Other Treatments for Lymphoedema

by: J.R. Casley-Smith & Judith R. Casley-Smith (L.A.A., University of Adelaide)

Pump Therapy

Pumps are generally plastic sleeves that surround the limb and inflate and deflate to encourage the fluid in the limb to move from the end to the top of the limb.There are two types of pumps available: 1. Multi-Chambered (sequential, segmental) in which there are a number of compartments which pump in sequence and in which the pressures may be graded (ie: there is more pressure applied to the end of the limb and less pressure applied to the top of the limb) and 2. Single Chambered, where the limb is simply enclosed by a the sleeve (or stocking) and is compressed all at once, then released. The former is more efficient and effective in moving fluid; and because of this the Casley-Smiths believed them to be more likely to cause the unwanted accumulation of fluids at the top of the limb or the adjacent trunk, if these areas have not been first been cleared manually by massage.
Most pumps use compressed air to squeeze the swollen limb although a few use fluid and some are mechanical. Generally speaking, Grade 1 lymphoedemas (ie the earlier stage and more fluid ones) are better helped by pumps, whilst the later Grade 2 and 3 fatty and fibrous (hard) lymphoedemas generally do not respond as well.  Irrespective of the grade, however, the pump will generally work by removing the excess fluid component from the limb.

What can pump therapy can and cant do
In the original chapter on “Pumps” written by the Casley-Smith’s and last updated in 1998, they recommended against their use on the basis that they simply force fluid into areas adjacent to the limb. For example, in the leg this would be in areas such as the top of the thigh or the genitals. In this they stated that pump therapy did not improve drainage from a limb in the long term and suggested that it can never clear areas such as the abdomen or trunk into which the limb fluid can drain. However, recently there has been an increasing amount of reasonable quality evidence showing pumps can be beneficial if used appropriately. Using them properly means getting some advice from a trained health professional about how to clear the trunk and abdomen areas near to the limb as well as the top of the limb (which is generally not reached or treated by the pumping chambers). Clearing these areas normally involves massage (manual lymphatic drainage) applied by a health professional or the patient both before and after the pump is applied.
Some of the early style pumps used mercury as the pressure transmitting agent, giving a very high but smoothly graded compression. Since there were no reports of complications in their use (whether this is due to the lack of publishing of any adverse effects, or the fact that there are not many in use, is uncertain) The Casley-Smith’s reported these to be useful for treating very fibrotic (hard) regions of the limb. Currently there is little strong evidence in the literature for this action, although it does not seem an unreasonable possibility.  These pumps are however expensive and complex, and few therapists have or use them.

