How is lymphoedema treated?

There are a number of possible treatments for lymphoedema, many of which can be used together. International best practice guidelines recommend complete decongestive therapy (CDT) to manage and treat lymphoedema. Lymphoedema is a chronic condition (i.e. it cannot be fully cured), and is progressive (i.e. it worsens) if not treated.

Only basic information is provided here – please consult your lymphoedema specialist (a specially trained professional nurse, occupational therapist or physiotherapist, etc. ) for additional information.

Complete Decongestive Therapy

Complete Decongestive Therapy

A trained lymphoedema therapist will do a detailed assessment, and together with the patient will plan the best and most realistic treatment programme. CDT helps the impaired or damaged lymphatic system to function better and reduces the collection of lymph fluid in the swollen limb. This type of treatment does not ‘cure’ the problem and it needs to be maintained regularly. Treatment therefore involves an intensive phase, a maintenance phase as well as an important home management programme.

CDT includes gentle massaging known as manual lymph drainage (MLD), use of a multi-layered compression bandages on the swollen limb, compression garments, exercise (with your therapist and at home), and nail & skin care.

Manual Lymph Drainage

Manual Lymph Drainage

Manual lymph drainage (MLD) is a very specific, gentle massage technique  that involves ‘soft tissue mobilisation’ at a superficial and/or deep level of the lymphatic system and aims to move fluid away from the swollen areas. It is unlike other massages (e.g. sports massage, normal physiotherapy massage, Swedish massage etc.). A typical session may last for 45 – 60 minutes (depending on the severity, as well the location of the swelling). It involves massage of the neck and trunk (body) first, and thereafter the swollen limb. This type of massage is performed by a therapist trained in lymphoedema therapy. For best outcomes it is recommended that MLD be performed daily during the intensive phase where possible, however this may be altered where circumstances don’t allow such intensive therapy.

While MLD is a gentle massage, there are certain situations where MLD should NOT be performed (ie MLD is contra-indicated).

These include cellulitis (infection), congestive heart failure, renal failure and recent deep vein thrombosis.

There are also other contra-indications that may be more specific to each patient and your therapist will need to take a thorough medical history before beginning treatment.

While MLD is an important part of the complete treatment, it is only effective when used in conjunction with the other components of CDT, in particular compression.

Multi-layered lymphoedema bandaging

Multi-layered lymphoedema bandaging

This involves the use of multi-layered lymphoedema bandaging (MLLB). Lymphoedema bandaging or wrapping is a multi-layered system of various sizes of short stretch, non-elastic pure cotton bandages. It is applied over cotton padding using uniform or graded spacing and tension to create compression around the swollen limb. The purpose of bandaging following MLD is to reduce the return of lymphatic fluid to the affected area and to enhance lymphatic flow. Foam is often used in the layering to reduce fibrosis and increase comfort. Self-bandaging or bandaging by a caregiver is very important if there is limited access to a skilled therapist. Good self-bandaging may also be part of the home management programme for the long term management of the persons’ lymphoedema once the intense phase of treatment is complete.

Compression garments

Compression garments

Once adequate reduction of the swollen limb is achieved, compression garments are applied to maintain the reduction. Garments can be custom-made or ready to use (off the shelf), depending on the shape and size of the limb, or if there are any special considerations. People living with lymphoedema wear the garments during the day and alternate these with bandaging at night during the maintenance phase of treatment. Compression garments are essential for long-term improvement and allow the person to do all their normal activities while still controlling their lymphoedema. They can also be used to prevent the progression of lymphoedema. Sometime a person at risk of developing lymphoedema (and who does not already have lymphoedema) will wear a sleeve for certain activities only e.g. long haul flights.

Garments can be categorised according to fabric construction (i.e. circular or flat knit) and the pressures exerted (Classes I – IV). Lymphoedema compression garments are currently not manufactured in South Africa. The compression classes for the different garments vary according to the country in which they are made. Assessment and measurement of garments require that the therapist and/or the orthopaedic supplier has a good understanding of the garment specifications and the patient needs. It is important to note that these are special compression garments manufactured for people with lymphoedema, and are not the same as garments that you may purchase form your local pharmacy. If you have any questions about the correct compression garment for you, please ask your lymphoedema therapist for advice.

Exercise

Exercise

Exercise through the use of muscle contraction and deep breathing increases lymphatic flow and is most effective in conjunction with short stretch bandaging or compression garments. Exercise programmes, differing in frequency and intensity, are important for people with lymphoedema and for those at risk. A specific exercise program for enhancing lymphatic drainage is tailor made for each persons’ needs and considering any other medical history that the person may have. Exercise can be categorised as lymphoedema exercise (non-resistive, active movement of the swollen limb, particularly related to how the lymph drains from the area), stretching (reducing tightness/scarring), resistive exercise (progressive weight resistance – this type poses the greatest risk) and aerobic conditioning (improving cardiovascular fitness). The following are important tips to remember when doing the programme given by your therapist.

