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Newsletter Article Reprint
Volume 11, No. 2
April–June 1999
Treatment of Lymphedema with Complete
Decongestive Physiotherapy
Joachim E. Zuther, Certified Instructor MLD/CDP
SUMMARY
Lymphedema, caused by a low output failure, i.e., a reduced transport capacity (TC) of the lymphatic system, which in the
case of lymphedema has fallen below the physiological level of the protein and water load, is a common and serious condition
worldwide.
Complete Decongestive Physiotherapy (CDP) is the treatment of choice, even in the most advanced stages of lymphostatic
edema — provided that both a physician with broad experience in clinical lymphology and a specially trained therapist are
available.
A sufficient lymphatic system is able to return the
physiological amount of protein and water load back to the
venous system.
The lymphatic protein load consists of plasma proteins
continuously leaving the blood capillaries. The fraction of
water ultra-filtrated in the area of the blood capillaries which
is not reabsorbed, is called the lymphatic load of water.
In the event of an increase of water and protein, a healthy
lymphatic system is, for some time, able to prevent the onset of
edema by increasing its lymph time volume (LTV), i.e.: lymph
angions will increase their pulsation frequency and amplitude.
This is called the lymphatic safety factor or safety valve function
of the lymphatic system.
The highest lymph time volume is known as the transport
capacity of the lymphatic system which is approximately ten
times higher than the lymph time volume under physiological
conditions10.
Lymphedema arises due to an imbalance between the
normal amount of protein load and the reduced transport
capacity of the lymph vascular system. This condition, known
as “mechanical insufficiency,” results in an accumulation of
proteins in the interstitial tissue with subsequent fibrosclerotic
changes.
Since, in such cases, the lymphatic system is not able to
activate its lymphatic safety factor, other pathologic
(inflammation, chronic venous insufficiency) can lead to even
more serious complications such as ulcerations.
Common causes for mechanical insufficiencies in the case
of secondary lymphedema are surgery, radiation, trauma or
inflammation. The reason for an insufficient transport capacity
in primary lymphedema is congenital malformations of the
lymphatic system. Primary lymphedema can be present at
birth or develop at some time during the course of life5,12.
Stages of lymphedema
If the reduced transport capacity is still sufficient in
managing the lymphatic load there is no clinical lymphedema
present. The time preceding the onset of lymphedema is called
the “latency stage5.”
The first stage of lymphedema (reversible stage) is
characterized by a smooth texture of the tissue. The area
affected with lymphedema is pitting and may vanish more or
less
over
night.
If
the
protein-rich
swelling
LYMPHEDEMA ~ TABLE 2
Stages
Characteristics
Latency stage
no swelling
reduced transport capacity
“normal” consistency
Stage I
(reversible)
edema is soft (pitting)
no secondary tissue changes
elevation reduces swelling
Stage II
(spontaneously irreversible)
fibrosclerotic changes
Hardening of the tissue (no pitting)
frequent infections
Stage III
(lymphostatic elephantiasis)
extreme increase in volume and
texture with typical skin changes
(papillomas, deep skin folds)
ETIOLOGY ~ TABLE 1
Primary Lymphedema
Secondary Lymphedema
aplasia
hypoplasia
hyperplasia
dissection of lymph nodes
radiation
post-traumatic
post-inflammatory
malignancies
self-induced (artificial)
fibrosis of lymph nodes
agenesis of lymph nodes
congenital
<35 years of age (lymphedema precox)
>35 years of age (lymphedema tardum)
factors that produce an increased level of lymphatic load
persists, fibrosclerotic tissue changes will result in increased
hardening of the tissues (stage II); elevation has no effect and,
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National Lymphedema Network • Latham Square • 1611 Telegraph Avenue • Suite 1111 • Oakland, CA 94612-2138 • Tel: 800-541-3259 •
Fax: 510-208-3110
in addition, patients are prone to developing frequent
infections which worsen the condition4.
