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Fig 2 Scheme of MLD maneuver sequences applied to the lower extremity (manual technique applied with both hands with low pressure, making a skin stretching in a caudal to cephalic direction). With patients in a supine position, MLD starts at the inguinal region (site A) (10 MLD maneuvers), progresses downward through the thigh, with 30 MLD maneuvers applied at the medial (site B) and 30 MLD maneuvers applied at the lateral (site C) aspect of the thigh. Next, MLD maneuvers were applied (gray in the scheme) 10 times immediately above (site D) and 10 times immediately below (site E) the popliteal fossa, followed by 30 MLD maneuvers applied in a downward direction at the medial (site F) and lateral (site G) aspect of the leg. The downward sequence finishes with 30 MLD maneuvers in the dorsal aspect of the foot (site H). Then, the MLD maneuvers were initiated upward: 15 repetitions of MLD maneuvers again at sites H, G, and F; 5 repetitions of MLD maneuvers at sites E and D; and 15 repetitions of MLD maneuvers at sites C and B.

Finally, the sequence ended with 5 MLD maneuvers at site A. A significant interaction group × time effect was found for pain on HRQOL (F 2,78=3.507; P=.035; partial η 2=.087), clinical severity (F 2,78=5.231; P=.007; partial η 2=.118), especially for venous edema (assessed with the VCSS), fatigue (F 1.67,65.21=4.690; P=.012; partial η 2=.107), and heaviness (F 1.57,61.32=9.702; P=.001; partial η 2=.199), with the experimental group improving from t0 to t1 and t0 to t2 in all of these outcomes. No effect of MLD treatment could be found for ankle muscle strength, ankle ROM, and leg volume.

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