CHAPTER 29 Conservative Treatments for Lymphedema
The treatment of lymphedema should be holistic, regardless of the area of the body affected.
The major traditional treatments improve lymphatic vessel function, soften any fibrotic tissues, reduce increased levels of connective tissues, and improve the skin as a barrier.
The mainstays of these treatments are manual lymphatic drainage (MLD) and compression bandages and garments.
Divergent opinions exist regarding the best treatment options.
An accurate assessment of the lymphedema must be made so any treatment program can be targeted and sequenced accordingly.
Many innovative treatments and management strategies have been developed that can enhance the more traditional treatment regimens.
As more is known about the lymphatic system and the effects of pathologies and surgical and radiologic disruptions on it, it is clear that various treatment and management strategies, including a multidisciplinary approach, are needed to rapidly and effectively resolve these issues and return the limb and patient to as normal as possible in a cost-effective and timely manner.
The treatment of lymphedema and its comorbidities and sequelae, whatever the cause or form, has developed into a multisystem support strategy, or what was called comprehensive medical care by von Winiwarter in 1892. 1 Although the names vary, depending on the group and country, lymphedema treatment is now commonly called complete decongestive physiotherapy (CDP) or complete decongestive treatment (CDT). The objectives of lymphedema treatment are holistic and include the following goals:
Improve lymphatic vessel function
Soften any fibrotic tissues
Reduce increased levels of connective tissues to normal or near-normal levels
Improve the skin as a barrier
Evidence for Treatment
Many treatments and strategies are available for lymphedema management. For some of these treatments, there is neither little evidence of their clinical, practical biologic, or statistical effectiveness nor a clear rationale for their use, given the presenting problems. However, there is reasonable experience and an expertise base supporting most treatments. We must continue to improve our knowledge and awareness of the plethora of available treatments, and we must support attempts to gain experimental and clinical research evidence of their effectiveness so we have a better idea of what to expect in patient outcomes.
The apparent lack of benefit of some of the core treatments in randomized controlled trials, meta-analysis, and systematic reviews can be daunting to a therapist or clinician. However, lymphedema is frequently a complicated pathophysiologic change to a variety of tissues and systems, and each patient is unique despite the common sign of swelling of a limb or other section of the body.
The most effective way to decide on a course of treatment may be for the clinician to weigh the evidence and information and to review consensus and best practice documents to determine where the patient fits in. Different treatment options can be initiated to see which work, and targeted, sequenced treatment can proceed.
In the early investigative stages of many new treatments, the clinical trials are often small, but many have a good design, objectivity, and a rigorous evaluation. Thus we can have confidence in the outcomes of such investigations. In addition to recognizing what treatments are available for a particular patient, it is important to obtain an accurate diagnosis and to know which patient to select for which treatment and the staging of these treatments. (These topics are covered in : Diagnosis of Lymphedema.)
Moreover, it is very clear from a review of the common core treatments of MLD and compression that a significant proportion of poor outcomes may result from an initial poor diagnosis of the underlying problem (the swelling is not always pure lymphedema) and perhaps poor targeting and sequencing of treatment. Also, there are often different techniques and strategies to determine the presentation, status, and staging of the condition.
Traditional Conservative Treatments
MANUAL LYMPHATIC DRAINAGE
The first component of CDP or CDT is a massage technique commonly called manual lymphatic drainage (MLD), of which there are many variations. Four key international variations are the Vodder technique, 2 the Földi method (based on Vodder), 3 the Leduc method, 4 and the Casley-Smith method. 5 A plethora of articles have been published on the effectiveness (or lack of effectiveness) of these methods, but to date no one has compared these methods. In today’s environment the treatment that a patient with lymphedema (or at least one who is identified as being at risk for lymphedema) receives depends on the training of the therapists.
Lasinski et al 6 showed that CDT as a bundled intervention and the individual component of MLD and compression bandages is beneficial. However, a meta-analysis by Huang et al 7 indicated no or little effect of MLD, throwing doubt into the minds of consumers and practitioners alike. Why this variation in outcomes and uncertainty about treatment? Most seem related to issues of methodology and rigor, but occasionally the variation results from the small size of the study groups. Although the confusion and uncertainty can be unsettling, selecting the best treatment must be dealt with, and this is where “best practice” and “templates for practice” 8 and consensus documents are useful, such as that of the International Society of Lymphology, 9 representing collective opinion from experience and based on individual and collective expertise.
The second component of CDP is compression. The major goal of compression is to reduce venous pressure and flow and thus outflow into the interstitium, which reduces lymphatic load and encourages uploading into the lymphatics by virtue of tissue pressure variations linked to any form of muscle movement.