Typical for the third stage of lymphedema (lymphostatic
elephantiasis), is an extreme increase of the swelling
combined with skin changes, loss of function and other
complications.
Lymphedema, if left untreated, may lead to invalidity or
even the development of angiosarcoma (Stewart-TrevesSyndrome)8.
Therapy
Since there is no cure for lymphedema10, the goal of
therapy is to reduce the swelling and maintain the reduction,
i.e., to bring the lymphedema back to a stage of latency.
For a majority of patients, this can be achieved by the
skillful application of Complete Decongestive Physiotherapy
— a non-invasive, safe and reliable method that shows good,
long-term results in both primary and secondary lymphedema.
CDP is also cost-effective:
y it transfers the care from the doctor to the
patient/family;
y it significantly reduces the risk factors of developing
cellulitis attacks, described by Olszewski as
“Dermatolymphangioadenitis” (DLA), by improving
lymph cysts, lymphocutaneous fistulas, varicose
lymphatics or fungal infections 7.
Even though the basic steps of CDP had already been
described by Winiwarter at the end of the last century, this
therapy became widely accepted only during the past two and
a half decades1,2,13.
Numerous studies have proven the effectiveness of this
therapy which is well established in European countries and is
now becoming widely recognized in the United States1,2,8,10.
CDP consists of four basic steps :
1. Skin and nail care, that may also include topical and
systemic antimycotic drug treatment (the skin must
be free of infections before treatment can be started)
2. Manual Lymph Drainage
3. Compression therapy
4. Decongestive exercises
The treatment itself is done in two phases8. In phase one,
the goal is to mobilize the accumulated protein-rich fluid and
to initiate the reduction of fibrosclerotic tissues (if present).
The average duration of this intensive phase is four weeks.
The treatment is done twice a day, five days a week. Another
important goal in this first phase is to instruct the patient in
techniques designed to maintain and improve the success of
the treatment (proper skin care, correct application of
bandages, wearing of compression garments, etc.).
The first phase of the therapy is immediately followed by
phase two, aimed to preserve and also to improve the success
achieved in phase one. This phase is, for the most part,
continued at the patient’s home.
With good patient compliance, the volume reduction can not
only be maintained, but also improved by progressive
reduction of fibrosclerotic tissues.
In more severe cases, it is sometimes necessary to repeat
phase one and if lymphedema is associated with other
conditions, the individual steps of CDP will be modified
accordingly.
STAGES OF LYMPHEDEMA AND
THERAPEUTIC APPROACH ~ TABLE 3
Stages
Duration
Latency
Phase I
(decongestive)
Phase II
(preserve and maintain)
patient instruction
Stage I
2-3
weeks
MLD 1-2x/day
short-stretch bandages
skin care
remedial exercises
patient instruction
MLD if necessary
compression garments
skin care
remedial exercises
Stage II
3-4
weeks
MLD 2x/day
short-stretch bandages
skin care
remedial exercises
patient instruction
repeat Phase I (1-2x)
MLD as needed (1-2x/wk)
compression garments
bandages at night
skin care
remedial exercises
Stage III 4-6
weeks
MLD 2-3x/day
short-stretch bandages
skin care
remedial exercises
patient instruction
MLD 1-2x/week)
compression garments
(in combination with
bandages)
bandages at night
skin care
remedial exercises
repeat Phase I (3-4x)
if indicated, plastic surgery
Manual Lymph Drainage is a gentle manual treatment
technique which improves the activity of intact lymph vessels
by mild mechanical stretches on the wall of lymph
collectors10. A better filling of lymph capillaries, achieved by a
mild increase in tissue pressure during MLD, also results in a
higher lymphangiomotoricity.
In most of the post-mastectomy patients, lymphedema not
only includes the arm but also the ipsilateral trunk quadrant,
since the collecting area of the axillary lymph nodes are the
upper extremity and the homolateral upper trunk quadrant. In
cases of secondary lymphedema of the lower extremities, the
lower trunk quadrant and/or the genitalia may be involved in
the lymphostasis because the inguinal lymph nodes receive
lymph fluid from the leg, the ipsilateral lower quadrant of he
trunk and the exterior genitals10.