Why Pumps can cause complications

Improper clearance of the root (top) of the limb
Some of the reduction achieved by Complex Physical Therapy, also known as Complex Lymphatic Therapy (CPT/CLT) is by simply making a space into which the fluid from the overloaded lymphoedematous (swollen) part can drain. This is the “empty bucket” principle, ie: you can-not put more fluids into an already full bucket – it must first be emptied. The principles on which good conservative therapy depends for lymphoedema treatment are therefore not applied if a pump is used on the limb without first clearing the top of the limb and the adjacent trunk/abdominal area. So it is crucial to undertake this clearance each time prior to using a compression pump.  Doing this properly could take between 10 and 20 minutes, but your therapist can advise you about how to do this for your particular condition and limb. It would also appear to be ideal if the top of the limb and the trunk areas are also cleared at intervals whilst the pump is in use. Undertaking this clearance manually should avoid compression pump complications, such as fluid accumulation at the top of the limb or the formation of a fibrotic (hard) ring around the area where the pump stops on the limb. In their 1998 revision of this chapter, the Casley-Smiths had some reservations as to whether manually clearance could over come these potential problems, at the moment (2006) there is no strong evidence either way.
The delicate and superficial nature of the lymph vessels
Another reason why pumps (and other harshly applied treatments) may have adverse effects is that the most superficial lymphatic capillaries are close to the limb surface, very small and fragile and even too harsher a massage has been shown to damage them. These are easily damaged and their integrity destroyed when a pressure of more than 60 mm Hg is applied. (Pumps are often used at very much greater pressures in the belief that higher pressure is better, so beware of this possible side effect).  Without the functioning of these delicate vessels, there is no inter-connecting network over the body through which at least some of the fluid (lymph) can be transported and drained away from the limb. The slightly deeper vessels and some of the smaller collecting lymphatics, may also be damaged although the larger and deeper lymph collectors are unlikely to be affected.  Some of the damaged lymphatic capillaries and smaller lymph vessels may regenerate (regrow), given time, but the newly formed fibrotic (scar) tissue may hinder this process.
Of course, the deeper vessels may be encouraged to drain more by the action of the pumps. However, we must question what might happen when the drainage of these vessels is either inadequate or is blocked further along (ie at the top of the limb at the site of surgery or radiotherapy), what might occur then? If there is a blockage, then the region just proximal to (ie above) the 'sleeve' of the pump can become overloaded as the fluid moved by the pump is unable to drain adequately through the blocked area. If this occurs, the lymphatics in this area can rupture and leak lymph to form a new area of lymphoedema. In the longer term this can lead to the formation of fibrous tissue like a 'cuff' around the upper part of the limb. This may then contract and strangle the remaining lymphatics and reduce the ability of any nodes in the surrounding area to continue to filter the lymph. Thus their ability to drain fluid from adjacent areas (such as the chest wall) may be reduced. In the 1998 update the Casley-Smith’s indicated that when pumps are inappropriately used on a lymphoedema arm, the abdominal wall on the same side (as the swollen arm), the opposite chest, breast, and sometimes the opposite arm can also become swollen (lymphoedematous).  However, a recent search and check of the literature (Nov 2006) has not shown any well founded information which supports these claimed adverse possibilities.
If a lymphoedema of the leg is treated with a pump, the areas where the fluids can be inappropriately pumped into include the abdominal wall and, critically, the genital area. If this overload is great then the genital area may become swollen (lymphoedematous) as might the opposite and previously 'normal' leg (In primary lymphoedema, the other leg often has abnormal lymphatics even if it shows no evidence of swelling in both primary and secondary lymphoedema). In secondary lymphoedema of the leg, the pelvic drainage may also be affected. Thus the un-swollen 'normal’ leg may also be 'at risk' (of swelling) if a pump is inappropriately used.
Fistulae creation with pump use
Fistulas (i.e. holes through the skin from which lymph leaks) may be produced proximal to (above) the sleeve of the pump, and also in the genital area (of both men and women). These are sites where bacteria can easily enter and so cause infection and inflammation of the tissues (known as ‘cellulitis’ or ‘erysipelas’). Continuing infection can worsen the lymphoedema and can even be life-threatening. This is why it is important to inspect the skin after each pump therapy and to treat any broken areas with an appropriate antiseptic to reduce the likelihood of bacteria entering the area and causing an infection.
Pumps may also transmit infection from one patient to another, so cleaning them thoroughly after each use is very important. They may also increase the risk of infection in areas where the skin is abraded (rubbed) through the motion of the sleeve. The Casley-Smith’s also indicated that pumps could cause damage to the small blood vessels in the tissues and hence lead to bruising, which can add to the load on the lymphatic system, thus tending to worsen the lymphoedema.

Complications caused by pumps reported by the Casley-Smiths include;

• Genital lymphoedema (including fistulae by which lymph leaks through to the skin, and bacteria may enter and cause infection),

• Lymphoedema of the trunk (and breast) adjacent to the affected arm,
• Lymphoedema in the (previously apparently ‘normal’) opposite limb,
• Transferring the lymphoedema to that part of the limb not covered by the cuff of the pump (ultimately causing a fibrous band which blocks any remaining lymphatics and their ability to properly drain fluid).
• Bruising and aching of the limb.

General Advice
A recent systematic review of the literature (2005) suggests that pump therapy can help in reducing the volume of the lymphoedema limb and help in how the limb feels. However, our advice regarding the use of pump therapy in lymphoedema is as follows;

