A Pilot, Prospective Evaluation of a Novel Alternative For Maintenance Therapy of Breast Cancer-Associated Lymphedema

Olivia Wilburn , Paul Wilburn and Stanley G. Rockson BMC Cancer 2006, 6:84 doi:10.1186/1471-2407-6-84

Published

29 March 2006Abstract (provisional)

Background Prospective investigations of complete decongestive lymphatic physiotherapy (CDPT), including manual lymphatic drainage (MLD), have validated the efficacy of these interventions for the initial reduction of edema and long-term maintenance of limb volume in lymphedema. However, CDPT demands substantial time and effort from patients to maintain these benefits; the treatments are not always well-accepted, and patients may suffer from a deterioration in quality-of-life or a time-dependent loss of initial treatment benefits.

A new device designed for home use by the patient, the Flexitouch, has been developed to mechanically simulate MLD. We have undertaken a prospective, randomized, crossover study of the efficacy of the Flexitouch, when compared to massage, in the self-administered maintenance therapy of lymphedema.

Methods

A prospective, randomized, crossover study of maintenance therapy was performed in 10 patients with unilateral breast cancer-associated lymphedema of the arm. Each observation phase included self-administered treatment with the Flexitouch or massage, 1 hour daily for 14 days, respectively, followed by crossover to the alternate treatment phase. Each treatment phase was preceded by a 1 week treatment washout, with use of garment only. The sequence of treatment was randomly assigned. The potential impact of treatment modality on quality of life was assessed with serial administration of the SF-36.

Results

Statistical analysis disclosed that the order of treatment had no outcome influence, permitting 10 comparisons within each treatment group. Post-treatment arm volume reduced significantly after the Flexitouch, but not after self-administered massage. The patients' mean weight decreased significantly with Flexitouch use, but not with massage.

The Flexitouch device was apparently well-tolerated and accepted by patients. Serial SF-36 administration showed no deterioration in physical or psychosocial scores compared to baseline measurements; there were no statistical differences in scores when the two treatment modalities were compared.

Conclusion

This short-term prospective evaluation of the Flexitouch suggests that the device may provide better maintenance edema control than self-adiminstered massage in breast cancer-associated lymphedema. The apparent ease of use and reliability of response to the device suggest that further broad-scale testing is warranted.

BiomedCentral

Complete Study

The Lebed Method Focus on Healing Through Movement and Dance

In a previous post, I shared about Aquatic therapy and its benefits for lymphedema patients.

I would like to share another wonderful lymphedema therapy that I think is wonderful and beneficial both in terms of over all physical health, but in helping manage lymphedema.

This is from their page Who We Are

Mission Statement:

THE LEBED METHOD, Focus on Healing Through Movement and Dance, is committed to improving the physical and emotional well-being of breast cancer survivors, those with Lymphedema, as well all cancers and chronic illnesses in both adults and children. Our goal is to elevate quality of life through therapeutic dance and movement, healing body, mind and spirit. Mission Statement: "Focus on Healing is committed to the development and education of Breast Cancer Survivors and to help prevent loss of quality of life due to the aftermath of their surgery and treatment"

The Lebed Method, Focus on Healing through Movement and Dance, is a therapeutic exercise program for women who have had any kind of breast surgery, node dissection, radiation, chemotherapy, Lymphedema, or who suffer with chronic fatigue. Two physicians and a dance movement specialist created this program to help women:

Regain Range of Motion
Increase flexibility in Frozen Shoulder
Work with Balance issues both physically and emotionally
Help reduce swelling from Lymphedema
May help reduce the risk of Lymphedema
Decrease depression
Add to sexuality
Increase femininity
Promotion of positive self image and joy
Weight stabilization
is FUN and EASY to do
No special physical abilities required

Certain exercises can be one of the major preventatives for some future problems for survivors, from one day after surgery to 30 years after surgery. This quality program is needed to help Breast Cancer Survivors thrive once they have survived, with a better quality of life.

