ABSTRACT: We treated 119 consecutive patients with lymphedema with complex lymphedema therapy (CLT). Lymphedema reductions after CLT averaged 62.6% in the 56 patients with one affected arm and 68.6% in the 38 patients with one affected leg. In the 23 patients with bilateral affected lower limbs, lymphedema volume decreased by 3,681 cm³ in the right leg and by 3,433 cm³ in the left leg. Due to its small number, the group with bilateral affected arms was not analyzed. After 36 months' follow-up, the average reduction increased to 63.8% in individuals with one affected arm and remained at 62.7% in those with one affected leg. For statistical analysis, the amount of reduction after CLT in the group with bilateral affected legs was considered to be 100%. During follow-up, the right leg was maintained at 99.59% of the initial reduction and the left leg improved to 120%. Patients who were compliant showed significant increases in lymphedema reduction, whereas noncompliant patients lost part of their initial reduction. [ONCOLOGY 11(1):99-109, 1997]
Untreated lymphedema is most often a progressive, chronic, incurable disease. Macrophages become dysfunctional in the low oxygen tension of the lymphedema fluid. This results in progressive fibrosis and secondary infections. Ultimately, lymphedema produces not only physical sequelae, such as swelling, pain, decreased motor function, paresthesias, and loss of mobility, but also psychological problems, such as depressive disorder due to the unsightliness of the lymphedema and the associated medical problems. The physical stigma causes many individuals to withdraw from family and social functions, as well as the work environment.
A consensus document on the diagnosis and treatment of peripheral lymphedema, published in 1995 by the International Society of Lymphology Executive Committee, recommended comprehensive lymphedema therapy (CLT) as the initial treatment for lymphedema. This conservative, noninvasive, safe, nonoperative treatment has two phases. The first phase consists of skin care, manual lymphedema treatment, exercises, and compression with multilayered bandages. Phase 2 focuses on conserving and optimizing the reductions obtained in phase 1; this is done by means of compression with low-stretch elastic stockings or sleeves, skin care, special remedial exercises, and repeated manual lymphedema treatment as necessary.
Complex lymphedema therapy, as it is practiced today, was principally introduced, applied, and refined in Germany by the Foldis in the 1980s.[3,4] The technique, also known as combined physiotherapy, was modified and supplemented with specialized physical therapy exercises by the Casley-Smiths in Australia; they called this modified techique complex physical therapy (CPT).
The Foldis have treated 2,500 patients annually with CLT. Reductions averaged 50% after the completion of the course of therapy, and over 50% of patients maintained their reductions during phase 2.[3,7] The Casley-Smiths have reported reductions of over 60% in 618 lymphedematous limbs.
Our group described the initial use of CLT in 38 consecutive patients in the United States with follow-up of 1 year.[9,10] The initial 80% reduction in lymphedema observed following the course of CLT increased to 86% at the end of 1 year.
The current study presents 3-year follow-up data on 119 consecutive patients treated with one course of CLT at the Lymphedema Therapy facility in Woodbury, New York. The relationship of compliance to maintenance and optimization of lymphedema reduction is also analyzed.
This study includes all 119 consecutive patients with lymphedema treated with CLT at the Lymphedema Therapy facility in Woodbury, New York from 1992 to 1995. Of the 119 patients, 56 had a single affected arm, 2 patients had both arms affected, 38 patients had one affected leg, and 23 patients had both legs affected.
The demographic and disease characteristics of the patients with one afflicted arm, one involved leg, and two affected legs are summarized in Table 1. Because of the small number of patients with bilateral arm involvement, this group was not included in the analysis.
Lymphedema was graded according to the criteria of the International Society of Lymphology. Grade 1 denotes pitting edema and reversibility upon elevation; grade 2, nonpitting edema, fibrosis, and irreversibility; and grade 3, elephantiasis.
To determine the volume of lymphedema in each limb, circumferences were measured at 10-cm intervals with a flexible tape. The same physical therapist measured the patient's limb at each visit. Volume was calculated for each 10-cm segment by utilizing the formula for a truncated cone:
Volume = H (Ct² + Ct × Cb + Cb²) /12
Where H = height, Ct = circumference of the top of the cone, and Cb = circumference of the base of the cone. The total volume of lymphedema was calculated by adding the volume for each 10-cm increment.
