Lymphoedema Therapy in Australia; Complex Physical Therapy, Exercises & Benzo-Pyrones, on over 600 limbs

{Extracts from a paper presented at: XIV Int. Cong. Lymphology, Washington, 1993.
Published in: 'Progress in Lymphology XIV', ed. M & C Witte, Int. Soc. Lymphology, Tuscon & Zurich, 1994: 622-626.}

Judith R. Casley-Smith & J.R. Casley-Smith

Henry Thomas Lab. (Microcirculation Res.), Univ. of Adelaide, (c/o L.A.A. 94 Cambridge Tce, Malvern, Australia, 5061)

Results from many therapists we trained, mostly in Australia, allow analysis of the results produced by Complex Physical (Lymphedema) Therapy (C.P.T.), by specially designed exercises for it (2,3) and by the benzo-pyronedrugs in oral or two topical applications. These reduce lymphoedema and elephantiasis (reviewed: 4). This is an open trial, but objective measurements were used, except for 'Patient's Compliance'. Great care was taken to obtain results of all patients, not just the best ones. Half the data was from all patients passing through one clinic, to whose records we had complete access.

Patients, Techniques and Drugs

No selection was made. All who received more than three days of treatment are included. Lymphoedema was graded by I.S.L. criteria (6). A few had elephantiasis, but results did not differ significantly from Grade 2 and are combined with it.

Complex Physical Therapy

C.P.T. has been organised and modernised by the Földi's, particularly using Kubik's work on work watersheds and lymphotomes (13, 14). Our regime and teaching, is based on this, but modified and upgraded (5). A Course lasts about 4 weeks, with some 11 months between Courses. These have four main parts: 1. skin care to cure infections and improve skin condition; 2. special massage which opens lymphatics, including collaterals so that unaffected regions can help drain the affected area; 3. special exercises supplement massage; 4. low-stretch (non-elastic) compression bandages (Comprilan, Beiersdorf, Germany) and padding during the course, compression garments (for lymphoedema, not for venous disease) after it. Ready-made were: Elvarex (Varitex, Beiersdorf, Germany), Vairox (Jobst, USA), Sigvaris (Ganzoni, Switzerland), Venosan (Salzmann, Switzerland). For most of the trial, the only made-to-measure ones in Australia were: O.A.P.L. and Second Skin. Now, Elvarex, Vairox , Sigvaris, Varisma and Venosan supply them. One Australian-made garment maintained worse (p < 0.01) than the others, which did not differ significantly from each other.

The Exercises

These follow the sequence and rationale of the massage (2, 3). During a Course patients do them daily, separately from the massage ('Exercises During' in Results) and daily in the Intermediate Period. Some did them for at least 3 months before the start of the First Course ('Exercises Before'). Illustrated books (2, 3), music cassettes and a video help correct performance.

The Benzopyrones

Lodema (Hamilton Laboratories, Adelaide, Australia; 400 to 800 mg/day) and HR ('Paroven'/'Venoruton' - Zyma, Nyon, Switz.; 3-6 g/day) were used. There were no significant differences between them and they are combined. They help in all high-protein oedemas, including lymphoedema by making macrophages lyse more excess protein (7-12,15,16).

Some took oral benzo-pyrones while waiting for the First Course, for at least 3 months. These were analysed separately. Topical applications of Lodema were given as a 10% solution in polyethylene glycol (PEG) or as a 10% mixture in sterile talc. The powder is used by the therapist as a lubricant for the hands and by the patient when putting on a compression garment. The ointment form may affect the life of compression garments, but seems excellent under bandages, especially on ulcers, inflamed areas and fibrotic or 'calloused' areas.

Measurements of Lymphoedema and Statistical Analysis

Measurements were of circumferences at standardised points and volumes calculated (1). Oedema, and alterations, may be represented in a number of ways (1), here:

Diff. in Vol. / Initial Vol. and Diff. in Oedema = Final Vol./Normal - Initial Vol./Normal

Using just unilateral limbs reduced numbers from 618 to 414. Extra numbers for the first eqn. (Diff./Init. Vol.) gave much smaller errors. Approximate Normal values come from the unilateral limbs. The First Course of C.P.T., the Intermediate Period between them, and the Second Course, were analysed separately, using Multivariate Analysis.This separates the individual effects of each Factor which influences the final result.

Results and Discussion

In both First and Second Courses, the benzo-pyrone (Lodema) powder and ointment had both very great and very significant benefits, as did exercises during the Course. During the Intermediate Period, the oral benzo-pyrones, the patient's compliance and the exercises had similarly great and significant benefits. Arms were more unstable than legs: improving more during the Courses, but worsening more during the Intermediate Period.

Exercises before a Course of C.P.T.