• The formation of an oedematous band at the proximal end (above) the pump's sleeve must be avoided. This can lead to a collection of high-protein fluid in this area which will cause a chronic inflammatory response and eventually a fibrotic (hard) band. This, as mentioned before, may contract and hinder any remaining lymph drainage which is still present. If pumps are used, this adverse outcome can be avoided by measuring the limb just above the cuff of the pump. It is suggested that pump therapy be immediately stopped if this region starts to increase in size. This also applies if the limb becomes red, bruised or painful.
• When legs are undergoing pump therapy, the genitalia (in both men and women) must be examined frequently, to monitor whether lymphoedema is forming in this region. Once formed, this is much harder to treat, and causes far more difficulties for the patient than simple lymphoedema of the leg.
• Pumps can cause significant adverse effects if most of the lymph nodes draining a limb have been destroyed by surgery and/or radiation. They should also not be used in primary lymphoedema.
• It is vital that the pressures applied by the pump are no higher than about 40 mm Hg; since as mentioned earlier, using greater pressures risks even more damage to the lymphatic vessels.
• When pumps are used, ensure they are used under supervision by a health care professional who can monitor the response of the limb and any adverse effects. Some clinicians considered that pumps were valuable for some patients, but they had to be fully supervised and used carefully. They should never be used indiscriminately at home, but only by well-trained operators! (this may include the patient and their significant other, if they have been adequately trained in applying massage and the pump therapy). Detailed outcomes of the consensus meetings can be gained from the International Society for Lymphology website or through other informed groups. It must re remembered that this is a consensus only among these members and that other groups may have different recommendations or beliefs. Another group who has provided a best practice document is wounds UK and some details about their version of what is best is detailed on http://www.pharmaceutical-int.com/categories/lymphoedema-management/best-practice-for-the-management-of-lymphoedema.asp
• At the International Congress of Lymphology (Washington, 1993) and at the follow-up congresses and finally in the most recent congress in Salvador Brazil in 2005 there was some agreement that, if pumps are used at all, the 'body reservoirs' (i.e. the  trunk and abdominal areas adjacent to the swollen limb) should be cleared first by massage (manual lymphatic drainage).
• It must also be remembered that pumps are not cheap to purchase. Costs of using them often equal or exceed a continuing course of CPT/CLT., which may give as good if not better results. Some therapists and doctors even sell them to patients (at great personal profits) to take home with them for unsupervised use. Both the wisdom and the ethics of this are highly dubious. If you do purchase a pump, make sure you are well educated in the application of massage (to clear the areas adjacent to the limb) and the pump and that you are under the supervision of a health care professional.
• Some therapists (often encouraged by health insurance companies) are trying to save costs by mixing the application of pumps with massage, limb exercises and compression bandaging and garments.  There is nothing wrong with this but ensure that the combination of what is being offered seems right for you. Ask for the evidence that this is so!

All this is not to say that pumps should never be used. Properly trained C.P.T./C.L.T. therapists are unfortunately not available everywhere and some hospitals and clinics can only offer pump therapy. However, it is important that their dangers be appreciated and minimiased as far as possible.

When must pumps NOT be used?

The Casley Smith’s believed strongly that pumps should not be used as a stand alone therapy but in particular, they should never be used in the follwing circumstances:
In Legs:

• When there is even a suspicion of genital lymphoedema.

• In primary lymphoedema of the leg (in case it precipitates lymphoedema of the other leg or the genital area).
• In secondary lymphoedema of the leg when the inguinal nodes (in the groin) or the deep pelvic ones have been removed or given radiation treatment.
• When there is any evidence of arterial disease (e.g. in diabetes).
• When more than one area of the body is lymphoedematous.

In Arms:

• When a bilateral mastectomy (or irradiation) has been performed. (In this scenario it is important not to overload the opposite side with fluid through the collateral and inter-connected drainage that is normally present.)

• Where another area of the body is already swollen (e.g. the adjacent chest wall or, in primary lymphoedema, other parts of the body).

Pumps should not be used if patients who have the following conditions:

• Congestive cardiac failure (where the heart can not effectively pump blood around the body) - since pump therapy may shift significant amounts of fluid from the limb and therefore put an extra load on the already failing heart.
• Acute deep vein thrombosis (a blood clot in the vein of the leg) – as this may become dislodged.
• Limb infection (cellulites) or inflammation – as there is a risk of spreading the bacteria and infection).
• Active malignancy (cancer) - it is theorised that certain therapies may spread cancer to other sites through the lymphatic system).

Studies on the Effects of Pumps

In terms of adverse effects related to pump therapy, at the Congress of the International Society for Lymphology (Sep 95) the Casley-Smith’s and their colleagues (Dr. M. Boris and Mrs. Bonnie Lasinski) presented two studies:

• An analysis of the responses to questionnaires sent to 1,517 Australian lymphoedema sufferers in which 1,036 replied. This was a self report study.
• A study of Genital involvement (ie: genital swelling) in the first 128 consecutive patients with leg lymphoedema presenting at a USA lymphoedema treatment centre. Of these patients, 53 had been previously had pump therapy, whilst the other patients had not.

