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29 Manual Lymph Drainage (Leduc Method)
249
2. Leduc O. Rehabilitation after breast cancer treatment. European consensus. Eur J Lymphology
Relat Probl. 2008;19(55).
3. Ciucci JL. Consenso latinoamericano para el tratamiento del linfedema Linfologia Nayarit.
ed. 1 Edn. Argentina;2008.
4. Doldi SB, Latuada E, et al. Ultrasonography of extremity lymphedema. Lymphology. 1992;
25:129-133.
5. Szuba A, Rockson SG. Lymphedema: anatomy, physiology and pathogenesis. Vasc Med.
1997;2(4):321-326.
6. Vaughan BF. CT of swollen legs. Clin Radiol. 1990;41(1):24-30.
7. Idy-Peretti I, Bittoun J, et al. Lymphedematous skin and subcutis: in vivo high resolution mag-
netic resonance imaging evaluation. J Invest Dermatol. 1998;110(5):782-787.
8. Fumière E, Leduc O, et al. MR imaging, proton MR spectroscopy, ultrasonography, histologic
findings in patients with chronic lymphedema. Lymphology. 2007;40(4):157-162.
9. Leduc A, Lievens P. Les anastomoses lympho-lymphatiques: incidences thérapeutiques. Trav
Soc Sci Belge Kinésithérapie. 1976;IV(1):7-11.
10. Leduc O, Bourgeois P, et al. Manual lymphatic drainage: scintigraphic demonstration of its
efficacy on colloidal protein reabsorption. In: Partsh H, ed. Progress in Lymphology XI.
Amsterdam: Excerpta Medica; 1988:551-554.
11. Kafajan-Haddad AP, Janeiro Perez MC, et al. Lymphoscintigraphic evaluation of MLD for
lower extremity lymphedema. Lymphology. 2006;39(1):41-48.
12. Leduc A, Caplan I, Leduc O. Lymphatic drainage of the upper limb. Substitution lymphatic
pathways. Eur J Lymphology Relat Probl. 1993-1994;4(13):11-18.
13. Sappey C. Anatomie. Physiologie. Pathologie des vaisseaux lymphatiques de l’homme et des
vertébrés. V. A Delahaye et Cie Ed. Paris;1874.
14. Leduc A, Bastin R. Experimentele bijdrage tot de invloed van druktherapie op de lymfestroom.
Werkem B.W.V.K.; 1985.
15. Partsch H, Mostbeck G et al. Experimental investigation on the effect of a pressure wave
massage apparatus (Lympho Press
®
) in lymphedema. Phlebologie und Proctologie. 1980;9:
124-128.
16. Dereppe H, Hoeylaert M et al. Répercussions hémodynamiques de la pressothérapie. J Mal
Vasc. Paris, Masson,1990; 15:267-269.
17. Leduc O, Peeters A, et al. Approche expérimentale de l’influence de la contraction musculaire
par méthode isotopique. Kinés Scient. 1991;300:43-45.
18. Leduc O, Bourgeois P, et al. Scintigraphic demonstration of its efficacy on colloïdal protein
reabsorption during muscle activity. In: Nishi M, Uchino S, Yabuki S, eds. Progress in
Lymphology. Amsterdam: Elsevier Science Publishers B.V.; 1990:421-423. Congress Book
Tokyo 1989.
19. Wilputte F, Renard M, et al. Hemodynamic response to multilayered bandages dressed on a
lower limb of patients with heart failure. Eur J Lymphol Relat Probl. 2005;15(45):1-4.
Chapter 30
Compression Therapy
Stanley G. Rockson
Intermittent pneumatic compression has been employed in the medical approach to
vascular diseases for more than 80 years.1 Multilayered bandage compression and
elastic graduated compression garments are now both considered mainstays in the
management of lymphedema, forming two of the elements of complex decongestive
therapy for this condition.
sion devices that are available.
Graduated Compression Garments
2-4
These represent two of the many varieties of compres-
Standardized manufacture of stockings and sleeves has permitted the assignment of
a standard grade of compression. This is calculated by creating a maximal value at
the apex (i.e., the ankle or wrist) and a minimal value at the base (thigh or upper arm).
