Decongestive Therapy for the Treatment of Lymphedema

Chapter 12 Decongestive Therapy for the Treatment of Lymphedema*

Lymphedema, a disorder characterized by chronic swelling, affects approximately 140 million to 250 million people worldwide. This chapter explores a treatment technique for lymphedema known as complete decongestive therapy (CDT). The components consist of skin and wound care, lymphatic massage, compression, exercise, and patient education. Because of the possible complications associated with lymphedema, this technique should only be performed by or under the direction of a licensed medical professional after a thorough evaluation and plan of care have been established.

Lymphedema is an excessive accumulation of protein-rich fluid in the tissues caused by a transport failure of the lymphatic system and may be acquired through primary or secondary causes. Primary lymphedema is usually caused by a developmental disorder of the lymphatic system. It may manifest in infancy, adolescence, or late adulthood. Primary lymphedema occurs predominantly in females and typically affects either of the lower extremities. It is estimated that approximately 1 in 6000 individuals will acquire primary lymphedema (Dale, 1985).

Secondary lymphedema is most commonly caused throughout the world by filariasis, a parasitic infection that is carried by mosquitoes and settles in the lymphatic vessels. According to the Centers for Disease Control, filarial lymphedema is thought to affect as many as 120 million people in more than 80 countries.

In developed countries, cancer or its treatment is the most common cause of secondary lymphedema—the result of blockage by the tumor itself, excision of lymph nodes, or radiation therapy. Kissin et al. reported a 25% incidence of lymphedema after mastectomy, rising to 38% in patients treated with axillary lymph node dissection and radiation (Kissin et al., 1986). A comprehensive literature review concluded that the overall incidence of arm edema after mastectomy was 26% with a range from 0% to 56% within 2 years (Erickson et al., 2001). Patients who undergo treatment for cervical, vulvar, and prostate cancer have similar incidences for lymphedema of the lower extremities. The risk increases with an increase in the number of lymph node dissections and radiation therapy (Petereit et al., 1993).


The lymphatic system is a one-way drainage system that functions in concert with the circulatory system. It is primarily responsible for the uptake of plasma proteins that leak from the vascular system, as well as uptake of antigens and bacteria from the interstitium. It also transports fat from the gastrointestinal system, filters body fluids, and fights diseases with the production of white blood cells. Uptake of these molecules from the tissue spaces occurs via diffusion and osmosis across the lymph capillary membranes. Once in the lymph capillaries, the lymph fluid moves through a system of vessels and lymph nodes, where it is filtered and eventually returned to the circulatory system.


Lymphedema may occur under several conditions:

In addition to the subcutaneous skin changes that occur in chronic lymphedema, the risk of infection increases as a result of the decreased ability to fight infection and the increased concentration of tissue proteins. Multiple bouts of cellulitis can lead to even further degradation of the subcutaneous tissues. The individual’s normal activities may decrease as well, resulting in decreased pumping action of the muscles. This contributes even more to the insufficiency of the lymphatic system. Without treatment to minimize the edema, the patient may begin to experience other complications associated with chronic swelling, such as loss of mobility, joint stiffness, weakness, pain, and poor psychological adjustment (Figure 12-6).


Because of the complexity of the disorder, it is often best to adopt a team approach to management. Members of the team may include a physician, nurse, physical or occupational therapist, the patient, family members, certified garment fitter, nutritionist, and psychologist. Always use sound clinical judgment when initiating treatment, and consult the referring physician when in doubt. Also, be mindful of absolute and relative contraindications and precautions before initiating treatment (Table 12-1). Absolute contraindications indicate that treatment is not appropriate in the presence of certain conditions. Relative contraindications and precautions indicate that treatment may be appropriate in the presence of certain conditions only with proper monitoring and good clinical reasoning. When in doubt, consult the prescribing physician.

Treatment for lymphedema begins with a thorough assessment of the patient and includes a comprehensive history and physical examination. Once the evaluation has been completed, treatment may be initiated. Although severity of the disease process, physical limitations, and lifestyle will ultimately determine the frequency and duration of treatment, in general the best results are achieved with daily treatments over a period of 2 to 3 weeks. If there are complications such as fibrosis, scar tissue, or wounds, the treatment may need to be extended beyond this time frame. After the initial treatment phase is completed, the patient will begin the second phase of the treatment with a self-management program. Follow-up may or may not be necessary afterward, depending on the patient’s response to treatment.


Physical Exam

After taking the medical history, it is time to move on to the physical exam. Observe the patient’s posture and alignment, and note any abnormalities. Observe the skin in the entire affected quadrant. Look for excessive skin folds, lack of bony prominences, scarring or adhesions, and skin changes such as thickening of the skin (hyperkeratosis), rough areas (papillomatosis), orange peel consistency (peau d’orange), or wounds (Figure 12-7). It may be necessary to perform a full musculoskeletal examination of adjacent joints including palpation, strength, range of motion, and special tests to address any concomitant problems that may have arisen as a consequence of the lymphedema.

The next step in the physical exam is to quantify the amount of edema in the extremity. This can be done using water displacement methods or calculated volume derived from girth measurements. It has been shown that geometric formulas correlate strongly with water displacement methods (Karges et al., 2003; Sander et al., 2002), and because girth measurement is quicker and easier to perform, it is the preferred method for many clinicians. It is also a good idea to take pictures initially and periodically during the course of treatment to help support the data.

The volumetric method is a water displacement method using a tool called a volumeter. Water is filled into a special vessel just to the overflow spout. The extremity is placed in the vessel, and the displaced water flows out of the spout and into a beaker where the volume can be measured.

Girth measurements can be performed by taking circumferential measurements at 10-cm intervals and applying the following formula for volume of a truncated cone at each segment:


where V is the volume, h is the height between intervals, C is the circumference at one end of the segment, and c is the circumference at the other end of the segment. The total volume is the sum of all segments. In unilateral involvement, the normal limb can be used to determine the amount of edema present. Progress should be tracked on a weekly basis to determine the efficacy of treatment (Casley-Smith, 1998; Karges et al., 2003; Sander et al., 2002).

After the examination has been completed, take some time to discuss your findings and explain the treatment rationale. Patients tend to be more compliant when they have clear goals and a basic understanding of the treatment rationale. This is especially important for this type of therapy because so much of the success is directly related to the patient’s ability to follow through with the program at home.


Jun 4, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Decongestive Therapy for the Treatment of Lymphedema

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