Why Compression Pumps Cause Damage in Lymphedema

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Wanted to share this article written by those wonderful Australian lymphedema doctors which goes into detail exactly why pumps cause further damage to lymphatics.

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Why Pumps cause Complications from the Lymphoedema Assoc of Australia, written by .R. Casley-Smith &Judith R. Casley-Smith.

Almost all use compressed air to squeeze the swollen limb. There are a variety available. Some patients (Grade 1 lymphoedema) are helped by these; most (Grades 2 and 3) are not. Usually lymphoedemas which have only been present a short time respond best; very fibrotic ones do not respond at all. However the incidence of serious complications is the same for both Grades.

What does a pump do? What does it not do? Why do we advise againsttheir use? They simply force fluid into the adjacent area. They do not improve drainage from a limb in the long term. They can never clear an area of the trunk into which the limb can drain.

There are two types of pumps available:

1. Segmental (sequential,multi-chambered), i.e. a number of compartments which pump in sequence (the pressures in these may be graded);

2. non-segmental (single chambered), where the limb is simply enclosed by a continuous sleeve or stocking and is compressed all at once, then released. The former is more efficient; because of this it is also more dangerous and can cause much more damage. This is especially the case if the trunk (body) has not first been cleared manually.

Mercury is used in a few pumps, giving a very high but smoothly graded compression. These seem not to give complications like the pneumatic ones (when used with care) and are particularly useful for very fibrotic regions; but they are rather expensive and complex, and few therapists have them.

Why Pumps cause Complications.

So much of the reduction by C.P.T./C.L.T. is obtained by simply making a space into which the overloaded lymphoedematous part can drain.

The principles on which good conservative therapy depends for lymphoedema treatment are therefore completely negated as far as the clearing of the affected limb is concerned. Even if the trunk is cleared prior to the pumping of the limb, this is usually inadequately done. At least 30 minutes would be needed to clear the trunk properly. This would need to be continued during the pumping process to minimise damage. Even with this, in some cases, the avoidance of damage is not possible.

The most superficial lymphatic vessels are very small and very fragile.

These are easily damaged and are certainly broken when a pressure of more than 60 mm Hg is applied. (Pumps are often used at very much greater pressures. ) Without these vessels, there is nointer-connecting network over the body through which at least some of the lymph can be transported. The slightly deeper vessels, very small collecting lymphatics, may also be damaged. Some of these will regenerate, given time, but meanwhile fibrotic (scar) tissue forms and blocks the drainage in the adjacent tissue channels.

The deeper vessels may be encouraged to drain more by the pumping - but what happens when their drainage is either inadequate or is blocked further along the lymphatic drainage system? Then the region just proximal to (i.e. above) the 'sleeve' of the pump becomes overloaded.

The lymphatics in it often rupture and leak lymph to form a new area of lymphoedema. This can lead to the formation of fibrous tissue like a 'cuff' around the upper part of the limb. This then contracts and strangles the remaining lymphatics. Any nodes which remain and are still filtering the lymph, but are already overloaded, as is the superficial network in adjacent areas. Thus their ability to collect from adjacent areas is reduced, e.g. from the chest wall for lymphoedema of the arm. With lymphoedema of the arm, the opposite chest, breast, and sometimes the opposite arm and the abdominal wall on the same side, can also be made lymphoedematous.

In lymphoedema of the leg this is the abdominal wall and, even moreimportantly, the genital area. In fact this overload can be so severe that not only the genital area is made lymphoedematous, but the previously 'normal' leg also swells. (In primary lymphoedema, the other leg often has abnormal lymphatics even if it shows no evidence of swelling in both primary and secondary lymphoedema.) In secondary lymphoedema pelvic drainage may be affected. Thus the 'normal leg is a leg 'at risk'.

Fistulae (i.e. holes through the skin from which lymph leaks) can be produced proximal to the sleeve of the pump, and also in the genital area (of both men and women). These are sites where bacteria can easily enter and so cause infection and inflammation.

These worsen the lymphoedema and can even be life-threatening.

Pumps can also transmit infection from one patient to another, or make one more likely by abrading the skin. They can cause damage to the small blood vessels and hence bruising. Again, this tends to worsen a lymphoedema. Pumps cannot remodel the limb in the way that CPT (CLT) can becausethey work on the limb as a whole and cannot concentrate on individualparts.The results of using pumps have very seldom been published - and never the long-term results. Those that have been are poor compared with CPT (CLT). Even when the trunk and adjacent areas have been cleared prior to pumping a limb, the results are poor compared with those of other treatments (e.g. CPT plus benzo-pyrones) and the complications still occurred in some cases.

The complications caused by pumps are several:

Genital lymphoedema (including fistulae by which lymph leaks to theskin, and bacteria may enter), lymphoedema of the trunk (and breast) adjacent to the affected limb, lymphoedema in the (previously apparently normal) opposite limb, transferring the lymphoedema to that part of the limb not covered bythe cuff of the pump (ultimately causing a fibrous band which blocks any remaining lymphatics), and bruising and aching.

We know of many cases where the genital areas of men or women(previously normal) were made lymphoedematous by pumps.Sometimes the other limb, which was clinically normal, but is always a 'limb at risk', was overloaded by the pump and has also started to swell.

They can cause lymphoedema in an arm, breast and one side of the chest which was 'at risk' but still normal before the pump (e.g. especially after a bilateral mastectomy). Lymphoedema of the abdomen may be caused, or made much worse.

