Complete Decongestive Therapy (CDT)
The best global treatment of lymphedema, according to the international guidelines of the International Society of Lymphology is CDT (complete decongestive physiotherapy). Many studies have demonstrated the effectiveness of CDT for improving lymphedema symptoms such as swelling and pain.
It is an intensive program that combines many different treatment approaches, including bandaging, compression garments, manual lymphatic drainage, exercise, and self care. As a technique, CDT originated in Europe and Australia but is now becoming more prevalent in the United States.
- Can effectively reduce the volume of lymphedema,
- Improve patients’ mobility
- Increase quality of life.
- Comprises two phases.
- Phase I(the intensive phase) consists of the mobilization of fluid and the initiation of a decrease in the proliferated connective tissue.
- Phase II(maintenance phase) maintains the swelling reduction and aims for optimization of connective tissue reduction.
Complete decongestive therapy (CDT) consists of:
- Manual Lymphatic Drainage (MLD): A light skin stretching technique that stimulates the lymphatic system.
- Compression: Layered bandaging with foam or specially fitted garments that support the area to control swelling.
- Exercises: With compression, special exercises will help to pump lymph out of the swollen area.
- Skin Care: Keeping the skin clean and moisturized will help prevent infections that often can happen with lymphedema.
- Self-Care Management and Training: Learning how to manage lymphedema at home.
Active Phase (Phase 1)
- Phase I consists of the mobilization of fluid and the initiation of a decrease in the proliferated connective tissue.
- The number of weeks depends on the amount of swelling and tissue firmness.
- Complete decongestive therapy for one-hour sessions, 4 to 5 days per week.
- Bandages with foam are worn about 23 hours per day and often only removed to bathe.
Maintenance Phase (Phase 2)
- Maintenance phase maintains the swelling reduction and aims for optimization of connective tissue reduction
- Phase 2 should last for months or for years.
- Elastic compression garments that fit like a second skin are worn during the day.
- Often bandages with foam are worn at night to decrease daily daytime swelling.
- Exercises are done while wearing compression.
- Self manual lymphatic drainage is done for 20 minutes per day.
Manual Lymphatic Drainage
Compression therapy is a very important tool in the treatment of lymphedema.
- Even when MLD is performed correctly, swelling does not decrease without compression (in most cases).
- Compression bandages should remain on the extremities until the next session of MLD.
Products used for compression therapy are low-stretch bandages and elastic garments (elastic stockings/sleeve/gloves).
- Bandaging is a mainstay of treatment for stage 2 and stage 3 lymphedema (moderate to severe lymphedema). Bandaging involves creating a soft cast on the arm or upper body by wrapping with multiple layers. This is a main component of the complete decongestive therapy.
The 7 minute video below goes through the technique.
Bandaging is a reductive therapy, meaning it makes the limb smaller. When the arm is bandaged, muscles are “held in” by the multi-layer soft cast every time the arm is used (this is known as working pressure). Doing prescribed exercises with the bandages on, or using the arm as for normal activities, creates an internal pumping action that moves fluid out of the tissues and into vessels of the lymphatic system. The bandage cast helps prevent fluid from flowing back into the limb, and it also softens the tissue under the skin.
2. Compression garments are designed to keep a continuous pressure on the swollen/affected area to assist the drainage of fluid and minimize swelling. Image R: Lymphedema compression sleeve, displayed on mannequin
- External compression provides a counter force to the working musculature (ie working pressure). Working pressure helps to prevent re-accumulation of fluids which were evacuated during intensive complete decongestive therapy (CDT) and conserve the results achieved during manual lymphatic drainage (MLD).
Research studies have not yet looked at the effectiveness of compression sleeves alone in treating lymphedema. However, studies find them an effective as part of the overall treatment plan. Eg:
- Sleeve worn on the arm
- Fingerless glove or a gauntlet (which does not have individual finger openings), often worn with a sleeve
- Support bra for the chest area or a vest for the entire trunk area
All of the garments are made of flexible fabric. Sleeves are tighter at the bottom than they are at the top creating the graded pressure that keeps the lymph moving out of the arm. There is a variety of fabrics available: Some feel softer, others stiffer, and some may include materials such as wool or latex.
Bandaging vs. compression sleeves
Bandages work differently than compression sleeves, which support the flow of lymph ie move fluid out of and decongest the limb. Sleeves apply what’s known as resting pressure, meaning that the pressure is higher when the arm is at rest. When you move your arm, the elastic fabric moves right along with it, which actually reduces the amount of pressure. A compression sleeve may be enough for mild lymphedema, however more advanced cases require bandaging before a compression sleeve can be used. Bandaging works by reducing limb volume.
Initial exercises consist of gentle stretching and range of motion exercises (helping the muscles contract and relax, which is thought to help push the lymph along) and also strengthen the lymphatic system. eg making a fist and extending fingers; doing wrist curls; or gentle punching motions to extend and flex the elbow.
Once symptoms improve and the lymphedema is stable, the exercise plan expands to include aerobic exercise (improves physical fitness and reduces body weight). This kind of exercise includes swimming, cycling, walking, dancing tai chi and gentle yoga (excluding positions putting weight on the upper body least at first), swimming, and/or lifting light weights, depending on clients status.