MLD is therefore performed in steps: the first step is to
stimulate the lymph vessels in the non-affected contralateral
trunk quadrant which results in a suction effect6 on the
lymphatics of the affected trunk quadrant. In the second step,
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National Lymphedema Network • 2211 Post Street • Suite 404 • San Francisco, California 94115 • Tel: 800-541-3259 • Fax: 415-921-4284
edema fluid is cautiously pushed from the congested quadrant
into the quadrant free of edema
via tissue channels, initial lymphatics and lymph vessels
bridging the watersheds, thus creating a connection between
regional lymph nodes on the contralateral and ipsilateral sides.
After the trunk is decongested, the upper part of the
extremity is treated and, later on, the distal part and the
hand/foot – always making sure not to overwhelm the
drainage areas previously stimulated.
Many patients we see report that even though they
received many treatments in “Manual Lymph Drainage,” the
lymphedema didn’t improve and sometimes the limb size even
increased. Asking the patient how the treatment was performed,
in many cases we hear that the therapist performed an effleurage
beginning at the fingers or toes or used massage techniques on
the swollen extremity.
As mentioned before, MLD is a very gentle manual
technique consisting of four basic strokes and any
combination of same. MLD has nothing to do with “classical”
or “Swedish” massage and shouldn’t be called massage. The
word “massage” means “to knead” (Greek: massain) – Manual
Lymph Drainage does not have kneading elements and
generally is applied suprafascially, whereas massage usually is
applied to subfascial tissues.
Compression Therapy
Since the elastic fibers of the skin are damaged in
lymphedema, it is mandatory to apply sufficient compression
to the affected area in order to prevent re-accumulation of
fluid. Compression therapy increases the tissue pressure (TP)
which results in lower effective ultra-filtration and better
reabsorption on the venous end of the blood capillaries. It also
promotes the filling of initial lymph vessels, improves the
function of the muscle pumps and helps to reduce
fibrosclerotic tissue.
In phase I of the therapy compression is applied via shortstretch bandages. Short-stretch bandages have a high working
pressure (pressure the bandage exerts on the musculature
working underneath) and a low resting pressure (pressure
exerted on the tissue while resting). Long-stretch bandages
have exactly opposite characteristics and, therefore, are not
indicated in the treatment of lymphostatic edema since they
tend to cut into the tissue while resting, causing a tourniquet
effect and thus impeding sufficient lymph and blood flow.
Long-stretch bandages also fail to produce an effective
counterforce to the working muscles.
In order to avoid irritation on bony prominences and
tendons, padding with cotton bandages or foam is applied
underneath the bandages.
To enhance the reduction of fibrosclerosis, high density
foam is frequently used in combination with short-stretch
bandages.
Low pH-lotion is used to keep the skin moist and tubular
bandages to avoid allergic reactions and to protect the bandage
materials are also applied.
During phase I of CDP, compression therapy during day
and night is achieved by short-stretch bandages. In phase II,
the patient wears compression garments during the day and
applies bandages for the night. Measurements for these elastic
support garments should be taken at the end of phase I by the
therapist or the supervising physician. An incorrectly fitted
sleeve or stocking will have negative effects on the
lymphedema itself and on the patients compliance. To achieve
the best results with CDP, good compliance of the patient is
absolutely necessary.
The compression class and the type of garment (round or
flat-knit style) depends on the severity of the swelling, the
patients age and any other relevant factors. In general the
pressure of the garment should be as high as the patient can
tolerate14.
For lower extremity lymphedema, compression classes III
(30-40 mm/Hg) or IV (>50 mm/Hg); for lymphedema of the
upper extremities, compression classes I (10-20 mm/Hg) or II
(20-30 mm/Hg), sometimes compression class III, are suitable.
In some cases, it might be necessary to apply even a greater
compression than class IV which can be achieved by wearing
two stockings on top of each other, or by the application of
bandages on top of a stocking. To have the maximum effect,
garments must be worn every day and replaced after six
months.
