Currently lymphedema is thought by most authorities to be a permanent problem with little hope for a permanent cure. The mainstay of treatment has been non-surgical, massage-type therapy. This can be performed by a therapist with special training and may involve the use of special sequential pumps and devices.
Manual lymphatic drainage (MLD) is a massage type therapy designed to move the lymphatic fluid and proteins out of the affected area and back into the circulation.
Complete decongestive therapy (CDT) may combine MDL, bandaging and compression garment therapy, breathing exercises and dietary measures.
NATIONAL LYMPHEDEMA NETWORK POSITION PAPER
The following information was found in the position paper by the National Lymphedema Network:
Lymphedema (LE) is a chronic condition characterized by the abnormal accumulation of interstitial fluid due to insufficiency of the lymphatic system. Lymphatic dysfunction may be related to primary malformation of the lymphatic system, or to secondary causes. The leading cause of LE in the United States today is cancer and its treatment.
The progression of LE is characterized by swelling, as well as changes of the skin and subcutaneous tissue.1 Changes typically manifest as roughness, dryness, and hardening of the skin.2 Limbs may become grossly enlarged and distorted in contour with exaggerated skin creases, folds, and lobules.3 Progressive LE may be complicated by medical morbidity including recurrent tissue infections and non-healing wounds. Functional, psychological, and social morbidity can occur as well. LE has no cure but can be successfully managed following timely diagnosis with appropriate treatment. Diagnosis may require evaluation by a physician with expertise in LE and, when indicated, diagnostic testing.
TREATMENT OF LE: COMPLETE DECONGESTIVE THERAPY (CDT)
CDT is comprised of an initial reductive phase (Phase I) followed by an ongoing, individualized maintenance phase (Phase II). 4
The primary goals of CDT are to:
- Decrease edema
- Increase lymph drainage from the congested areas5
- Reduce subdermal fibrosis
- Improve the skin condition
- Enhance patient’s functional status6
- Enable the patient to adhere to an independent self-care program
Components of CDT
Manual lymph drainage (MLD), multi-layer, short-stretch compression bandaging, remedial exercise, skin care, education in LE self-management, and elastic compression garments comprise CDT.7
Frequency and Duration of CDT
Optimally, CDT is performed daily until the reduction of fluid volume has plateaued, often after 3 to 8 weeks.7,8
Therapists providing CDT should have completed at least 135 hours of training as recommended by the Lymphology Association of North America (LANA). (See NLN Training Position Paper.) Additional specialty training may be required for therapists treating facial, truncal, and genital LE, or LE in the context of advanced systemic illness.
Manual Lymph Drainage Manual lymph drainage is a specialized manual (hands-on) technique which stimulates superficial lymphatic vessels. MLD may direct lymphatic flow out of congested areas and into functional lymph node basins.
Multiple layers of short-stretch bandages are applied to the lymphedematous area(s). Short-stretch bandages have limited extensibility under tension (50%), in contrast to AceR bandages (300%). To achieve an effective compression gradient, bandages must be strategically applied with low to moderate tension using more layers in the distal, relative to the proximal, portions of the affected territory(ies).9 Pressure within the short-stretch bandages is low when the patient is inactive, “resting pressure”. Muscle contractions increase interstitial pressure, “working pressure”, as muscles expand within the limited volume of the semi-rigid bandages. Interstitial cycling between low resting and high working pressures creates an internal pump that encourages movement of congested lymph along the distal to proximal gradient created by bandaging. The non-elastic bandage sheath also counters refilling of fluid and reduces tissue fibrosis which further reduces volume.4
LE Exercises (Remedial Exercise)
LE exercises are beneficial for all patients. Although activity and exercise may temporarily increase fluid load, appropriate LE exercises may enable the person with LE to resume exercise and activity while minimizing the risk of exacerbation of the swelling.10 Compression garments or compression bandages must be utilized during exercise to counterbalance the excessive formation and stasis of interstitial fluid. (See NLN Exercise Position Paper for exercise guidelines.)
Skin and Nail Care
Meticulous hygiene is recommended to decrease dermal colonization with fungus and bacteria. Low pH moisturizers should be applied to limit dermal desiccation and microbial growth.11 Because of impaired local immunity in a lymphedematous limb, breaks in the skin may allow entry of bacteria and result in serious infections. (See NLN Position Paper on Risk Reduction.)
Following maximal volume reduction with Phase I CDT, patients should be fitted with a compression garment. Properly fitted garments are essential for long-term control of LE volume.12 Garment style and compression strength should be prescribed to enhance patient compliance and volume control. Garments should be washed regularly to maximize the garment’s longevity and effectiveness. Garments must be replaced at regular intervals.
LE is a life-long condition. Patient education in self-management techniques is therefore a critical dimension of effective treatment. All LE patients should be taught LE risk reduction, self- manual lymph drainage, the importance of skin care, the signs and symptoms of cellulitis, the proper fit and care of garments, the importance of weight control, and an individualized LE exercise program. Emphasis on specific LE self-care elements should be adjusted on a case-by-case basis.
Modifications and Individualization of CDT
CDT programs should be individualized based on the presence of concomitant medical conditions. Patients with wounds, musculoskeletal problems, adhesive scars, or post-radiation fibrosis causing limited mobility of the involved area or areas adjacent to the swelling, may require adjunctive therapeutic interventions in addition to CDT.13-15
Alternative non-elastic compression devices are often helpful adjuncts to simplify nighttime compression. These devices may enhance Phase II CDT effectiveness in persons who are unable or unwilling to apply traditional short-stretch compression bandages. In selected cases, they may be useful during Phase I treatment in combination with short-stretch bandaging.
Pressotherapy (Intermittent Pneumatic Compression, “Compression Pump”)
Pressotherapy is not a component of conventional CDT. Pressotherapy may be used as an adjunct to CDT.16 Pressotherapy involves insertion of the lymphedematous extremity into a multi-cell inflatable appliance, which is attached to an air compression pump. Sequential inflation and deflation of the cells creates a distal to proximal compression wave that moves the water component of the lymph and interstitial fluid out of the affected territory. There is a two-phase pump that creates a proximal to distal gradient (preparation phase) and a distal to proximal gradient (drainage phase) to simulate MLD.
Pressotherapy can decrease capillary filtration, thereby decreasing lymph formation. Pressotherapy does not accelerate lymph return 17 and does not enhance the removal of the excess protein component of lymphatic fluid. Potential complications of pressotherapy include displacement of the edema to the proximal limb, adjacent trunk and/or genitalia. A fibrosclerotic ring may develop above the proximal end of the pump appliance, further obstructing lymphatic flow. The use of a pump should be supervised by a trained therapist or healthcare provider experienced in lymphedema management. Pump pressures generally range from 30-60 mmHg.