Exercises before the First Course of C.P.T. resulted in significantly less reduction during it. Probably preliminary exercises, for at least 3 months, caused reductions which would otherwise have been made by C.P.T. Relative amounts of oedema compared with normal, in unilateral limbs, at the end of the First Course were not significantly different with or without these preliminary exercises: without Pre-Course Exercises 114.7% (SE 0.82%, n=394); with Pre-Course Exercises 111.1% (3.56%, n=14). At the start of the Course these oedemas relative to Normal were: without Pre-Course Exercises 137.1% (SE 1.56%, n=394); with Pre-Course Exercises 128.6% (6.54%, n=14). So, exercises before treatment did not improve the final result, but did reduce the amount of oedema by the time C.P.T. was started, which would have improved the patient's comfort while waiting.

At the end of the Second Course, patients doing exercises over the Intermediate Period had Difference / the Volume at the start of the Intermediate Period of -15.3% (SE 2.83%, n=24); those who did not only had -1.77% (SE 1.21%, n=51); very significant (P = 0.00011). Exercises over the Intermediate Period were most helpful, not only then, but for the Second Course.

Oral Benzo-pyrones before a Course

Oral benzo-pyrones taken for 3 months before the First Course caused very great and significant improvements in the reduction from C.P.T. One presumes they reduced the fibrosis as well as some oedema, just as these drugs do when used alone (5), allowing more oedema to be removed by C.P.T. Oral benzo-pyrones also produced a very great and a very significant improvement during the Intermediate Period.

Yet they had no significant effect on the Second Course, when taken over the Intermediate Phase! This is because they reduced the amount of oedema before the start of the Course, as exercises did. After the Second Course, those taking oral benzo-pyrones over the Intermediate Period had Difference/Volume at start of the Intermediate Period of -17.1% (SE 3.34%, n=16); those who did not only had -3.13% (SE 1.33, n=59); P = 0.0010!

Age & Grade

Age had a very significant (p < 0.001) effect on reductions in the First Course: -0.090% per year. Graphs are given for the mean age of 50 years. Grade had a considerable effect on 'Oedema as a % of Normal' (2nd. eqn.). It did not achieve significance on 'Volume/Initial Volume' (1st. eqn.).

Pumps

A few therapists used pumps plus C.P.T. (no significant differences between makes). In the First Course they had no significant effect; in the Second they were just significant - but deleterious (+4.6%)! Perhaps the users did not massage sufficiently or clear proximal regions properly, so pumps just pushed fluid into unaffected regions!

Factors which did NOT have significant effects

Some possible Factors were not statistically significant and are combined: sex and, cause and duration of the lymphoedema, also primary and secondary lymphoedema.

References

1. Casley-Smith, J.R. Measuring and representing peripheral oedema and its alterations. Lymphology 1994; 27: 56-70.

2. Casley-Smith, Judith R. Exercises for Patients with Lymphoedema of the Leg. 2nd. edn. Adelaide: Lymphoedema Ass. Australia (University Adelaide), 1991, 15pp.

3. Casley-Smith, Judith R. Exercises ibid. of the Arm. 2nd. edn. ibid., 1991, 14pp.

4. Casley-Smith JR, Casley-Smith Judith R. High-Protein Oedemas and the Benzo-Pyrones. Sydney & Baltimore, 1986: JB Lippincott. [Copies now only available from the authors.]

5. Casley-Smith Judith R, Casley-Smith JR. Modern Tratment for Lymphoedema. Adelaide: Lymphoedema Assoc. Australia (Univ. Adel.), 1994.

6. Casley-Smith JR, Földi M, Ryan TJ et al. Lymphology 1985; 18: 175-180.

7. Casley-Smith JR, Piller NB, Morgan RG. New Eng J Med 1993; 329: 1158-1163.

8. Casley-Smith JR, Jamal S, Casley-Smith Judith R. Ann Trop Med Parasitol 1993: 87; 247-258

9. Casley-Smith JR, Wang CT, Casley-Smith Judith R, Cui Zi-hai. Brit Med J 1993; 307: 1037-1040.

10. Clodius, L. and Piller, N.B. (1982). In: "Advances in Lymphology", ed. V. Bartos and J.W. Davidson, Avicenum, Prague, 471-474.

11. Cluzan R, Pecking A. In: Nishi M, Uchino S, Yabuki S, eds., Progress in Lymphology XII, Excerpta Med Int Cong Ser 887. Amsterdam: Elsevier, 1990: 453-454.

12. Desprez-Curely JP, Cluzan R, Pecking A. In: Casley-Smith JR, Piller NB, eds. Progress in Lymphology X. Adelaide: Univ Adelaide Press, 1985: 156-158.

13. Földi E, Földi M. Folia Angiol. 1981; 29: 161-168.

14. Földi M, Kubik S. Lehrbuch der Lymphologie . Stuttgart & NY: Fischer, 1989.

15. Piller, N.B. and Clodius, L. (1982). In: "Advances in Lymphology", ed. V. Bartos and J.W. Davidson, Avicenum, Prague, 475-479.

16. Piller NB, Morgan RG, Casley-Smith JR. Brit J Plastic Surg 1988; 41: 20-27.

This document was last amended on 6 December, 1998.