HISTORY OF THE LEBED METHOD

In 1979, Sherry Lebed Davis' mother, Rita Lebed was diagnosed with breast cancer. Losing her breast and knowing that this disease had already claimed the lives of her mother and her sister were too much for her. First she stopped smiling, then she stopped fighting. Her brothers and Sherry knew they had to so something for their mother. Sherry had been a professional dancer and teacher for fifteen years, and her brothers are both physician/surgeons and together they developed a medically sound program "The Lebed Method,' Focus on Healing."

For their mother, this creative, therapeutic exercise program gave her back the range of motion in her arm. More importantly, it brought back her smile. Dr. Marc and Joel Lebed and Sherry Lebed Davis, knew they had to give this gift to others who were suffering as their mother had.

Sherry began by working with breast cancer survivors at several major Medical Centers in Philadelphia, one being, Albert Einstein Medical Center in 1980. By 1986, they had published two reports in the American Physical Therapy Journal: ""Physical Therapy and Dance in the Surgical Management of Breast Cancer" and "Dance: A Therapeutic Modality for the Breast Surgery Patient", presented at the Sixtieth Annual Conference of the American Physical Therapy Association.

"The Teacher Becomes the Student" The journey Sherry began with her mother has now come full circle. Diagnosed with breast cancer in 1996, Sherry had found many techniques helpful, but exercise and dance gave her the spirit to live and be able to have a better quality of life. In 1999 Sherry was diagnosed with Lymphedema and Dr. Marc Lebed and Sherry Lebed Davis developed a new program; The Lebed Method, Focus on Healing for upper and lower Lymphedema, which decreases swelling in the affected limb. This program was introduced in 2000 at the National Lymphedema Network National Conference in Florida.

For more information please request an informational packet: info@focusonhealing.net

The Lebed Method

The Lebed Method

14418 47th Place West

Lynnwood, Wa 98037

phone: 1-877-365-6014

fax: 425-742-6873

Choosing a Lymphedema Therapist

From time to time members of our various groups have asked, "just how do you go about finding a credible lymphedema therapist? What do you look for and what questions should you be asking?"

Hopefully this can be of help.

As far as finding an actual therapist, the National Lymphedema Network hasexcellent requirements on this:As of November 1, 2002, the NLN requires lymphedema training programs tooffer a minimum of 135 hours of intensive training (1/3 theoretical, 2/3practical) in order to qualify for a listing in the NLN Resource Guide (referredtoas Affiliate Membership).

Lymphedema therapists (independents) must havecompleted a recognized 135 hour training program, and treatment centers must haveon staff at least one lymphedema therapist who has completed such a program.

Please view the NLN Position Paper on Training (pdf format, 128kb) for more information on what you should look for in any lymphedema therapist.

Finally, the Circle of Hope Lymphedema Foundation also has a page on questions you should ask when looking for a therapist:

1. Where did you get your training?
2. What approach do you use? Vodder, Foeldi, Casley-Smith etc.
3. How many hours of training have you had? (120 to 160 hrs. or more isgood)
4. Are you an OT., PT., MT. ? Where did you get your degree?
5. How long have you been doing CDT/MLD ?
6. What certification do you have?
7. How many times a week will I have treatment and for what length of time?
8. How long will my consultation be?
9. Will there be a therapist on call at all times?
10. Is there a doctor, APRN, or nurse connected with the facility?
11. How oftenwill I be seen by them?

Circle of Hope

The Lymphology Association of North America (LANA) has strict requirements that therapists must undergo before they can be credentialed through them.

Visit their website at LANA and here is their page on the LANA Exam Outline

Here are some helpful pages also that can help you find a therapist in your area

Lymphedema Schools of Therapy - Find a Therapist

Listings of Lymphedema Therapists United States

Lymphedema Therapists - Hospital Clinics

Lymphedema Therapists - Canada

Lymphedema Therapists - Australia

Lymphedema Therapists - Austria, Greece Dubai

Lymphedema Therapists - Ireland

Lymphedema Therapists - New Zealand

Lymphedema Therapists - Singapore

Lymphedema Therapists - United Kingdom

Lymphedema Therapists - Europe \ Lympfoedeem, Lymphodem Resources Europa

Arm Swelling and Leg Swelling

Arm Swelling and Leg Swelling

Related Terms:

Edema, Oedema, Fluid Retention, Water Retention, Swollen Leg, Swollen Arm, Lymphedema, Lymphoedema

Swelling

Swelling is simply defined as the enlargement of an effected body part, generally arm or leg as a result of fluid rentention. It may also effect the skin, organs, hand, fingers, foot and even toes. The fluid collects because the body is not able to eliminate the excess liquids.

