Results of Treatment of Lymphoedema; Complex Physical Therapy, with & without Benzo-Pyrones

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

Treatment of lymphoedema with benzo-pyrones alone has been covered in another Section (and in more detail of course in the papers referred to in it). This section discusses results which obtained with Complex Physical (Lymphedema) Therapy (C.P.T./C.L.T.).

C.P.T. is far more rapid initially than the benzo-pyrones; however after the first huge reduction (over the 4-6 weeks of the Course of C.P.T.) there is then a relative plateau. During this, the condition is fairly stationary. However more reductions can still occur or, if the patient does not follow instructions or has the bad luck to get an infection, there can be a worsening.

By contrast, the benzo-pyrones usually give hardly noticable reductions until some six months have elapsed. However by the end of a year reductions from them are about half those for with C.P.T. If both C.P.T. and benzo-pyrones are used together, reductions - and the maintenance of them - are considerably better than with either alone.

Recently we presented the results of a multivariate analysis of 618 limbs which had been treated by therapists we had trained and a few others. A statistical technique was used to separate out the various factors which affect the final results: exercises, oral and topical benzo-pyrones, make of garment, the care of the garment, the patient's compliance, etc.

It was evident that best results were obtained by patients who took oral benzo-pyrones (especially if taken for 3 months before starting C.P.T.), who had the benzo-pyrone ointment and powder, who performed the exercises thoroughly, and who took care both of their limbs and their compression garments.

We also compared the therapists. All the well established ones got very good results, as indeed did many of those with less experience. Also, even those who were not so good in their technique got good results when they used the oral and topical benzo-pyrones.

Of course it was always possible that some people only sent us their good cases, however we emphasised to them that it was vital that we had all of their results, bad as well as good. We are convinced that they did this. We used the original records for over half of the patients, with no possibility of any being omitted.

We also compared different compression garments. Apart from one Australian manufacturer (who does not state the compression) all the others gave very good results. Of course some garments are easier to put on, or to wear, or to maintain, and some are a better fit on some limbs. So they can be chosen for these features. Provided they have a suitable compression, all do a good job.

Summary of the Results of Combinations of C.P.T. and Benzo-Pyrones

Average reductions of oedema in the first Course of C.P.T. were 60 percent, for both arms and legs. These were considerably improved with benzo-pyrones, exercises and patient compliance.

It is more accurate, although not as meaningful, to express reductions as a percentage of the total initial volume of the lymphoedematous limb. Using this measure, the average reductions were 14% for the 363 legs and 15% for the 249 arms. Over the next year, this average for both legs and arms worsened by 1 % of this initial volume (122 legs and 94 arms). Note these are averages (Standard Errors were 5 % for the oedema alone; using initial volumes, they were 0.6 % for the Course and 1.5% for the Year.)

The value of both oral benzo-pyrones and coumarin ointment and powder was clearly shown. Older people had much better reductions than the young; this had never been suspected before.

As expected, Grade 1 was reduced more than Grades 2 or 3, but - surprisingly - the higher Grades held their reductions better in the 12 months after the Course. Perhaps we should think of higher compression garments for Grade 1?; or were more of the patients with the lesser Grade being careless?

In fact, patient compliance had a very great effect on how well the reductions were maintained after the Course. This has often been suggested, but this is the first time that it has been verified. Patients who did not look after their garments, or protect their limbs, had far worse results (by 9 percent of the limb volume at the end of the Course, i.e. some 60 percent of their initial oedema returned), compared with those who were careful. We are sorry; we wish we had a magic wand; but long-term success or failure of treatment rests squarely on the shoulders of the individual patient!

However all is not quite lost. Even patients with poor compliance still maintained their reductions - if they took oral benzo-pyrones and if they performed the exercises (even though these are much more successful when used with a good compression garment).

However if benzo-pyrones were taken AND the exercises were done AND the compression garments were looked after properly, the reductions improved very greatly during these 12 months - so that the average final limb was about equal to the normal one! It is up to the patient!

Finally, it was also quite evident that the specific L.A.A. exercises are very helpful indeed. Performing them, alone, before a Course of C.P.T. reduced the limb by an average of 5.3 percent of its initial volume - i.e. about 20 percent of the oedema, or one third of the effect of a complete Course of C.P.T. alone!

In the 12 months after the first Course, patients who performed the exercises had average reductions of a further 15 percent of the volume at the end of the Course; those who did not do them only reduced by 2 percent! Thus it is very evident that the exercises work, and work very well! Anyone who is not doing the exercises, and doing them properly, should think again!

Other Reports on these Treatments of Lymphoedema

A simplified version of the above will shortly be published in Lymphology, giving what reductions 75 percent of patients can expect to have or exceed, from various combinations of treatments over one year.

Other reports on the results of Complex Physical Therapy are available.
In 399 patients, with no active malignancy, Földi reported (Annals Plastic Surgery 22 (1989) 505-515) that a reduction of more than 50% of the oedema was achieved in 56% of cases, a reduction of between 25 and 49% in 31% of cases, a reduction of between 1 and 24% in 8% of cases, and no reduction or an increase in 5%. After 3 years, 177 of these patients showed that these reductions were maintained in 54% of cases, an insignificant increase was found in 35% of cases, and significant ones in 10% of cases. After 3 years some patients with lymphoedema could even abandon their compression bandages, since their lymphatic function had been increased sufficiently.

Similar results were reported by some therapists he had trained (European J. Lymphology 3 (1992) 88-96): a 72% reduction of the oedema during the Course of C.P.T., worsening to 56% over the long-term, for 157 arms. A clinic in the U.S.A., whose therapists we trained, has also reported very good results (Oncology 8 (1994) 95-110): reductions of 73% for 38 arms and 88% for 22 legs - these reductions evn improved slightly over a year.

There is an earlier Australian study of our first 200 limbs (Australian J. Dermatology 33 (1992) 61-68). Just 78 arms are covered in more detail (J Hand Surgery 17B (British vol 1992) 437-441) and just 128 legs (Int. J. Angiology, appearing September 1995).

This document was last amended on 6 December, 1998