The first study estimated pump usage, results and complications for many patients, but relied on their own assessments. The second study investigated fewer cases, but each was assessed by trained observers.
Of the 1,036 patients involved in the first study, pumps had been used in 462. Of these, 199 noted some improvement, but complications increased from 13% (arms) and 30% (legs) to 32% and 55% (This increase was statistically significant p: < 0.001). The complications reported included: lymphoedema produced in previously normal genitals, in the trunk or in the contra-lateral (opposite) limb, proximal fibrous bands formed at the top of the limb and bruising and aching of the limb.
It was also found that earlier stage, Grade 1 lymphoedema (which is generally more fluidy) improved the most (59%),  followed by those with Grades 2 and 3 lymphoedema (37%). This improvement was statistically significant: p = 0.001); but the incidences of complications in grade 1 and grades 2 - 3 were identical (19%).
Sequential pumps (where there are multiple chambers that inflate and deflate at different rates) gave more improvements than single chambered pumps (47% compared to 34% p = 0.01), but also caused more complications (23% compared to 9% p < 0.001).
Of the 128 consecutive patients in the second study at a single USA treatment centre, genital lymphoedema was present in only 2 of the 75 patients who had never had pump therapy but was present in 23 of the 53 patients who had previously undergone pump therapy (p < 0.001). Whether this is a causal relationship here is uncertain but it does seem likely. Notably, the incidence (occurrence) of genital lymphoedema was not affected by the patients’ sex, age or duration, grade or causation of the lymphoedema.
Pump therapy in arm lymphoedema
A study by Dubios (2004) compared half an hour of massage combined with a half an hour of pump therapy over 25 sessions with 6 hours of sequential massage applied over 5 sessions. Both regimes resulted in identical limb volume reductions. It is important to note that in this study that there was an increase in the limb in those patients who did not continue any form of treatment after the trial.
Szuba et al (2002) studied the application of a sequential pump in combination with complex physical therapy (CPT) in comparison to CPT alone applied over 10 days. The CPT plus pump therapy resulted in a 45% limb reduction whilst the CPT alone resulted in a 26% reduction. Interestingly some of this reduction was not maintained in the CPT + pump group at follow up measurement, whereas the reduction in the CPT alone group was.
Szuba et al (2002) also studied the application of daily self massage followed by 1 hour of pump therapy over 1 month. Patients also wore a compression garment during this time. After 1 month there was an 89ml volume reduction. After this time, some patients continued to use the pump (on average 4 times a week) over 6 months. After 6 months 19 patients had an additional reduction in their limb but 5 patients had an increase in their limb volume.
Johansson et al (1998) compared the wearing of a compression garment over 2 weeks followed by the application of a multi-chambered, gradient pump for 2 hours a day, 5 days a week for 2 weeks. They found that wearing the garment alone resulted in a 49ml reduction in limb volume compared to a 28ml reduction when the pump was applied. Wearing a garment also resulted in greater reductions in arm tension and heaviness.
Pump therapy in leg lymphoedema
Bergan et al (1998) investigated 3 different types of pumps (two non-gradient pumps and one multi-chambered, gradient pump) in patients with leg lymphoedema who had and had not undergone radiotherapy as part of their cancer treatment. It was found that the multi-chambered, gradient pump was the most effective in reducing limb volume, with a 32% reduction in those who had not had radiotherapy and a 29% reduction in those who had. The fact that those who had not undergone radiotherapy had a slightly better result maybe related to less limb tissue fibrosis in this group, but this was not formally measured in this trial.
Conclusions
From these above mentioned studies, the following conclusions may be drawn;

• Pump therapy is generally more effective in those with Grade 1 lymphoedema and maybe more effective in those who have not had radiotherapy as part of their cancer treatment.
• Multi-chambered, gradient pumps appear to be more effective in reducing limb volume in comparison to single-chambered, non-gradient pumps.
• The volume reductions obtained by pump therapy (both in the short and long term) can be variable, so each patient must be treated on an individualized basis and be regularly monitored.
• Pumps generally work best when combined with other established therapies for lymphoedema (such as massage and compression garments), which supports the Casley-Smiths assertion that pumps should probably not be used as a stand alone therapy.
• After intensive treatment it is important that patients undertake some form of continuing therapy to maintain the reductions obtained during treatment.
• Areas adjacent to the limb, such as the chest wall or the genitals must be regularly monitored to make sure lymphoedema is not forming in these areas during or after pump therapy.