Compression is commercially available in four distinct classes: I, with an applied
pressure of 20–30 mmHg; II, 30–40 mmHg; III, 40–50 mmHg; and IV, more than
60+ mmHg. In patients with lymphedema, it is typically recommended that chronic
compression be administered at a minimal value of 30–40 mmHg (Class II). Sleeves
generally extend to the upper reaches of the arm and end below the axilla, although
shoulder attachments and anchoring devices are also available. For the legs, though
knee-length stockings can be purchased, either thigh-length garments or a panty
hose–style garment, is recommended for use by patients with lymphedema.
Once a level of compression is selected, the garment is carefully fitted on the
basis of meticulous limb measurements. Such garments lose their compressive
capabilities after 3–6 months and must be replaced.
S.G. Rockson
Division of Cardiovascular Medicine, Stanford University School of Medicine,
Falk Cardiovascular Research Center, Stanford, CA, USA
B.-B. Lee et al. (eds.), Lymphedema,
DOI 10.1007/978-0-85729-567-5_30, © Springer-Verlag London Limited 2011
251
252 S.G. Rockson
Perhaps the greatest impediment to the chronic utilization of maintenance com-
pression is the difficulty that patients encounter when donning the garments. While
class II compression does not pose extraordinary difficulties for the average patient,
higher degrees of compression become limiting,5 especially in the settings of
advanced age, obesity, or arthritis.1 Fortunately, many manufacturers provide assistive devices that partially combat this problem.
1
For those patients who cannot successfully utilize the elasticized stockings and
sleeves, a variety of devices have been devised to serve as alternative forms of maintenance compression. In addition, these devices, which include, but are not limited to, the
Circ-Aid, the Reid sleeve, and the Jovi-Pak, can be used to augment the baseline
compression achieved with the standard garments, particularly during nocturnal
use. Analogous forms of compression devices have also been marketed for the
nonappendicular forms of lymphedema (chest wall, breast, genitalia, head, and neck).
The efficacy of graduated compression garments has been quantitated and vali-
dated in various contexts.
6-9
During the maintenance phase of lymphedema therapy,
it often is recommended that patients utilize the garments for up to 20 h/day; statistically significant reductions in edema volume have been demonstrated after use of
the garment for 6 h consecutively per day.10 The garments are typically removed
during nocturnal recumbency.
Multilayered Bandage Compression
The use of repetitive, sequential, multilayered bandaging represents a mainstay of
the acute approach to lymphedema of the limb.
3,11
These bandages behave as a nonelastic envelope. As muscle contraction evokes pressure in the limb, there is a variable response of the pressure within the bandaged part in relation to the contraction
intensity.12 The bandaging materials affect the quality of the treatment response: use
of non-elastic, low-stretch bandaging materials will result in a resistance to stretching that will maximize the pressure generated during muscle contraction. The efficacy of this therapy in the clearance of macromolecules from the interstitium has
been demonstrated through lymphoscintigraphic imaging.
13
Daily sequential treatment in this manner results in a progressive decline in limb
volume (Fig. 30.1). The most significant reduction in volume typically occurs during the first week of treatment.
Intermittent Pneumatic Compression
Intermittent pneumatic pump devices can also be used to deliver the desired external
compression to lymphedematous limbs.
therapy, they are generally recommended to be used adjunctively; the use of sequential
14
While at times employed as stand-alone
30 Compression Therapy
0
1234 5 678910
Day of treatment
n = 220
s = 0.28
1
2
3
4
5
6
cm
Fig. 30.1 The impact of
daily multilayered bandaging
upon edema volume in
lymphedema (Reproduced
with permission from Leduc
12
et al.
)
253
gradient pumps should be avoided in the absence of a multidisciplinary treatment
program.11 This subject is addressed in more detail in Chap. 31.
Impact of Compression Therapy upon Lymphedema Outcomes
Taken together, the use of multilayer bandage compression in the first phase of lymphedema treatment and of compression garments in the maintenance phase, represents the core of the complex physiotherapeutic intervention for lymphedema.
4,11
As
such, the efficacy of intensive, short-term decongestive lymphatic therapy has been
prospectively documented.
15,16
It has been demonstrated that the appropriate therapeutic use of these elements can effectively promote acute limb volume reductions
in patients with various causes of lymphedema and, with the use chronic compression therapy in the form of garments, as one of the elements of self care, long-term
control of lymphedema is achievable (Fig. 30.2).
