Comprehensive Lymphdema Managment: Results of a 5-year follow-up.
Bonnie B. Lasinski, MA, PT, CLT-LANA and Marvin Boris, MD
Presented at the 18th Congress of the International Society of Lymphology
Genoa, Italy, September 2001
Published in Lymphology 35 (Suppl):301-304, 2002
146 patients with unilateral extremity lymphedema were treated with Complex Lymphedema Therapy (CLT), also known as Complete Decongestive Therapy (CDT). Lymphedema reductions after CLT averaged 67.7 % in the 112 patients with one affected arm, and 71.6 % in the 34 patients with one affected leg. At 5-year follow-up, the average reduction in-patients with one affected arm increased to 75%, and decreased to 62% in those with one affected leg.
Successful maintenance of initial lymphedema reduction is dependent upon compliance with the daily home self-care program. This program includes individualized lymphedema exercises which combine self manual lymphatic drainage, deep abdominal breathing, sequential isotonic/isometric exercises, instruction in risk reduction techniques/skincare to avoid infection in the affected limb, and 24 hour compression on the affected limb via compression garments/bandages.
Sufficient time is needed for patients to successfully learn how to apply all the components of the home program. Patients who were compliant showed significant increases in lymphedema reduction, whereas non-complaint patients lost part of their initial reduction.
These results showed that reductions in lymphedema achieved from a single course of CLT/CDT can be successfully maintained for 5 years without further treatment, provided the patient is taught a proper self-care program and is compliant with that program on a daily basis.
Full Comprehensive Lymphdema Managment Report
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 With One Affected Arm (N=112)
Type of lymphedema
Stage of lymphedema
Type of lymphedema
Stage of lymphedema
Mean (+/- SD) duration
of lymphedema Mean (+/- SD) duration of lymphedema
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.
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.
Marvin Boris, MD