Pumps can also cause fistulae to form (leaking channels through theskin) and blisters of lymph, via which bacteria readily gain access to the lymphoedematous tissue with disastrous results.

Any formation of an oedematous cuff at the proximal end of the pump's sleeve must be avoided. This is a collection of high-protein fluid which will cause chronic inflammation and a fibrotic band, which will contract and hinder the little lymph drainage which is still present.

If pumps have to be used, this tragedy can be avoided by measuring the limb just above the cuff of the pump. Stop the pump at once if this region starts to increase in size. The more efficient,multi-compartment pumps are the most dangerous!

When legs are being pumped, the genitalia (in both men and women) MUST be examined frequently, otherwise genital lymphoedema may be produced.

This is much harder to treat, and causes far more difficulties for the patient than simple lymphoedema of the leg.

If a limb becomes red, bruised or painful, stop the pump and tell thetherapist.

Pumps are always very dangerous if most of the lymph nodes draining a limb have been destroyed by surgery and/or radiation, and should not be used in primary lymphoedema. If pumps are used, it is VITAL that the pressures are no higher than 40 mm Hg; using greater pressures risks even more damage.

At the International Congress of Lymphology (Washington, 1993) there was a general agreement that, if pumps are used at all, the 'body reservoirs' (i.e. the quadrant of the trunk adjacent to the affected limb, and the two quadrants adjacent to this) should be cleared first by massage. Some considered that pumps were valuable for some patients, but they had to be fully supervised and used carefully. They should never be used indiscriminately at home, but only by well-trained operators!Pumps are not cheap. Costs of using them often equal or exceedC.P.T./C.L.T., which would give much better results with far fewerrisks. Some therapists and doctors even sell them to patients (at great personal profits) to take home with them for unsupervised use. Both the wisdom and the ethics of this are highly dubious.Some therapists (often encouraged by health insurance companies) are trying to save costs by mixing pumps, massage, exercises andcompression bandaging and garments. Patients should be aware that (from the so far published results) this does not give as good reductions as properly applied Complex Physical (Lymphedema) Therapy (C.P.T./ C.L.T), the pumps can still cause the complications mentioned above, and it appears that the costs are not reduced - indeed in some cases they are increased!

All this is not to say that pumps should never be used. Properlytrained C.P.T./C.L.T. therapists are unfortunately not availableeverywhere. Some hospitals can only offer pumps. However it isimportant that their dangers be appreciated and avoided as far aspossible.

When must pumps NOT be used?

Based on our findings and those from many colleagues in Australia and in many countries, we believe that pumps should not be used alone.

In particular, they should never be used:

In Legs:

In any case with even a suspicion of genital lymphoedema.In primary lymphoedema of the leg (in case it precipitates lymphoedemaof the other leg or the genital area) .

Secondary lymphoedema of the leg when the inguinal nodes (in the groin)or the deep pelvic ones have been removed or irradiated.

When there is any evidence of arterial disease (e.g. in diabetes).

When more than one area of the body is lymphoedematous.

In Arms:

When a bilateral mastectomy (or irradiation) has been performed. (It is imperative not to overload the contralateral side through the collateral drainage normally present.)

Where another area of the body is already involved (e.g. the adjacent chest wall or, in primary lymphoedema, other parts of the body).

Studies on the Effects of Pumps

At the Congress of the International Society for Lymphology (Sep 95) we and our colleagues (Dr. M. Boris and Mrs. Bonnie Lasinski) presented two studies:a).

a.) Responses to questionnaires sent to 1,517 Australian lymphoedema sufferers (1,036 replied).

b). Genital involvement was studied in the first 128 consecutive leg lymphoedemas at a USA lymphoedema treatment centre. Of these, 53 had been exposed to pumps, the rest had not.

The former (a) estimated pump usage, results and complications for many patients, but relied on their own assessments. The latter (b) studied fewer cases, but each was assessed by trained observers.

Of the 1,036 patients (a), pumps had been used in 462. Of these, 199 noted some improvement, but complications increased from 13% (arms) and 30% (legs) to 32% and 55% (p <>

Grade 1 improved more (59%), than Grades 2 and 3 (37%, p = 0.001); but the incidences of complications were identical (19%).

Sequential pumps gave more improvements than single chambered (34%became 47%, p = 0.01), but also more complications (9% became 23%, p <>

Of the 128 consecutive patients (b) at a single USA treatment centre, genital lymphoedema was present in only 2 of the 75 unexposed to pumps; it had been caused by pumps in 23 of the 53 exposed to them (p <>

Thus, pumps gave somewhat better results in Grade 1 than Grade 2 lymphedema, but still caused just as many complications. These were both frequent and very serious.

Summary

Pumps should never be used alone.

In particular, they should never be used:
after a bilateral mastectomy,
after pelvic operations when the tops of both legs have started toswell,
in primary lymphoedema (it is risky even with only one limb involved; the other may start to swell),
if a patient has more than one area of the body involved (either primary or secondary lymphoedema).

The pump may quite simply be responsible for 'blowing up' the next area, which up to that time wasapparently 'normal' and may well have remained so! If there is already genital lymphoedema,in Grade 2 lymphoedema, when there is much fibrosis.

The Lymphoedema Association of Australia

http://www.lymphoedema.org.au/

Related Pages:

Compression Pump Therapy

Lymphedema Decongestive Therapy