16
The individual contribution of multilayer bandaging to the overall treatment
response has also been prospectively studied. In a study of 90 women with unilateral lymphedema of the upper or lower limbs, a 24-week treatment regimen was
undertaken, using either a garment alone, or a garment coupled with 18 days of
multilayer bandaging.3 The study revealed that the reduction in limb volume by
multilayer bandaging followed by garment use was approximately double that of
using the garment alone, and was sustained throughout the period of prospective
observation.
Lymphedema is a chronic condition that mandates life-long treatment. The judicious application of compression is efficacious and has proven benefit, both in
the reduction of limb volume and in the maintenance of the achieved benefits
over time.
254 S.G. Rockson
1,800
1,600
1,400
1,200
1,000
800
600
400
200
0
Leg
Limb volume difference (ml)
Pre treatment
Post treatment
Follow-up
Arm
Fig. 30.2 Efficacy of the treatment intervention. Differences in limb volume (affected – unaffected limb) before treatment, after decongestive treatment, and at follow-up after self-management, which features the chronic use of compression garments. The pre – post treatment differences
in volume were significant (P < 0.0001 for the arm, P < 0.005 for the leg), as were the differences
from baseline to follow-up (P < 0.0001 for arm, P < 0.005 for leg) (Reproduced with permission
from Szuba et al.
16
)
References
1. Choucair M, Phillips TJ. Compression therapy. Dermatol Surg. 1998;24(1):141-148.
2. Rockson SG. Precipitating factors in lymphedema: myths and realities. Cancer. 1998;
83(12 suppl American):2814-2816.
3. Badger CM, Peacock JL, Mortimer PS. A randomized, controlled, parallel-group clinical trial
comparing multilayer bandaging followed by hosiery versus hosiery alone in the treatment of
patients with lymphedema of the limb. Cancer. 2000;88(12):2832-2837.
4. Rockson SG. Diagnosis and management of lymphatic vascular disease. J Am Coll Cardiol.
2008;52(10):799-806.
5. Szuba A, Rockson SG. Lymphedema: classification, diagnosis and therapy. Vasc Med.
1998;3(2):145-156.
6. Horner J, Fernandes J, Fernandes E, Nicolaides AN. Value of graduated compression stock-
ings in deep venous insufficiency. Br Med J. 1980;280(6217):820-821.
7. Horner J, Lowth LC, Nicolaides AN. A pressure profile for elastic stockings. Br Med J.
1980;280(6217):818-820.
8. Christopoulos DG, Nicolaides AN, Szendro G, Irvine AT, Bull ML, Eastcott HH. Air-
plethysmography and the effect of elastic compression on venous hemodynamics of the leg.
J Vasc Surg. 1987;5(1):148-159.
9. Partsch H. Compression therapy of the legs. A review. J Dermatol Surg Oncol. 1991;17(10):
799-805.
10. Bertelli G, Venturini M, Forno G, Macchiavello F, Dini D. An analysis of prognostic factors in
response to conservative treatment of postmastectomy lymphedema. Surg Gynecol Obstet.
1992;175(5):455-460.
30 Compression Therapy
11. Rockson SG, Miller LT, Senie R, et al. American cancer society lymphedema workshop.
Workgroup III: diagnosis and management of lymphedema. Cancer. 1998;83(12 suppl
American):2882-2885.
12. Leduc O, Leduc A, Bourgeois P, Belgrado JP. The physical treatment of upper limb edema.
Cancer. 1998;83(12 suppl American):2835-2839.
13. Leduc O, Bourgeois P, Leduc A. Manual lymphatic drainage: scintigraphic demonstration of
its efficacy on colloidal protein reabsorption. In: Partsch H, ed. Progress in Lymphology.
Amsterdam: Elsevier Science Publishers B.V.; 1988:551-554.
14. Brennan MJ, Miller LT. Overview of treatment options and review of the current role and use
of compression garments, intermittent pumps, and exercise in the management of lymphedema.
Cancer. 1998;83(12 suppl American):2821-2827.
15. Ko DS, Lerner R, Klose G, Cosimi AB. Effective treatment of lymphedema of the extremities.
Arch Surg. 1998;133(4):452-458.
