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Treatment
There is no cure for lymphedema (1). With proper diagnosis and management, it’s progression and complications can be managed to improve patient’s quality of Life (1). There are many different possible treatment options that the patient can undergo to manage their condition. Here we go through the most common management options for lymphedema.
Complete Decongestive Treatment
Complete Decongestive Treatment (CDT) or Decongestive Lymphatic Therapy (DLT) is the recommended treatment for lymphedema (1). CDT relies on various different physiotherapeutic approaches to first lower swelling due to lymphedema and then managing it to minimize its effects (2). This therapy consists of two phases; the intensive phase, and the maintenance phase (1). The intensive phase focuses on reducing swelling to normal levels and alleviate pressure on the tissues (1). In this phase, manual lymphatic drainage, multilayer bandaging, skin care/education, and exercises are performed (1,2). The patient would typically attend 15 to 30 sessions over a period of 4 to 6 weeks while in this phase (2). Once swelling is reduced to normal levels, the treatment can transition over to self-care and maintenance phase (2). In this phase, the patient continues to care for their skin and continue their exercises while adding self-drainage to their schedule (1). It is also recommended for the patient to wear compression garments (1). A study assessing this treatment option showed that CDT showed lower edema volume, increases lymphatic function, fewer lymphedema symptoms, improved function and improved quality of life (2). Adherence to the long term maintenance phase is an important aspect of this treatment and the treatment plan (2).
Figure 1: A figure that shows both phases of Complete Decongestive Treatment and how both phases overlap. Image obtained from: https://www.lymphcareusa.com/fileadmin/z-brands/Lymphcare/images/Therapy_solutions/cdt_chart_1.jpg (7)
Manual Lymph Drainage
Manual Lymph Drainage (MLD) is a commonly used therapy in Lymphedema. It is also part of the popular Complete Decongestive Treatment (1). MLD is performed by a trained therapist who would massage the skin in a specialized manner (3). The specialized technique uses gentle hand movement and it improves lymph flow and reabsorption without increasing capillary filtration (3). Typically, MLD begins with the stimulation of the central lymph nodes present in the neck, superficial and deep abdomen (1). It then moves to the stimulation in the functioning lymph in drainage regions (e.g. axilla and groin) and the anastomosis regions (e.g. thorax, back, lateral trunk) (1). The result of this therapy is reduction in tissue swelling and the softening of fibrosis (3). MLD is usually not implemented alone, but rather part of the CDT treatment described above. The success of Manual Lymph Drainage for lymphedema treatment still needs to be further studied with large sample sizes (3).
Compression Therapy (Multilayer Bandaging + Compression Garments)
Compression Therapy is a vital part of Complete Decongestive Treatment for lymphedema treatment (4). It is present in both phases of CDT and is considered one of the most effective therapeutic procedure for the treatment of lymphedema (4). It takes the form of Multilayer bandaging in the intensive phase and compression garments in the maintenance phase (4).
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Multilayer Bandaging
Multilayer bandaging is applied in the initial treatment phase that reduces lymphedema symptoms(1,4). These low-stretch bandages are wrapped in multiple layers, hence the name multilayer bandaging, on the affected limb after it has been covered with foam and/or cotton padding (1). The bandages exert light pressure on the limbs during rest and high pressure when the muscle is contracted (5). The variable pressure exerted by the bandages also acts like a massage to the limbs (5). This increased variable pressure prevents skin extension and facilitates passive lymphatic flow (5). The bandages are applied from the edges of our limbs (from the hands and feet) and gradually reaching our shoulders and groin (1). They are kept for up to 24h and replaced every day (1).
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Compression Garments
Compression Garments are the other part of Compression treatment. Compression garments are usually used in the maintenance part of Complete Decongestive Treatment (4). These garments are prescribed by a medical professional and are ideally custom made per the patient’s need (1,4). The compression class, material, size, and design of the garment is usually customized for each patient according to their lymphedema status (1). These garments may also be worn on the early onset of lymphedema symptoms as an attempt to prevent the development of lymphedema in at-risk patients (1). Using compression garments after multilayer bandaging has double the reduction in limb volume when compared to compression garments alone (4). Cost of these garments may be partially or completely covered by the government of Ontario through their Ministry of Health and Long-Term Care’s Assistive Devices Program (See Lymphedema Association of Ontario in the Resources Tab).
Figure 2: An image showing a patient recieving multilayer bandaging from their healthcare professional. This technique helps lower the swelling lymphedema patients get. Image obtained from: https://www.lymphireland.com/gold-standard-treatment/ (9)
Exercises
Exercising as part of lymphedema management help enhance patients’ physical and emotional well-beings (1). In the past, physicians believed that cancer and lymphedema patients should avoid exercising because it could cause an adverse effect but recent studies appear to say the opposite (1,6). Recent studies show that exercising after cancer treatment can prevent secondary lymphedema because overweight patients are more at risk to develop secondary lymphedema and physical inactivity decreases lymph circulation (6). Performing exercises that maintain or improve range of motion are shown to be effective as a preventive measure to lymphedema (6). Under structured and proper conditions, tailored strength and resistance exercise programs have the possibility of improving symptoms of lymphedema (1). The video below from Cancer Research UK shows a few arm exercises lymphedema patients can perform (8).
References
(1) Borman, P. (2018). Lymphedema Diagnosis, Treatment, and Follow-up from the View Point of Physical Medicine and Rehabilitation Specialists. Turkish J. Phys. Med. Rehabil, 64 (3), 179–197. https://doi.org/10.5606/tftrd.2018.3539.
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​This article outlines the responsibilities of the Physical Medicine and Rehabilitation Specialist to have the knowledge and education to diagnose and treat this condition including possible complications. The article also reviews the epidemiology and pathophysiology approaches of lymphedema.
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(2) Rockson, S. G. (2018). Lymphedema after Breast Cancer Treatment. N. Engl. J. Med, 379 (20), 1937–1944. https://doi.org/10.1056/NEJMcp1803290.
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​This journal article analyzes a case in which the patient had recently been diagnosed with breast cancer and had lumpectomy and axillary-node dissection in which 12 lymph nodes were obtained. The focus is placed on decreasing the risk of lymphedema especially in cases of lymphadenectomy.
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(3) Liang, M.; Chen, Q.; Peng, K.; Deng, L.; He, L.; Hou, Y.; Zhang, Y.; Guo, J.; Mei, Z.; Li, L. Manual Lymphatic Drainage for Lymphedema in Patients after Breast Cancer Surgery. Medicine (Baltimore). 2020, 99 (49), e23192. https://doi.org/10.1097/MD.0000000000023192.
This article focuses on the effects of manual lymphatic drainage on lymphedema related to breast cancer surgery. The researchers conducted an experiment to compare the treatment and prevention effect of Manual lymphatic drainage.
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(4) Mosti, G.; Cavezzi, A. (2019). Compression Therapy in Lymphedema: Between Past and Recent Scientific Data. Phlebology, 34 (8), 515–522. https://doi.org/10.1177/0268355518824524.
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​This article compares and discusses the scientific data from both past and recent studies available on Compression therapy treatments for lymphedema. The authors conclude that low compression pressure exerted by a material with low stiffness was the most effective in lower limb Lymphedema.
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(5) Oh, S. H.; Ryu, S. H.; Jeong, H. J.; Lee, J. H.; Sim, Y. J. (2019). Effects of Different Bandaging Methods for Treating Patients with Breast Cancer- Related Lymphedema. Ann. Rehabil. Med, 43 (6), 677–685. https://doi.org/10.5535/arm.2019.43.6.677.
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This resource investigates the effects following bandage treatment with the spiral and spica methods on patients with breast cancer-related lymphedema. Researchers used the spiral method on the first treatment group and spica method for the second group to conclude the spica method being a better volume reduction method.
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(6) Baumann, F. T.; Reike, A.; Hallek, M.; Wiskemann, J.; Reimer, V. (2018). Does Exercise Have a Preventive Effect on Secondary Lymphedema in Breast Cancer Patients Following Local Treatment - A Systematic Review. Breast Care, 13 (5), 380–385. https://doi.org/10.1159/000487428.
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This resource explores the effect that exercise has on lymphedema patients and how it can be used as a therapeutic resource. The authors concluded that exercise did have a preventive measure in regards to secondary lymphedema but more research is needed for a general conclusive statement.
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Media References
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(7) Complete Decongestive Therapy https://www.lymphcareusa.com/patient/therapy-solutions/complete-decongestive-therapy.html (accessed Mar 30, 2021).
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​This resource talks about Complete Decongestive Therapy. This resource was used for Figure 1 only and no other information was taken from there.
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(8) Arm exercises for lymphoedema | Cancer Research UK - YouTube https://www.youtube.com/watch?v=zcQB6pZmdN0&ab_channel=CancerResearchUK (accessed Mar 30, 2021).
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​This resource from Cancer Research UK shows some potential exercises that patients with lymphedema can perform to manage their condition. Video is embedded into the website and no information was used from the video.
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(9) Gold Standard Treatment - Lymphoedema Ireland - the patient body https://www.lymphireland.com/gold-standard-treatment/ (accessed Mar 30, 2021).
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This resource from lymphedema ireland describes the most common treatment option for lymphedema being Complete Decongestive Treatment. Resource was only used for Figure 2 and no information was taken from here.
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