Remedial exercises aid the lymphokinetic effects of joint
and muscle pumps and should be performed by the patient
wearing the compression bandage or the garment. The
exercise program should be customized for each patient
depending on the individual capacities. Exercises should be
performed slowly and with both the affected and non-affected
extremity. Vigorous movements or exercises causing pain
must be avoided.
When does CDP fail?
Phase I :
malignant lymphedema
artificial lymphedema
improper treatment (MLD as the only
treatment, no MLD or improper bandage)
associated illnesses
lack of compliance
Phase II :
lack of compliance
lack of hygiene
reoccurrence of cancer
associated illnesses
Conclusion
Lymphedema can be treated successfully by a skilled
therapist with extensive training in all components of
Complete Decongestive Physiotherapy and good patient
compliance. The treatment success must be monitored by
circumferential and/or volumetric measurements.
If phase I of CDP is performed in the early “pitting” stage
of lymphedema, total remission of the swelling is possible. In
later stages of lymphedema, phase I only reduces the swelling
but fibrosclerotic tissue changes will still be present. For these
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National Lymphedema Network • 2211 Post Street • Suite 404 • San Francisco, California 94115 • Tel: 800-541-3259 • Fax: 415-921-4284
more advanced stages, phase II of Complete Decongestive
Physiotherapy not only preserves the treatment success
achieved in the intensive phase but also improves the edema
over time, restoring the limb to a normal or near normal size.
REFERENCES:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Marvin Boris, et al. Lymphedema Reduction By Noninvasive Complex
Lymphedema Therapy Cornell University School of Medicine and
Lymphedema Therapy. Woodbury, NY, Sept. 1994
G.Bringezu, O.Schreiner Die Therapieform Manuelle Lymphdrainage
Otto Haase Verlag, Germany 1987
J.R. Casley-Smith Lymphedema, The Poor and Benzo-Pyrones: Proposed Amendments To The Consensus Document Lymphology 29, 1996,
137-140
J.Casley-Smith, R.Morgan, N.Piller Treatment of Lymphedema of the
arms and legs with 5,6-Benzopyrone New England Journal of Medicine
Vol. 329 No 16, Oct. 14, 1993
L.Clodius, M.Foeldi Therapy For Lymphedema Today Inter. Angio., 3
1984
E.Földi, M.Földi, L.Clodius The Lymphedema Chaos: A Lancet Ann
Plast Surg 22:505-515, 1989
E.Földi Preventions of Dermatolymphangioadenitis By Combined
Physiotherapy Of The Swollen Arm After Treatment For Breast Cancer
Lymphology 29, 1996, 48-49
M.Földi Treatment of Lymphedema (Editorial) Lymphology 27,1994 1-5
M.Földi, E.Földi Das Lymphoedem Gustav Fischer Verlag, Germany
1991
M.Földi, S.Kubik Lehrbuch der Lymphologie Gustav Fischer Verlag,
Germany 1992
S.Kubik The Lymphatic System Springer, NY 1985
R.Lerner, J.Petrek Lymphedema Diseases Of The Breast, Lippincott,
pgs. 896-902 – Raven, 1996
J.Zuther Understanding Lymphedema, Pathophysiology and Treatment PT&OT Today Vol.5, No. 39
The Diagnosis and Treatment of Peripheral Lymphedema Consensus
Document of the International Society of Lymphology Executive
Committee Lymphology 28 (1995) 113-117
Joachim E. Zuther is a Certified Instructor for MLD/CDP and the
founder of the Academy of Lymphatic Studies based in Florida. He
is also the Director and primary Instructor at the ulmkolleg, Dept.
of Lymphology in Ulm, Germany and the Director of Quality
Control at Lerner Lymphedema Services.
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National Lymphedema Network • 2211 Post Street • Suite 404 • San Francisco, California 94115 • Tel: 800-541-3259 • Fax: 415-921-4284