It is not uncommon and has been experienced by many many people. Usually, this swelling is temporary and goes away after the underlying condition is healed.

If it effects a specific area i.e. arm or leg it is referred to a localized edema, if it effects the entire over all body it is referred to as generalized swelling

Temporary Swelling

This temporary swelling may be caused by an infection, burn or sunburn, insect bites, an injury to the leg such as a sprain, surgery, or even medications such a hormone drugs, steroids, blood pressure drugs, or may be an allergic reaction in which is it referred to as angioedema. This may also be an part of the inflammatory response your body goes through it trying to protect and heal the leg or arm from the cause of the trauma.

Long Term Swelling.

Long term swelling is referred to as edema. This is usually related to specific medical conditions. These conditions may include diabetes, congestive heart failure, blood clot, varicose veins, kidney failure, liver failure or a number of cardio-vascular problems.

Treatment for this long term swelling is in conjunction with the treatment for the condition that caused it. Usually diuretics are also used to relieve the swelling or water-retention.

Permanent Leg or Arm Swelling

****In the situation of any permanent leg or arm swelling whether the cause is known or unknown, the diagnoses of lymphedema must be considered****

There are several groups of people who experience leg or arm swelling from known causes, but it doesn't go away or unknown causes where the swelling can actually get worse as time goes by.

Group One

his group includes those who have had the injuries, infections, insect bites, trauma to the leg, surgeries or reaction to a medication. When this swelling does not go away, and becomes permanent it is called secondary lymphedema.

Group Two

Another extremely large group that experiences permanent leg or arm swelling are cancer patients, people who are morbidly obese, or those with the condition called lepedema. What causes the swelling to remain permanent is that the lymph system has been so damaged that it can no longer operate normally in removing the body's waste fluid.

In cancer patients this is the result of either removal of the lymph nodes for cancer biopsy, radiation damage to the lymph system, or damage from tumor/cancer surgeries.
This is also referred to as secondary lymphedema.

Group Three

Group three consists of people who have leg or arm swelling from seemingly unknown reasons.

There may be no injury, no cancer, no trauma, but for some reason the leg simply is swollen all the time.

The swelling may start at birth, it may begin at puberty, or may begin in the 3rd, 4th or even 5th decade of life or sometimes later.

This type of leg or arm swelling is called primary lymphedema. It can be caused by a genetic defect, malformation or damage to the lymph system while in the womb or at birth or be part of another birth condition that also effects the lymph system.

This is an extremely serious medical condition that must be diagnosed early, and treated quickly so as to avoid painful, debilitating and even life threatening complications. Treatment should NOT include the use of diuretics.

What is Lymphedema?

Lymphedema is defined simply as an accumulation of excessive protein rich fluid in the tissues of the leg. The accumulation of fluid causes the permanent swelling caused by a defective lymph system.

A conservative estimate is that there may be 1-2 million people in the United States with some form of primary lymphedema and two to three million with secondary lymphedema.

What are the symptoms of Lymphedema?

If you are an at risk person for lymphedema there are early warning signs you should be aware of. If you experience any or several of these symptoms, you should immediately make your physician aware of them.

1.) Unexplained aching, hurting or pain in the arm or leg.

2.) Experiencing "fleeting lymphedema." This is where the limb may swell, even slightly, then return to normal. This may be a precursor to full blown arm lymphedema.

3.) Localized swelling of any area. Sometimes lymphedema may start as swelling in one area, for example the hand, or between the elbow and hand. This is an indication of early lymphatic malfunction.

4.) Any inflammation, redness or infection.

5.) You may experience a feeling of tightness, heaviness or weakness of the arm or leg.

How is Lymphedema Treated?

The preferred treatment today is decongestive therapy. The forms of therapy are complete decongestive therapy (CDT) or manual decongestive therapy (MDT), there are variances, but most involve these two type of treatment.

It is a form of massage therapy where the leg is very gently massaged to actually move the fluid out of the leg and into an area where the lymph system still functions normally.

