Combined (Complex) Decongestive Therapy for Lymphedema: Challenging our Current Standard of CareBy: Lindsay Davey, MScPT, MSc, CDT
September 24, 2012
Editors: Ryan Davey, PhD and Lindsay Davey, MScPT, MSc, CDT
There is no consensus on a single best therapy for treating the chronic swelling condition known as lymphedema. As a result, the gold standard treatment is in fact a combination of techniques known as Combined (or “Complex” or “Comprehensive”) Decongestive Therapy (CDT). The components of CDT: manual lymphatic drainage, compression, exercise and education, each have shown beneficial effects for reducing lymphedema, as well as synergistic effects when combined. While CDT is an established and effective strategy for managing lymphedema, additional treatment modalities continue to be investigated with the hopes of either improving therapy, or simply to provide additional management options.
So does our current standard of care need updating? Three recent studies examine potential alternatives and improvements to the technique:
Thermotherapy and CDT
Although CDT therapists typically advise against heat for a lymphedematous limb, thermotherapy has actually been proposed as a potential adjunct to CDT for treatment of lymphedema. Past studies have suggested that temperatures around 40 degrees celsius could potentially improve the transportation of lymph, and thereby decrease limb volume. While temperature changes will certainly elicit vascular responses, a role in CDT is unclear. A recent study (Mariana VF., de Fatima GG., Maria Pde G. The effect of mechanical lymph drainage accompanied with heat on lymphedema. J Res Med Sci. 2011 Nov;6(11):1448-51) examined this possibility by comparing mechanical lymph drainage (via a device that passively mobilizes limbs) with and without the addition of heat. In support of current clinical practice, reduction in limb volume for the lymphedematous limbs tended to be greater without heat, although the results were not statistically significant. The same conclusion was also observed for normal non-lymphedematous limbs. Although the results of this study were limited by an absence of long-term follow-up, and by the study’s narrow experimental design, the authors conclude that thermotherapy is not currently warranted as an add-on therapy to CDT.
This month a well-known team of lymphedema researches published new data on a more intensive version of CDT that included once-weekly sessions of 3 to 4 hours of manual and mechanical lymph drainage, exercise with facilitating tools, and the use of a medical compression sleeve, among other more minor interventions (Pereira de Godoy JM. and Guerreiro Godoy MD., Evaluation of a new approach to the treatment of Lymphedema resulting from breast cancer. Eur J Intern Med. 2012 Sept 7). As expected, the studied concluded that this more intensive protocol showed good effectiveness for reducing lymphedema. However, CDT-only controls were not included in this study, so no conclusion can be drawn about relative efficacy versus traditional CDT. In addition, the intensive nature of the protocol limits real-world utility for most patients.
Intermittent Pneumatic Compression and Self Manual Lymphatic Drainage
A third study published this month examined replacing manual lymphatic drainage and compression bandage therapy with self-administered manual lymphatic drainage and intermittent pneumatic compression (IPC), a mechanical device that uses an air pump to provide pulsing pressure on a limb (Gurdal SO, et al. Comparison of intermittent pneumatic compression with manual lymphatic drainage for treatment of breast cancer-related lymphedema. Lymphat Res Biol. 2012 Sep;10(3):129-35). While global health status and functional and cognitive functioning scores appeared to only be improved in those patients that received conventional CDT, the researchers found that their alternative strategy did in fact provide an equivalent level of limb volume reduction.
At first glance I found this result to be quite surprising. Use of IPC is quite controversial since the non-specific pumping compression that it provides cannot appropriately redirect lymphatic fluid away from damaged lymph drainage basins, and thus would be expected to provide only temporary limb volume reduction at most. However, incorporation of such non-specific compression directly following a session of manual lymphatic drainage could foreseeably enhance and/or maintain lymph drainage, regardless of its non-specific action. Perhaps supplemental non-specific compression pumping like IPC could be particularly beneficial in cases of non-optimal manual lymphatic drainage, such as that which is self-administered. Although the authors suggest that this combination may be a viable alternative to CDT for those otherwise unable to access treatment, the patient still needs self-massage guidance and a specialized IPC device. It seems that a more practical, longer-term, and seemingly more beneficial approach would be to seek out a certified CDT therapist who should already routinely provide guidance on self-massage, self-compression, exercise, and education on skin care and prevention.
While none of the above revolutionizes lymphedema therapy, it is encouraging to see that the gold standard method for treating lymphedema continues to be challenged. Like the methodology itself, all patients suffering from lymphedema should continue to challenge themselves to advance and update their own knowledge and tool sets for managing the condition. Your CDT therapist can help facilitate this by providing guidance on self-manual lymphatic drainage massage practice, home-based exercise, and education on skin care and flare-up prevention strategies.