mainly because one of the Cochrane criterion is to include only randomised controlled trials and many studies on lymphoedema are cohort studies (one group all receiving the same treatment) and not RCT’s (two or more groups receiving comparative treatments, usually with one group acting as a control and receiving no treatment at all).

Systematic Reviews (SR) are very different to Literature Reviews. In a Literature Review it is possible for a single author to ‘cherry pick’ the included articles to support a particular point of view. In a Systematic Review the authors must accept and include all the published papers which meet the stated criteria for the review. This reduces the possibility that the authors have biased the review in favour of their own opinions. Additionally an SR must have at least two authors and will commonly have a whole team performing the review.

In this review, although the search found 834 articles on MLD, the authors excluded 805 – either because the title itself or the abstract (a short synopsis of the whole paper) indicated they were not suitable for inclusion. Then, when the remaining 29 papers were closely evaluated only six met the strict inclusion criteria that had been set at the commencement of the review. It is important to realise when you are reading an SR that whilst it will give you the best available evidence for the intervention under review, it is not representative of all the available peer reviewed literature that has been published on the subject.

You can read the full article at
but unless you are academically trained you might go cross-eyed trying to follow the complicated process by which the reviewers have come to their conclusions!

At a minimum I suggest you read:

  • The first 6 pages
  • Page 11
  • And look at the ‘Forest Plots’ starting on page 15.

Forest plots graphically compare the results of the trials. The green square indicates the weighting given to each included trial and the thin line through it indicates the range of results for individual trials. The black diamond summarizes this for all trials in the graph. In this review most of the forest plot comparisons are of only one trial at a time so the black diamond is pretty much the same width as the line. If the thin line or the black diamond crosses the vertical line then the results are less definitive than when  all the data is on one side only.

From the forest plots in this review you can see that:

  1. MLD + compression therapy was better then SLD (self massage) + compression in reducing excess limb volume but not better than a compression pump + compression.
  2. MLD + compression sleeve was only slightly better than SLD + compression sleeve in reducing total limb volume.
  3. A greater % change in lymphoedema volume was achieved using MLD than using SLD or a pump.

You might also like to read the results on subjective symptoms reported on page 18. I value self-reported symptoms very highly in my clinic. After all, it is about how the person experiences their conditions that really matters, not how many mls reduction is achieved (although the two are often closely linked).

It is good to read the authors Discussion (pages 19 – 21)  but if you are already too mind boggled by now you can cut to the Conclusion (page 22).

The main points that I have taken from this review are;

  • Performing MLD  in the reduction phase of treatment may have the greatest benefit in earlier stages of lymphoedema than in later stages. This reinforces my personal view that we need to advocate for earlier intervention.
  • Skipping bandaging and going straight to a sleeve is not as effective as persisting with the initial phase of short stretch bandaging.
  • Off the shelf sleeves are not as effective as custom made sleeves.

One big issue that I have with most trials on MLD is the lack of description of the technique used – not all MLD is equal. And again in this review you can’t tell if the ‘MLD’ used in any trial was the Dr Vodder technique or lymphatic effleurage. I am yet to see anywhere a trial that compares these two forms of lymphatic drainage but I do believe that they are not the same and will not produce the same results.

Until authors of original research – and that includes authors of reviews of original research – more explicitly describe the MLD techniques used, I believe we do not yet have a clear picture of the effectiveness of Dr Vodder’s MLD.