Compression is initially delivered by bandages and then by garments in later stages (called the maintenance phase by some). Compression is usually applied with short-stretch bandages that maintain good pressure and pressure variation on movement. Equal pressure is provided at a given level of the limb by a range of padding; there is less pressure on a flat surface compared with a curved one, and stronger curves have higher pressure. A pressure gradient is established distally to proximally by careful bandaging by the therapist and at times with garment pressure monitoring. Again, benefits vary; for example, a recent trial outcome showed no benefit to below-the-knee bandaging in reducing the incidence of lymphedema, whereas other studies have generally supported its benefits, with some reservations. There are summary best practice and consensus documents from the groups previously indicated. 6 , 10 – 12 Furthermore, groups such as the National Lymphedema Network and the International Union of Phlebology offer specific advice on compression to help practitioners with these issues. 13 , 14
The other way to deliver compression is through intermittent compression therapy (IPC). Although IPC has shown some benefit, its use remains controversial. Feldman et al 15 stated, “In select patients, IPC use may provide an acceptable home-based treatment modality in addition to wearing compression garments.” Shao et al 16 indicated that although IPC could alleviate lymphedema, there was no statistically significant difference between routine management (taken to mean best practice) of lymphedema with or without a pneumatic pump. However, within these divergent viewpoints, some trials have had good outcomes, but the results are not always consistent.
Contemporary Conservative Treatments
In addition to traditional conservative treatments, many patients seek contemporary treatments, and it is important for clinicians and therapists to be aware of the range of other options for a patient with lymphedema. It is also important that the clinician and therapist are aware of any comparative benefits of these therapies. This section presents some contemporary treatments for lymphedema with which the specialist, therapist, and patient may be confronted. Some treatments are patient based with minimal or no therapist or clinical input (although this must always be encouraged so that there is good continuity of care), and some are administered by a lymphedema therapist or clinician.
Contemporary treatments can be broadly categorized as follows:
They vibrate the tissues, encompassing a range of frequencies and amplitudes and durations.
They involve a pharmacologic agent that induces or promotes a biologic event (presented in more detail in Chapter 30).
The treatment electrically stimulates the tissues and the lymphatics.
They vary tissue pressures, including exercise (really a form of vibration).
The treatment encourages diet change and weight management.
These treatments are perhaps best described as the “placebo effect.”
It should be emphasized that just because a treatment is not included here does not mean it does not work, and just because one is mentioned does not mean it is the best therapy of the group. Figures and graphs are not presented here, because these data are available in the articles and critical reviews in this chapter’s references. 11 This section will describe the available treatments, the results of clinical studies, and what reasonable outcomes might be expected.
Lymphatic vessels pulsate between 6 and 10 times per minute. We have shown that electrical stimulation reduces limb volume compared with the current best practice self-management group. 17 Pain, heaviness, tightness, and perceived leg size (all of which are very important to the patient because they affect activities of daily living and quality of life) also improved. Other units, such as the “circulation booster,” which delivers electrical stimulation, similar in function and principle to a transcutaneous electrical nerve stimulation (TENS) unit, have also been shown anecdotally to reduce lymphedema, but trials are still in progress. Electrical stimulation of the lymphatics and surrounding skeletal muscles is likely to hold great benefit in helping lymph flow in patients with motor neuron diseases and disorders and in patients with paraplegia or hemiplegia resulting from a motor vehicle accident.
IMPACT OF MEDICATIONS ON THE LYMPHATIC SYSTEM
The flavonoid and benzopyrone groups are the best known group of medications that have an impact on the lymphatic system, directly or indirectly. A range of studies have been conducted on these medications, but perhaps those of Pecking et al, 18 who first investigated Daflon, and Cluzan et al, 19 who studied Cyclo 3 Fort, are the most representative trials. In both of these trials there were significant objective improvements in the patient groups receiving these medications. Two studies 20 , 21 showed that another medication, Lodema, produced good outcomes in reducing patients’ lymphedema, but another study 22 found that Lodema had little objective effect. Maybe this was the result of the later finding that coumarin (5,6 benzo-[alpha]-pyrone), which is the active component of Lodema, had a hepatotoxic effect in some patients. We are now aware that this serious side effect resulted from a genetic issue that affects the metabolism of coumarin. Because of our improving genetic and genomic knowledge, we can undertake genetic screening to eliminate the potential for this adverse outcome and determine who will respond well (and who may have an adverse outcome) not only to coumarin but also to the range of pharmacologic interventions aimed at improving lymphatic structure or function. (Further information on these and other pharmacologic interventions is detailed in Chapter 30.)
LOW-LEVEL SCANNING AND HANDHELD LASER AND LIGHT DEVICES
Although there have been many reported case studies, the first trial with a low-level laser specifically targeting lymphedema was reported in 1993. 23 According to the work of Huang et al, 24 the dose per treatment area and the timing between those treatments are crucial. A double-blind, crossover, placebo-controlled trial indicated subjective and objective outcomes when low-level treatments were spread over several months. 25
A continual problem in other trials and general treatment philosophies has been a lack of thought in the targeting and sequencing of treatments. I think this is one of the key reasons for the often reported poor outcomes not only for laser treatments but for treatment in general. For instance, in trials with low-level scanning and a handheld laser device, the best overall results were achieved when low-level laser therapy was used to target existing fibrotic induration of the tissues, most often associated with surgical/radiotherapeutic scarring. This therapy not only resulted in a softening of the tissues, but also a reduction in limb swelling, an improvement in in scar mobility, and generally an improvement in how the whole limb feels. 26 More substantial evidence of the effects of laser therapy is still being accumulated. 27 As previously mentioned, the optimal treatment time is generally short (associated with low-dose delivery), with gaps between treatments to allow the treatment effect to develop. 28