With these massage treatments, swelling is reduced and then the patient is fitted with a pre-measured custom pressure garment to keep the swelling down and/or is taught to use compression wraps to maintain the leg size.

What are some of the complications of lymphedema?

1. Infections such as cellulitis, lymphangitis, erysipelas. This is due not only to the large accumulation of fluid, but it is well documented that lymphodemous limbs are localized immuno-deficient.

2. Draining wounds that leak lymphorrea which is very caustic to surrounding skin tissue and acts as a port of entry for infections.

3. Increased pain as a result of the compression of nerves usually caused by the development of fibrosis and increased build up of fluids.

4. Loss of Function due to the swelling and limb changes.

5. Depression - Psychological coping as a result of the disfigurement and debilitating effect of lymphedema.

6. Deep venous thrombosis again as a result of the pressure of the swelling and fibrosis against the vascular system. Also, can happen as a result of cellulitis, lymphangitis and infections.

7. Sepsis, Gangrene are possibilities as a result of the infections.

8. Possible amputation of the limb.

9. Pleural effusions may result if the lymphatics in the abdomen or chest are to overwhelmed to clear the lung cavity of fluids.

10. Skin complications such as splitting, plaques, susceptibility to fungus and bacterial infections.

11. Chronic localized inflammations.

Can lymphedema be cured?

No, at the present time there is no cure for lymphedema. But it can be treated and managed and most of the complications can be avoided. Life with lymphedema can still be active and full, with proper treatment, patient education, and patient life style adaptation.

Summer Tips for Lymphedema

Spring has sprung and it won't be long before the sunny days of Summer are upon us. Here is a marvelous little article on Summer Tips for Lymphedema

Beat the Heat

Stay Cool

When indoors, stay in well air-conditioned places
Limit time spent outside between 11 am and 3 pm
Take cool or lukewarm showers vs. very cold water
Drink lots of water
Avoid salty foods
Wear light, loose, non-constricting clothing to allow for the free flow of the lymphatic system.
Do not wear items that leave indentations

Garment Care

If insurance allows, get measured for garments after the hot weather starts and after it ends. Normal seasonal changes in edema can occur.
Wash your compression garment. Sweat, body oils, lotions such as sunscreen can cause the fabric to deteriorate more quickly.
Follow the manufacturer's instructions very carefully regarding whether lotion can be applied prior to donning the garment.

------------------------

SUMMER HAZARDS

Insects

Avoid putting insect repellent on skin and then wearing a compression garment over it.
Treat insect bites immediately to lessen the histamine effect.

Clothing

Wear to protect from accidental scratches, poison ivy, etc.
Well fitting shoes with lymphedema in legs.
Avoid heavy backpacks.

Sunburn

Wear sunscreen
Avoid excessive sun exposure.

------------------------

SUMMER HOBBIES AND SPORTS

Gardening and Lawn Care

Wear gloves to protect the hands from injury when gardening.
Avoid using affected arm to start lawn mower.
Take breaks.

Swimming

Wear swimming shoes if swimming in fresh water to avoid cuts and scrapes to feet.
Do put compression garment on after getting out of the water.

Sports

Take caution with extremely vigorous or contact sports.
Pace yourself.
Play for shorter periods of time.
Take breaks at regular intervals.
Wear compression garments or bandage affected limb.

------------------------

TRAVEL TIPS

Before Your Trip

If you obtain a new sleeve, wear it for one week before your trip to build up a tolerance to the sleep and evaluate the fit.
If the flight will be long, consider arranging a "stop-over" for 1-2 days on the way.
Break in new shoes prior to vacation.
Consider asking for a prescription for antibiotics in case of an infection in the arm.
Purchase some 20-30+ sunscreen (you can get sunburned through a garment).

Luggage

Suitcases:

* Consider packing two light suitcases rather than one heavy one.
* To help avoid carrying heavy bags, use the push carts at airports to help move luggage.
* Purchase a suitcase with wheels.
* Use the unaffected arm to pull your suitcase.

Hand Luggage:

* Avoid carrying your shoulder bag on the affected shoulder.
* Carry your medication with you.
* Make sure your compression garments are in good condition, carry a spare with you.

Car, Train, or Bus Travel

Car, train, and bus are worse for leg lymphedema.

Use air conditioning to avoid overheating.
When not driving, sit in the back seat to elevate your affected limb.
Take frequent breaks to get up and walk around.
Avoid long periods of driving if you are at risk for arm lymphedema.
Do exercises while in your seat.

During Travel

Keep your compression garment/bandages on until you arrive atyour hotel or destination.
Stay well hydrated. Drink plenty of water.

During Vacation

Avoid sunburn.
Avoid overheating
Be aware of overdoing sports that you are not used to.
Keep your limb cool and well moisturized.
Wear protective footwear on the beach to protect the skin. If you do walk barefoot on the sand, be sure to wash your feet and check for cuts and scrapes.

Permission to Use of the article can only be granted by - please contact
Institute of Physical Medicine and Rehabilitation6501 N. Sheridan Rd.Peoria, Illinois 61614309-692-8110

http://www.ipmr.org/

quality@ipmr.org .

Lymphedema After Sentinel Lymph Node Biopsy for Cutaneous Melanoma

A Report of 5 Cases

David A. Wrone, MD; Kenneth K. Tanabe, MD; A. Benedict Cosimi, MD; Michele A. Gadd, MD; Wiley W. Souba, MD; Arthur J. Sober, MD
Arch Dermatol. 2000;136:511-514.

Background Sentinel lymph node (SLN) biopsy has rapidly become the procedure of choice for assessing the lymph node status of patients with 1992 American Joint Committee on Cancer stages I and II melanoma. The procedure was designed to be less invasive and, therefore, less likely to cause complications than a complete lymph node dissection. To our knowledge, this is the first report in the literature documenting extremity lymphedema following SLN biopsy.
Observation We report 5 cases of lymphedema after SLN biopsy in patients being routinely followed up after melanoma surgery at the Massachusetts General Hospital Melanoma Center, Boston. Three cases were mild, and 2 were moderate. Potential contributing causes of lymphedema were present in 4 patients and included the transient formation of hematomas and seromas, obesity, the possibility of occult metastatic melanoma, and the proximal extremity location of the primary melanoma excision. Four of the patients underwent an SLN biopsy at our institution. We used the total number of SLN procedures (N=235) that we have performed to calculate a 1.7% baseline incidence of lymphedema after SLN biopsy.

Conclusions Sentinel lymph node biopsy can be complicated by mild and moderate degrees of lymphedema, with an incidence of at least 1.7%. Some patients may have contributing causes for lymphedema other than the SLN biopsy, but many of these causes are difficult to modify or avoid.

From the Massachusetts General Hospital Melanoma Center (Drs Wrone, Tanabe, Cosimi, Gadd, Souba, and Sober), and the Departments of Dermatology (Drs Wrone and Sober) and Surgery (Drs Tanabe, Cosimi, Gadd, and Souba), Massachusetts General Hospital, Boston.

RELATED ARTICLES

Archives of Dermatology Reader's Choice: Continuing Medical EducationArch Dermatol. 2000;136:568-569. FULL TEXT

Archives of Dermatology

Lymphedema Survey

Good Morning Everyone

We are cooperating with a number of groups and are trying to conduct a web wide patient lymphedema survey.We are looking for some information from all of you concerning your lymphedema. Please help us by filling out this poll.

We need to know: gender, age, when diagnosed, how treated, primary or secondary, how you acquired it, and upper or lower. LOL - I understand how people feel about polls, but this is important and could help a great deal in understanding the needs of our members and LE patients.

Please take a moment to cut and paste this into an email and send

to: advocatesforlymphedema@gmail.com

This is for members and visitors alike - the only requirement is that you have lymphedema

Thanks a million!!!!!!! Pat

( ) Gender - male
( ) Gender - female

( ) Primary
( ) Secondary answer 23 or 24

( ) arm
( ) leg
( ) upper body
( ) lower body

( ) diagnosed as a child
( ) diagnosed as an adult
( ) diagnosed as a teenager

( ) I had trouble getting a diagnosis
( ) I treated with an OT for MLD
( ) I treated with a LMT for MLD
( ) I use compression stockings/garments only
( ) I use a pump
( ) I can't afford any treatment, do some on my own

( ) I have a child with lymphedema
( ) My age is 18-25
( ) My age is 26-40
( ) My age is 41-65
( ) My age is 66-80 or over 80

( ) My le is from cancer or surgery
( ) My le is from other cause

Don't forget advocatesforlymphedema@gmail.com

Comprehensive Lymphedema Managment: Results of a 5-year follow-up.

Bonnie B. Lasinski, MA, PT, CLT-LANA and Marvin Boris, MDPresented at the 18th Congress of the International Society of LymphologyGenoa, Italy, September 2001Published in Lymphology 35 (Suppl):301-304, 2002

It is well known that lymphedema, untreated, is a progressive, chronic, incurable disease. While the incidence of lymphedema secondary to treatment for breast cancer is reported to average between 6-30% , the incidence of lymphedema secondary to other cancer surgeries and treatments has not been well reported. In addition, primary lymphedema (other than connatal which appears at birth) which develops in childhood, adolescence, or later life, is often misdiagnosed and under-treated. Lacking accurate information about which individuals are at risk prevents proper screening and education in lymphedema risk management strategies. Early diagnosis and intervention can minimize the lymphedema progression from Stage 1, which is easily reversible, into Stage 2 and Stage 3.

Experts in the field of lymphology generally agree that the initial treatment for lymphedema should be Complete Decongestive Therapy (CDT)/Complex Lymphedema Therapy (CLT). Complete Decongestive Therapy (CDT)/Complex Lymphedema Therapy (CLT) is a two-phase program. The first phase consists of meticulous skin care and treatment of any fungal infections/ulceration of the skin, manual lymphatic drainage, exercises that mimic the pattern of lymphatic drainage appropriate for the individual patient, and compression with multi-layered, short-stretch bandages. Phase 2 focuses on conserving and optimizing the reduction in lymphedema achieved in phase 1. This is accomplished by patient compliance with a self-care program.

This program consists of the skin care regime adopted for that individual during Phase 1 and attention to risk reduction strategies for the involved limb(s). In addition, compression of the affected areas is achieved by means of low-stretch elastic compression stockings or sleeves (supplemented with nightly compression bandaging instead of stockings/sleeves if needed. Individuals must perform their lymphedema exercise/self-lymphatic drainage program twice daily for optimal results.

The importance of regular follow-up visits for evaluation of the affected areas including girth/volume measurements, review/modification of self-care program, and fitting/modifying compression stockings/sleeves cannot be underestimated. Individuals with lymphedema, like diabetes or any other chronic medical condition, deserve to have the appropriate skilled medical and psychological support provided to achieve continued success with their Phase 2 program. Additional intensive CDT/CLT treatment should not be routinely necessary. However, there are situations that exacerbate lymphedema (such as trauma, infection, surgery on or adjacent to, the involved areas. Additional treatment may be warranted if the individual is unable to reduce the exacerbation independently by following their Phase 2 program, supplemented by self-bandaging daily for a short period of time.

Complex Lymphedema Therapy, as practiced today in the US, was principally introduced, applied, and refined in Germany by the Foldis in the 1980's . This technique, also called Combined Decongestive Physiotherapy (CDP) was modified and supplemented with specific physical therapy exercises by the Casley-Smiths in Australia. They called the technique Complex Physical Therapy (CPT) . Several other authors have reported varying results of CDT with average lymphedema reductions ranging from 15% to 68.6%

Critics of CDT question whether individuals can continue to maintain their reductions with compliance with their Phase 2 home program without additional intensive Phase 1 type treatment. The goal of this study is to demonstrate that the excellent reductions in lymphedema and fibrosclerotic changes achieved through a single course of CDT/CLT can be maintained over a 5 year period without further intensive treatment, provided that the individual's medical condition remains stable.

PATIENTS AND METHOD

SStudy PopulationOur group examined the initial and follow-up results of 146 consecutive patients with unilateral extremity lymphedema who were treated with a single course of CLT/CDT at the Lymphedema Therapy facility in Woodbury, New York, USA from 1992 to 2000. The number of treatments ranged from 10-34 with the average being 18.7. The demographic and disease characteristics of the study group are summarized in Table 1.

Table 1 - Demographic and Disease Characteristics of Study Subjects

Patients With One Affected Arm (N=112)

Age (years)
Mean 56.7 (+/- 11.8)
Range 32-82

Gender Female 110
Male 2

Type of lymphedema Primary 1 Secondary 111

Stage of lymphedema

Stage 1 -21
Stage 2 - 90
Stage 3 - 1

Arm affected

Right 48
Left 64

Patients With One Affected Leg (N=34)

Age (years)
Mean 58.2 (+/- 16)
Range 33-85

GenderFemale 19
Male 15

Type of lymphedema

Primary 13
Secondary 21

Stage of lymphedema

Stage 1 - 3

Stage 2 - 29

Stage 3 - 2

Leg affected

Right 15
Left 19

Mean (+/- SD) duration of lymphedema Mean (+/- SD) duration of lymphedema
3.4 (+/- 6.1) years Range- 3 wks-31 years 11 (+/- 12.9) years Range - 4 wks - 42 years

Lymphedema was classified according to the criteria accepted by the International Society of Lymphology . Stage 1 lymphedema is defined as lymphedema that pits on pressure and is reversible upon elevation of the affected area. Stage 2 lymphedema is defined as edema that is irreversible, difficult to pit or is completely non-pitting. As it progresses, there may be subcutaneous tissue fibrosis and skin alterations. Stage 3, lymphostatic elephantiasis, is defined clinically by severe fibrosclerotic tissue changes with skin alterations that may include papular lesions, warty changes, the development of lymphoceles, skin flaps/bulges, the presence of chronic fungal and bacterial infections, and lymphorrhea.

Clinical Analysis

To determine the volume of lymphedema in each limb, circumferences were measured at 10-cm intervals with a flexible tape. Volume was calculated for each 10-cm segment by utilizing the formula for a truncated cone: Volume = H(Ct2 + Ct x Cb + Cb2) / 12p .

Treatment

Patients received a single course of CLT/CDT which is described in detail in reference numbers 11,14,16.Each treatment session lasts approximately 2 hours per day and is administered 5 days per week for an average of 18.7 sessions, with a range of 10-34 treatments. All of the procedures are performed by a licensed physical therapist/physical therapist assistant who has undergone specific training at our center with a certified Casley-Smith School instructor.

Upon completion of CLT, patients are fitted with compression garments, ranging in pressure from 20-60mm HG, depending upon the limb /limbs involved, severity of the lymphedema, and other individual medical and social factors. The home-maintenance program following CLT consists of 24-hour compression garment wear and a patient- specific physical therapy exercise program to be performed twice daily at home for 15 to 20 minutes.

Statistical Methods

All available patients (over the age of 18) were included in the study, excluding 17 individuals who had to undergo additional treatment at some point after their initial 15-20 day course. Patients with bilateral upper or lower extremity lymphedema were excluded from this report.

A mixed models repeated measures analysis of covariance (RMANCOVA) was used to analyze the data for each group separately. The within-groups factor was the time since the initial course of therapy. The between-groups factor was the degree of compliance (compliance with exercises and the use of compression garments averaged together).

For the purpose of this analysis, compliance at the initial visit was set at 100%. All assumptions were examined for each model and appeared to have been met. None of the demographic and disease characteristics (age, gender, and type of lymphedema, lymphedema grade, and duration of lymphedema) differed significantly between the compliant and non-compliant patients.

In this study, compliance was evaluated by the percentage of time the patients wore a compression garment and their adherence to special physical therapy exercises, which included some self-lymphatic drainage, built into the program. Compliance was analyzed at each follow-up visit. No additional courses of CLT/CDT were administered to the study group.

Forty-four individuals were eliminated from this study because they had expired and seventeen had moved away from the area.

RESULTS

All 146 patients who received a single course of CLT/CDT for the lymphedema in one arm or one lower limb were analyzed separately. Lymphedema reductions after CLT/CDT averaged 67.7% in the 112 individuals with one affected arm, and 71.6% in the 34 individuals with one affected leg. At 5-year follow-up, the average reduction in individuals with one affected arm increased to 75%, and decreased to 62% in those with one affected leg.

Lymphedema Therapy