  • Remember to perform exercises slowly and smoothly, in a gentle manner, they should not be painful
  • Wear bandages/compression sleeve while exercising if available – this will further enhance the pumping action of the lymphatic vessels
  • Exercises start with the trunk to help with lymph drainage centrally, followed by exercises of the swollen limb: firstly using the proximal muscles (i.e. the muscles closest to the centre of the body e.g. shoulder/upper arm; hip/thigh) then the distal muscles of the limb last (i.e. muscles furthest from the centre of the body e.g. forearm and fingers; calf, ankle and toes).
  • Do exercises in the order advised by your therapist
  • Include deep breathing – this causes a pressure change which acts like a vacuum inside the ribcage, helping to drain lymphatic vessels towards the trunk
  • Get into a routine, a time of day that fits in with your lifestyle
  • A person’s exercise programme is tailored to the individual and will depend on their age, occupation, lifestyle, level of fitness and current health

It is important to know that exercise alone will not reduce the swelling effectively and that any programme should be carefully explained and tailored to your needs. Exercise is only one part of a complete treatment programme. If any exercise seems to cause you any problems or seems to result in further swelling, STOP, and seek professional advice.

Skin & Nail Care

Skin & Nail Care

Maintenance of skin integrity and quality, and careful management of skin problems are important to minimise the risk of infection. People with lymphoedema are at a higher risk of infection in the swollen limb than elsewhere in their body. Infection can significantly worsen lymphoedema. The principles of skin care for the affected area include:

  • Wash daily with a pH-neutral soap, natural soap or a soap substitute.
  • Dry your skin thoroughly, ensuring that skin folds (if present) or areas between your fingers or toes, are clean and dry.
  • Monitor your skin for cuts, abrasions or insect bites. Ensure that you carefully inspect areas where you experience numbness or loss of sensation as you may not feel the cut or bite. Treat any cuts or abrasions. If there are any signs of infection, seek medical advice.
  • Apply moisturising cream. Emollients, or moisturizers help keep the skin dry by reducing water loss from the epidermis – the outer layer of skin. Emollients keep the skin moist and supple by providing a protective film. For people with extremely dry skin, such as those with lymphoedema, emollients are an essential part of their daily skin care.
  • Avoidance of scented products, particularly in hot climates.  Vegetable-based products are preferable to those containing petrolatum or mineral oils.

Self-management

Self-management

Self-management by the person suffering with lymphoedema is a vital part of the treatment and long term management of lymphoedema. How well the lymphoedema is controlled and reduced is highly dependent on the person’s commitment to all the different aspects of treatment and home management, as well as their resources and support system. Self-management by the individual/caregiver involves education and training on massaging (Simple Lymph Drainage), bandaging, exercising and skin/nail care. As lymphoedema is a chronic condition (i.e. it is not cured), those affected by it have to master life-long management. Consistency is essential during self-management and returning to your therapist is mostly only needed intermittently for follow-up or if there is a problem.

Other treatment options

Medication

Few pharmacologic therapies have been found to be effective in the treatment of lymphoedema. However, chronic changes caused by the lymphoedema ( For example in conditions such as  elephantiasis nostra verrucosa (ENV), includes lymphatic filariasis, chromoblastomycosis, lipedema, lipodermatosclerosis, papillomatosis cutis carcinoides, popular mucinosis and pretibial myxedema ) can be treated with oral and topical treatment. Recurrent cellulitis (skin infection) should be treated with appropriate antibiotics as prescribed by your doctor.

Always consult your doctor when using prescribed medication. It is important to understand what the purpose of that prescribed medication is as it may be used to treat other medical conditions that you may have. For example ‘water tablets’ may be used to treat a cardiovascular condition rather than to reduce your swelling. The use of traditional or alternative medications must also be discussed with your doctor.

Surgery

Advances have been made in recent years in the surgical treatment of lymphoedema. However curative surgery is not available in South Africa. Even so, surgical procedures are an option for certain patients only, and depend on many different criteria. Most require attempted conservative treatment first, and some still require some treatment after surgery. These are specialised surgical techniques performed by highly trained in this particular type of surgery.

Surgical treatment is reserved for patients who do not improve with conservative measures or for cases in which the extremity is so large that it impairs daily activities and prevents successful conservative management. It is rarely indicated as the primary treatment modality. ‘Removal of excess skin’ may be necessary after significant decongestion following CDT.

Procedures, e.g. Charles procedure to ‘debulk’ the limb results in the removal of normal tissue (such as muscle, fat and possible intact lymphatic vessels) and CDT thereafter becomes challenging. Please consult with a lymphoedema therapist/specialist before embarking on any surgery.

Compression or Pneumatic Pumps

Pneumatic compression pumps are proposed as a treatment option for patients with lymphedema and should not be used in isolation but rather as a conjunction to CDT.  There are a variety of pumps available with varying design and complexity.

A lymphedema pump is an intermittent pneumatic compression device that consists of an inflatable garment that wraps around the arm or leg and an electrical pneumatic pump that fills the garment with compressed air. The garment is intermittently inflated and deflated with cycle times and pressures that vary between devices. This helps squeeze the lymph fluid through any lymph channels that are present. When the device deflates, blood is allowed to circulate through the area. After many repeated cycles, this device may reduce swelling from lymphedema.

This device should only be used under the recommendation and supervision of trained/qualified staff, and is not appropriate for every patient. It is also used in conjunction with the other aspects of CDT, especially compression.