Exercises with light weight do not affect the volume of lymphedema adversely. Although at first the extremity may become swollen, the volume of accumulated fluid is reduced after 24 hours . These exercises should be performed with caution and for low repetitions with little weight (particularly at the initiation phase).
Generally, a combination of stretching, monitored strengthening exercises, and aerobic activities are recommended, but the plan has to be individualized. If client has more ambitious fitness goals work towards this gradually.
Generally, it is acceptable for patients to either wear or not wear compression garments during exercise, provided that they wear suitable garments during the remaining hours of the day (eg Bandages, a compression sleeve, or other compression garments).
Example of exercises for upper limb lymphedema (given by a trained physiotherapist)
- warm up activity by active mobilization of large joints at moderate pace for 5 min;
- shoulder girdle mobilization-scapular retraction, protraction, depression, shoulder extension, elbow flexion and extension, wrist flexion and extension and ball squeeze;
- pectoral and trapezius muscles stretching.
- Patients comfortably seated, relaxed, with hands over their abdominal muscles, and deep breathing through the nose and a prolonged expiration through mouth without any strenuous effort (diaphragmatic breathing) and diaphragmatic breathing practised in between exercises.
Proper skin care is paramount. The skin of patients with lymphedema is usually very sensitive, dry, and itchy due to disturbances of skin metabolism as a result of the macro-and microcirculation alterations making it susceptible to inflammation and infection. Due to the impaired healing process, skin injury can lead to severe inflammation, infection (eg cellulitis) or even ulcers, worsening the condition, thus therapeutic and protective measures are essential components of skin care.
- Compression therapy may lead to a dry, broken, and sensitive skin which is prone to injuries. The down side of these garments being the damage caused by the interaction between the skin and the means of compression (ie medical bandages and garments). Damage being due to the: mechanical effects and absorption properties of compression bandages and garments; direct contact with the skin and consequent abrasion causing high mechanical pressure on the corneal layer; the fibers of the bandages and garments absorb sweat and skin oil, damaging the normal thin hydrolipidic layer of the skin and the protective acid layer.
- The aim is to keep the skin in a normal and healthy state, or to heal it as well as possible. In order to keep the skin flexible and durable, patients should choose a mild, soap-free cleansing lotion that is neutral(pH=7) or slightly acidic (pH=5) for daily useas well as bath oils that replenish the skin oil.
- Patients should take care to completely dry the skin after a bath or shower, especially in deep skin folds, to minimize the risk cutaneous fungal infection. After the skin has been cleaned, the skin must be hydrated using soft pharmaceuticals. Products for skin care should be used sparingly and applied with gentle massaging movements.
- Compression garments should not be applied if the products have not been fully absorbed.
- All skin infections should be treated and cleaned by a doctor.
- During treatment, special attention should be paid to the care of any secondary skin lesions resulting from radiation.
- The physiotherapist should discuss the skin care with the physician prior to treatment.
- Continual cooperation of a multidisciplinary team is essential for the optimal treatment of lymphedema.
Lymphedema skin complications (best managed by a multidisciplinary team)
- Infections: skin infections should be managed promptly.eg with antibiotic therapy and additional measures, as well as prophylactic interventions.
- Ulcers: Lymphedema-associated ulcers are managed with a combination of wound cleansing, debridement, exudate management, peri-wound care, appropriate dressings, compression therapy and surgical wound coverage if necessary.
Self-Care Management and Training
Education regarding “Self care” (ie everything client does at home to reduce the risk of the lymphedema coming back or getting worse in the future) is vital. As a lymphedema therapist you should teach clients how to
- Put on and care for their compression sleeves and garments. Patients need to understand the need to replace the garments on a regular basis to maintain sufficient compression. Each garment should be washed daily to restore the compression and replaced after 3 to 6 months of continuous use, although very active patients may require these to be changed sooner.
- Protecting arm, hand, chest, or other body part from cuts, injury, overuse, extreme temperatures, and other situations that can increase the production of lymph, which in turn increases lymphedema risk
- Educate re the signs and symptoms of infection, which is a special concern for people with lymphedema
- Help plan and set an individualised exercise and/or weight control plan
- Teach how to do manual lymphatic drainage on their own, at home. If “self-MLD” is appropriate and client can manage technique. Stress to client that doing more than is recommended, or being more aggressive with the massage strokes for MLD, could be harmful.
- The goal of complex decongestive therapy (CDT) is to provide permanent control of the volumetric and metaplastic tissue changes associated with lymphedema. This multimodal treatment approach is widely used to control chronic edemas and is emerging as an effective means of managing refractory edema at the end of life. It can also help decongest the face, trunk and genitals.
- Numerous studies have shown that CDT is clearly beneficial. When administered by appropriately trained therapists, CDT achieves and maintains limb volume reductions of 50 to 70 percent
- Several other treatment modalities available for lymphedema include electrostimulation, acupuncture, Kinesio Taping, low-level laser, deep oscillation, and ultrasound. However, there is insufficient evidence currently to recommend their use. Pharmaceutical therapies, including diuretics and benzopyrones, are not recommended for lymphedema treatment.
This is a good watch at 28 minutes on eg. MLD and exercise
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