Intermittent pneumatic compression for lymphedema management

Intermittent pneumatic compression (IPC) therapy is used to improve venous circulation, can it also improve lymphatic circulation in cases of secondary lymphedema?

Intermittent pneumatic compression was originally developed to improve venous circulation.  It accomplishes this through the use of an air-pressure controlled sleeve, glove or boot that provides a rhythmic compression of swollen limbs / limbs at risk of developing deep vein thrombosis.  IPC has also been investigated for treating lymphedema, although here its application is more controversial.

If intermittent pneumatic compression works to improve venous circulation, wouldn’t we also expect it to improve lymphatic circulation and thereby relieve the chronic swelling caused by lymphedema?  The simple answer is that lymphatic and venous insufficiency is not the same thing; they have different underlying mechanisms.  This is reflected in the success of the special combinations of hand pressures and strokes used in manual lymphatic drainage massage for lymphedema, but not for venous insufficiency.  Unlike the non-specific compression that IPC provides, manual lymphatic drainage acts to effectively re-direct excess lymph fluid away from the damaged lymphatic structures to those areas of the lymphatic architecture that are still functional, much like a detour route helps relieve traffic in a congested city by directing drivers away from road closures.

We remain skeptical of IPC’s efficacy for managing lymphatic swelling (in particular for cases of secondary lymphedema) and unfortunately the available clinical data we have seen is conflicting and inconclusive.  Our skepticism is supported by the Consensus Document of the International Society of Lymphology that concludes that the evidence for using IPC in combination with manual lymphatic drainage is inconclusive.

Thankfully, data released from a newly published randomized controlled trial sheds further light on the utility of IPC for secondary lymphedema (ref1).  The researchers collected 31 patients with lymphedema following mastectomy for breast cancer, and divided them into two groups. The first group received standard therapy consisting of combined (complex) decongestive therapy (CDT) which includes manual lymphatic drainage, compression bandaging and garments, exercise, skin care and education.  The second group was treated with CDT plus IPC.  Both groups received 5 treatment sessions per week over three weeks, and were then assessed for limb volume and dermal thickness (among other measures).  As expected, the authors observed significant reductions in lymphedema symptoms in both groups, but saw no difference between the groups.  The study size was small, but the design was good. This data suggests that IPC does not improve lymphedema in breast cancer patients already receiving CDT.

Just because it doesn’t add any benefit over CDT alone, does this mean that IPC has no utility for treating lymphedema?  IPC could be expected to provide some benefit, by virtue of the simple fact that it does increase tissue pressure and thereby resist fluid accumulation (similar to compression bandaging – but not nearly as practical, inexpensive, or suitability for extended use), and the non-directive rhythmic compression would result in at least some fluid being pushed out of the limb, if only by chance.  One area where IPC may be both beneficial and cost-effective is for patients where CDT is not available. A recent study that we reviewed here examined the use of IPC in conjunction with home –based self-massage for people without access to CDT (ref2). Even in this setting we were skeptical of its cost-benefit:

“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 to provide guidance on self-massage, self-compression, exercise, and education on skin care and prevention.”

IPC continues to have no primary role in the management of secondary lymphedema. At best it remains an acceptable home-based therapy when used by patients who can afford it, have been educated in lymphedema management, and who use it in conjunction with compression garments and self-massage.

References:

1. Uzkeser H., et al. Efficacy of manual lymphatic drainage and intermittent pneumatic compression pump use in the treatment of lymphedema after mastectomy: a randomized controlled trial. Breast Cancer. 2013 Aug 8 [Epub ahead of print].
2. Gurdal S.O., 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