Treatment Options For Lymphoedema
Essential Information for Patients
This is not a scientific presentation, but rather a useful document for patients in need of information. Language used is simplified to increase the understanding of the subject.
Facts About Lymphoedema Therapy
Many medical therapists/doctors are inadequately trained on the subject of Lymphoedema. Therefor seek information and treatment from someone who has done further studies in lymphoedema. You may choose to start by finding a therapist. Find a Therapist.
Do not agree to therapy unless a specific diagnosis has been made. This might require further investigations by a radiologist, physician, nuclear medicine physician, or vascular surgeon. Life-threatening conditions such as kidney, heart, and liver failure have to be excluded. Unilateral oedema could imply carcinoma, DVT, or lymphoedema. If you are not convinced, get a second opinion. Any decent, caring doctor will be quite happy to refer you for a second opinion.
Lymphoedema therapists vary quite substantially in their approach to therapy. There are different schools of thought internationally and these schools are often very black and white in their approach. The truth most likely lies somewhere in between, and outcomes are similar. If you are not happy with your therapist, find someone you can relate to, someone who scientifically can explain your condition to you, as you most likely will need your therapist for a long time.
Treatment will be in two phases:
PHASE 1 – This is when treatment is initiated. The therapist will diagnose, examine the patient and start intensive therapy to reduce swelling. The therapist will normally do manual lymph drainage (MLD) using both hands and/or use intermittent compression therapy (machine) to reduce oedema as much as possible. MLD is then followed by bandaging of the limb, to retain that oedema reduction that has been achieved and even further reduce swelling. This therapy will be repeated daily or as the therapist finds suitable until the circumference remains stable, and no further reduction is achieved. Some will mention CDT (Complete Decongestive Therapy) which is MLD, bandaging, plus an array of other actions (such as addressing skin conditions) to have a more holistic approach to therapy. Phase 1 could take 5 to 14 days depending on circumstances.
PHASE 2 – Once oedema is reduced to a point where no further reduction occurs(the therapist must measure), we have reached the maintenance phase. The maintenance phase though seldom provides a static result as maintenance compression often further reduces the circumference. This is because effective compression improves circulation and allows for the body to reorganize tissue. Especially intermittent compression therapy has shown this to be true(Szuba, 2002). Maintenance therapy could include any of the following options:
Short Stretch Bandaging
Seldom used in maintenance therapy but sometimes is the only option due to anatomic issues. Some lymphoedema schools teach bandaging at night as permanent therapy. This has a major effect on the quality of life and is probably outdated as long-term maintenance therapy.
Poly-urethane Foam Bandages and Sleeves
Foam bandages increase the circumference (Law of Laplace) and neutralizes some of the short stretch effect of bandages (foam gives) and therefor has a possible negative compression effect. Its major advantage is comfort to the patient because of an off-loading effect. The Polit study as quoted by the manufacturers shows that it failed as maintenance therapy. Newer foam sleeves seem to have a positive maintenance effect and increased quality of life (Marilyn RCT) especially when used as night-time therapy.
Circular Knit Compression Hosiery and Arm Sleeves
Probably the best option when chronic oedema/swelling is due to long-standing venous disease. Still the most common maintenance therapy due to low cost and ease to fit. Not ideal in the very large limb as it tends to tourniquet.
Flat Knit Compression Hosiery
Possibly the best product to use in the very large limb and severe obstructive lymphoedema. The downside is difficulty in application and thus is more used in younger patients with ample hand strength. This product is safe to use as it is less likely to tourniquet. Expensive but cost-effective as it is very durable.
Has the advantage that they are easy to apply and give the patient more control over therapy. These wraps utilize Velcro technology to adhere. Wraps are more useful in cooler continents such as Europe where sweating is not an issue. In the relatively hot climate of South Africa and Australia, wraps are hot and sweaty but may be useful in winter. A concern with wraps is the fact that the patient controls the compression which could be insufficient.
Intermittent Compression Therapy
These are machines capable of mechanical massage. Sleeves are fitted to the affected limb and swelling is removed by sequential air inflation into chambers. ICT machines are great for chronic control of swelling and are often the most cost-effective way for long-term maintenance. It is unrealistic to expect a patient to visit the therapist daily for the rest of their life and therefore this is an excellent option to consider. Always use under the watchful eye of a therapist that may suggest additional manual therapy. ICT machines have improved the quality of life of many patients with lymphoedema.