Based upon the variability of outcomes and possible complications associated with pump therapy, patients (and their significant other) need to be appropriately educated on the use of pumps and patients need to be regularly monitored by a health care professional.

Low level laser therapy

Experimental and clinical evidence indicates that Low Level scanning Laser Therapy has a multi faceted benefit in the treatment of chronic lymphoedema. The laser treatment is administered over the whole limb. L.L.L.T. is particularly effective when there is specific and localized scar tissue associated with the surgery, wound infection or radiotherapy or when there is generalized diffuse fibrotic induration as is often reported in lymphoedematous tissues.

Generally the number of laser treatments required varies according to the amount and distribution of the scar (fibrotic) tissue, although between 2 and 5 treatments over a 2-3 week period is most common. To improve the effectiveness of the laser treatment it is often administered in conjunction with lymphatic massage. Each laser treatment takes about one hour. clinical studies have shown that the treatment reduces the volume of the lymphoedematous limb but just as importantly it reduces feelings of heaviness, tension, aches and pain and bursting sensations.

Treatment effects generally last about 6 months, after which a follow up of an additional 1-2 treatments is recommended to maintain control. Results are generally better when there is an ability to self massage or obtain partner/carer massage between laser treatment sessions.

Surgery

There have been many operations for lymphoedema. In general, few of them work well in the long term; some make the condition much worse, and more difficult to treat. Lympho-venous anastomoses should never be attempted in primary lymphoedema. In a very few situations, certain specialized operations are useful, but these are not common. Almost all Lymphologists agree that adequate conservative treatment, by well-trained therapists, should be tried before resorting to surgery.

Liposuction makes lymphoedema much worse because the few remaining lymphatics are removed with the fat. It should never be used in lymphoedema. If liposuction is used for cosmetic reasons, it may even cause lymphoedema! Liposuction has been used with success in Sweden using very small canulae and a more sophisticated technique but compression sleeves still have to be worn continuously after operation. These patients were "unresponsive to previous conservative therapies - C.P.T.".

Elevation

Early, soft lymphoedemas (Grade 1) benefit from keeping the limb elevated whenever possible, or the foot of the bed raised. The longer-lasting the lymphoedema and the more excess fibrous tissue there is, the less use is elevation. Using elevation in these cases only needlessly inconveniences the patient. However patients with hyperplastic lymphatics may still benefit even if they have advanced lymphoedema (see under Bandages).

Diet

Patients sometimes think since excess proteins in the tissues cause the swelling, a low-protein diet should help. This is not so, and does not reduce proteins in the tissues; indeed protein is needed in the diet to maintain the integrity of the connective tissues and prevent them swelling more! A normal well-balanced diet is best. However excess fat will make the effects of lymphoedema more severe and harder to treat, this should be reduced.

The Swollen Ankles and Feet of the Elderly

As the body ages the skin gets less elastic and less able to maintain the size we are all used to (not just the ankles and feet!). All the systems of the body are not quite as effective as they used to be. We do not do as much exercise, we sit for longer in a chair - usually with our legs down. Because of this, ankles and feet often swell. This can lead to discomfort and infection - especially when a podiatrist cuts the skin or is over-zealous in cutting toe-nails. The way to deal with this is to:

a). Take Paroven or (bio)flavonoids orally (3,000 mg/day, but 6,000 mg if bioflavonoid complex).

b). Use either Lodema Cream or, if using a compression sock, Lodema Powder on the foot and leg (and around ‘arthritic’ knees or even hips, if these are a problem).

c). Use Urederm (Hamiltons) on calloused areas. NEVER let them be ‘shaved’ (cut) off. Urederm will soften them by drawing moisture inside the tissue to the outside, so leading to their disappearance.

d). Use a soft, calf-high light compression garment (e.g. Venosan Support Hose) & Lodema powder.

It takes about 3 months for a large swollen foot and ankle to return to ‘normal’. Massage would speed this, but is not really necessary and may be invasive and difficult. One of the major points about this fairly simple treatment is that the attacks of foot infection (leading to inability to walk, not to mention great pain and distress) are reduced. Mobility is maintained and life, at least in this regard, is enhanced. Many of the aspects of quality of life for the aged depend on mobility.

There are a number of other collections of information on lymphoedema which can be found on the
Lymphoedema Association of Australia's home page.