16. Szuba A, Cooke JP, Yousuf S, Rockson SG. Decongestive lymphatic therapy for patients with
cancer-related or primary lymphedema. Am J Med. 2000;109(4):296-300.
255
Chapter 31
Intermittent Pneumatic Compression Therapy
Stanley G. Rockson
The use of intermittent pneumatic compression (IPC) devices in the therapeutic
approach to lymphedema is perhaps the most controversial element of what is traditionally termed complex decongestive physiotherapy. In the United States, historically, pneumatic compression has been the mainstay of lymphatic therapy for
decades.1 IPC, preferably accomplished with multi-chamber pumps, effectively
removes excess fluid from the extremity.
Early enthusiasm for the benefits of IPC have been tempered by the theoretical
concern that the pressures generated by these devices might damage skin lymphat-
10,11
ics.
When used in lower extremity lymphedema, generation of genital edema is
also a theoretical concern.12 Development of a ring of fibrous tissue above the proximal margin of the device’s sleeve has also been reported.
Although IPC has this history of controversy surrounding its use, with the threat
of incurred complications, the American Cancer Society Working Group on the
Diagnosis and Management of Lymphedema designated intermittent compression
pumps as a potential adjunctive component of decongestive lymphatic physiotherapy when used as an adjunct to the other components. Recognizing that pneumatic
compression with lower pressures (£40 mm Hg) had been suggested to be effective
and to potentially court a lower risk of complications,14 we undertook a prospective, randomized study to investigate the safety and relative efficacy of pneumatic
compression therapy for the treatment of patients with breast carcinoma-associated
upper extremity lymphedema when used adjunctively with compression bandaging
and manual lymphatic massage.15 Twenty-three previously untreated, patients were
randomized to receive either decongestive lymphatic therapy (DLT) alone or
decongestive therapy with daily adjunctive IPC. The addition of IPC to standard
2-9
13
S.G. Rockson
Division of Cardiovascular Medicine, Stanford University School of Medicine,
Falk Cardiovascular Research Center,
Stanford, CA, USA
B.-B. Lee et al. (eds.), Lymphedema,
DOI 10.1007/978-0-85729-567-5_31, © Springer-Verlag London Limited 2011
257
258 S.G. Rockson
60
45.3 ± 18.2*
DLT & IPC
DLT alone
26 ± 22.1
0
10
20
30
40
% Edema reduction
50
Fig. 31.1 The effect of adjunctive, intermittent pneumatic compression (IPC) on initial deconges-
tive lymphatic therapy (DLT) in patients with breast carcinoma-associated lymphedema. The data
depict the percentage reduction in volume of the limb attained after 10 days of daily therapy with
either (1) DLT plus IPC or (2) DLT alone. The data are provided as the mean ± standard deviation
for each group. The asterisk denotes a statistically significant difference (p < 0.05)
DLT yielded additional mean volume reduction (Fig. 31.1). In 27 additional patients
assessed during the maintenance phase of therapy, the addition of IPC to DLT
enhanced the therapeutic response. In both the acute and maintenance phases of the
study, IPC was tolerated well without detectable adverse effects on skin elasticity
or joint range of motion.
Although the use of IPC in lymphedema has been hampered by individual reports
of complications and lack of efficacy,16 focused attempts to document the adverse
effects, such as the study cited, do not seem to support the pejorative implications of
IPC, particularly when the treatment modality is utilized in an adjunctive manner.
The ostensible benefits of IPC correlate well with experimental physiological observations, in which the promotion of lymph formation by tissue compression is related
to the number of compressions applied and the time interval between each compression. Thus, it would seem that the benefit accrues through centripetal emptying of the
terminal lymphatics, such that the vessels refill after each compression is released.
It is likely that continued refinement in the bioengineering and programmability
of the pneumatic compression devices will enhance their efficacy in translating the
physiological effects of intermittent compression to the therapeutics of lymphedema.
As an example, quite recently, an adaptation of IPC has been introduced that
purports to mechanically simulate the effects of manual lymphatic drainage. This
device, the Flexitouch
both the affected limb(s) and the trunk in a programmable fashion. When prospectively examined for its role in patient self-management, the device has demonstrated
®
System, delivers minimal, phasic external compression to
17