The treatment of lymphedema is a multi-component approach. Each of these components is essential for good outcomes and therefore equally important.
All of these components will help the patient to some extend, but in unison they can make a life changing difference for the patient. While the physician is initiating the treatment, the therapist is the person most often giving direction to the treatment. The patient however is the main determining factor in regards to the outcome of treatment. The patient has to be an integral part of the treatment, without this, treatment may as well be omitted.
The patient will have to show excellent adherence to all instructions given, be the primary monitor of progress and be progressive with their third party payer in order to get all DME needed. If the patient is unable to do so, family or friends have to be able to do this. If not, the program is destined to fail.
In order to prevent any kind of infection in the involved limb, cleanliness is essential. The patient will have to gently clean the limb whenever the bandages or garment is removed and apply a moisturizer whenever possible. Keeping the skin clean and healthy will help prevent opportunistic infections from happening. A well-moisturized skin also will have increased resistance to injury.
A highly specialized massage technique aimed at promoting the lymphatic flow. MLD has several functions. The first to gently move lymphatic fluid to the deep central vessels and the second is to stimulate the lymphatic system to a higher level of activity. In a normal situation, the lymphatic system works only at about 10% of its capacity. The MLD is attempting to increase this activity level by stimulating the smooth musculature around the lymph angion. A third function is to redirect the lymph flow to bypass blocked regions and to utilize anastomoses to create a flow across the watersheds.
Compression therapy can be in multiple forms; the most common in treatment is the use of a multi-layered short-stretch compression bandage. The compression bandage is to be worn as close to 24/7 as possible, of course allowing it to be removed for skin care. Because of this, it is important to teach the patient and/or family to apply an effective bandage. Reinforce this by ensuring the patient that any bandage they apply, as long as it is not constricting it is better than wearing no bandage at all.
The other form of compression therapy in clinical use can be a gradient-sequential vaso-pneumatic compression pump. The use of these is very controversial, but with the proper use they have proven to be a valuable addition to the treatment of more severe forms lymphedema.
These pumps come in a variety of sizes and number of air chambers (from 1-24), with a price range from $39.95 (IGEA) to $5000.00 (Lympha Press). Sleeves are available for upper extremities with shoulders pieces and for lower extremities with optional body parts.
Recommended settings for pumps are mostly in the 30-40 mmHg range. The patient can pump for several hours at home. It is recommended to perform self-massage before and after the pump application and to wear a compression garment or bandages afterward.
Exercising the affected limb while wearing a compression bandage will help promote the lymph flow significantly. First of all the motion of the limb will promote increased circulation and flow. Secondly, when the patient is wearing a compression bandage while exercising, the compression bandage will act as a resistance to the outward expansion of a muscle during a contraction and therefore stimulate the inward expansion and thus enhance the efficacy of the muscle pump function.
The exercise routine should breathing exercises, since proper breathing technique will further stimulate the lymphatic system.
To successfully complete a course of treatment it is imperative that the patient becomes an active partner in the treatment. The only way to achieve this is to extensively educate the patient and family about the management of chronic lymphedema. The more the patient understands lymphedema and its management, the better the chance for compliance the advice given. The education will include self-treatment, prevention of flare-ups and infections and the basic pathology of lymphedema. Often the family members will also have to be educated, since they may be assisting in the treatment by applying bandages or garments and possible the massage.
It is helpful to have a variety of patient hand-outs such as brochures on precautions, self massage and bandaging. A wide variety of these resources is also available on the internet, while the more practical applications are available as books or on video tape.
The original European treatment plans call for high frequency and duration of the clinical visits. There are even several inpatient treatment programs available. In order to fit lymphedema in the United States model, some sacrifices from the ideal standard will have to be made: