LymphLink Question Corner
January-March 2011
Catherine Tuppo, PT, MS, CLT-LANA
Q: Can you tell me if there are any new treatment techniques (discussed at the conference) that are being investigated for lymphedema?
A: While the standard of care remains Complete Decongestive Therapy (CDT) which incorporates skin care, manual lymph drainage, compression bandaging, compression garments, and exercise, presentations highlighted research investigating pneumatic compression, low level laser therapy (LLLT), aqua therapy, acupuncture, and surgery such as liposuction.
Researchers are studying the optimal design for pneumatic compression devices as well as protocols for application. Speakers discussed utilizing multi-chamber devices with varied methodologies. Several presented papers which utilized compression devices with both trunk and limb components for upper limb and lower limb edema, at lower compression settings. Another discussed tissue response at various compression settings for lower limb edema. Benefits were noted by each speaker based on the study methods presented.
The positive and negative effects of LLLT were debated in a pro and con session. Another speaker described a pilot study investigating the effects of treatment with LLLT and MLD. This pilot study (n=5) noted short-term improvements in tissue water and hardness with LLLT, but no long-term effects. The speaker clearly defined limitations of the study discussing that a more rigorous research protocol is needed with a larger subject population, before clinical inferences can be made.
One speaker discussed a study incorporating aqua therapy (pool exercise) for Phase 2 lymphedema treatment. Aqua therapy, in this context, was noted to improve adherence during the self management phase when compared to a conventional self management regime.
The use of acupuncture for lymphedema treatment has been considered somewhat controversial due to concerns for tissue injury and/or infection when the lymphadematous region (or area at risk) is utilized for insertion of the acupuncture needle(s). One paper investigated the rate of infection when acupuncture is applied to the involved or at risk lymphadematous segments. The speaker discussed that in this study (n=29), no incidents of infection were noted.
Several papers addressed the current state of surgical interventions for lymphedema management. One speaker reviewed liposuction as a treatment option for chronic lymphedema. The presenter noted that before an individual is considered a candidate for this type of surgery, he/she must have undergone the standard of care for lymphedema, CDT. After liposuction surgery, the speaker noted it is imperative that the patient wear custom compression garments at all times (24 hours a day, 7 days a week) in order for the limb reduction to be maintained. The patient may continue MLD and CDT after liposuction. More widely performed in Europe, liposuction for lymphedema management in the United States is less available.
It is exciting to see that research is moving forward in many areas. However, we must understand that additional research is needed in all of these areas before potential benefits and potential harms can be reliably demonstrated. Long-term follow up, case-control design, and larger subject populations will assist in bringing the rigor of the research forward.
Q: Have there been any further advances in the factors which may influence the development of breast cancer-related lymphedema?
A: Factors related to the development of breast cancer-related lymphedema continue to be studied in long-term research protocols. The influence of genetics on the development of secondary lymphedema is now being investigated. Specifically, researchers are interested in determining if there is a genetic predisposition for lymphedema in individuals who develop lymphedema after treatment for breast cancer.
Q: Is CDT or MLD (manual lymph drainage) effective for conditions other than lymphedema?
A: Therapists have been successfully applying the principles of CDT and MLD to other diagnoses. One presenter discussed the utilization of modified MLD, elastic taping and compression bandages, along with traditional modalities, for a patient after total knee replacement, noting improvements in edema, range of motion and pain. Another speaker discussed the beneficial application of MLD along with deep tissue massage (DTM) in the post-operative care of patients undergoing a variety of cosmetic surgeries involving different areas of the body (face, breast, abdomen, buttocks and thighs).
Q: Are there any new diagnostic imaging tests for lymphedema?
A: Lymphoscintigraphy and lymphangiography remain the primary diagnostic imaging techniques for lymphedema; however several studies discussed the use of NIR (Near Infrared Fluorescence Imaging) for visualization of lymphatic flow. NIR may have promise moving forward; however it is a costly test, and requires the injection of the imaging medium into the limb. Nonetheless, it does provide a dynamic view of lymphatic flow and may prove beneficial for use in investigational studies looking at the impact of various treatment techniques on lymphatic function.
Catherine Tuppo, PT, MS, CLT-LANA
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