The percentage change in edema was calculated according to the following formula:
Percentage change in edema = (Vf - Vi)/(Vi - Vn) × 100
Where Vi = the initial volume of the lymphedematous limb, Vf = the final volume of the lymphedematous limb, and Vn = normal limb volume.
Patients received CLT, which consists of the following four steps:
1. The skin is meticulously cleaned, lubricated, and debrided. Also, antimicrobial therapy is administered as needed, using standard techniques.
2. Gentle manual pressure is applied to each of the dermal lymphotomes to direct lymph flow to the nonobstructed lymph nodal areas. A firm, sustained manual pressure is applied to the watershed areas of adjacent lymphotomes, with particular emphasis on the lymphedematous region. A watershed is the area drained by a single lymphotome. This is carried out in a predetermined manner aimed at redirecting lymph flow by opening and dilating the collateral vessels across watersheds from the edematous to the normal lymphotomes. The pattern of manual pressure is individualized for each patient. Detailed descriptions of the manual pressure techniques, lymphotome clearances, and pathways of lymph drainage can be found in reference 6.
3. Using proper techniques, bandages are applied to the affected extremity to increase tissue pressure. First, the afflicted limb is covered with stockinette topped with cotton batting. Chips of latex in gauze bags are applied over fibrotic areas. Then, a low-stretch compressive bandage (Comprilan; Biersdorf AG, Hamburg, Germany) is wrapped in multiple layers over the affected extremity. All bandages are worn 24 hours daily throughout the course of therapy.
4. After the compressive bandages have been applied, individualized exercises are performed to enhance lymphatic flow from peripheral to central drainage compartments. These exercises are aimed at augmenting muscular contraction, enhancing joint mobility, strengthening the limb, and reducing the muscle atrophy that frequently occurs secondary to lymphedema.
The treatment regimen requires approximately 2 to 4 hours each day, and is administered over a 30-day period. All of the procedures are performed by a licensed physical therapist who has undergone specific training at our center.
Upon completion of CLT, patients are fitted with compression garments, ranging in pressure from 30 to 60 mm Hg. The maintenance program following CLT consists of 24-hour compression garment wear and a pa- tient-specific physical therapy exercise program to be performed twice daily at home for 15 to 20 minutes.
All available patients were included in the study. Separate analyses were performed for patients with one affected arm, those with one affected leg, and those with bilateral leg involvement. As mentioned above, since usable data were available for only two patients with two affected arms, this group was not analyzed.
A mixed models repeated measures analysis of covariance (RMANCOVA) was used to analyze the data for each group separately. The within-groups factor was the time since the initial course of therapy. The between-groups factor was the degree of compliance (compliance with exercises and use of compression garments averaged together).
For the purpose of this analysis, compliance at the initial visit was set at 100%. All assumptions were examined for each model and appeared to have been met. None of the demographic and disease characteristics (age, gender, type of lymphedema, lymphedema grade, and duration of lymphedema) differed significantly between the compliant and noncompliant patients.
In our study, compliance was evaluated by the percentage of time the patients wore a compression garment and their adherence to special physical therapy exercises. Compliance was analyzed at each follow-up visit. No additional courses of CLT were administered to the study group.
In the 22 patients with bilateral leg disease, the initial reduction in lymphedema was calculated as the total volume lost during CLT. The patients with bilateral lower limb disease did not have a normal leg to use for comparison in the calculation of percentage change in edema. Therefore, for the purpose of statistical analysis of this group, the total amount of volume lost (in cubic centimeters) at the initial visit was set at 100%. The subsequent percentage reductions were based on this initial setting.
After the initial course of CLT and lymphedema reduction, 9 of the 56 patients with unilateral arm lymphedema were lost to follow-up, 2 patients expired from their primary disease, 3 did not return for follow-up, and 4 patients moved out of the area. Among the 39 patients with unilateral lower limb lymphedema, 2 died, 1 was lost to follow-up, and 5 moved. Of the 22 with bilateral lower limb lymphedema, 2 expired, 2 were lost to follow-up, and 1 left the area.
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