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Lymphedema is a generally painless but abnormal accumulation of protein-rich interstitial fluid that causes swelling, chronic inflammation, and fibrosis of related tissues. 

It may impair wound healing and the body’s ability to fight infection, and can be painful when related to oncological processes, venous stasis, and joint inflammation. The most prevalent forms are caused by surgery, radiation, trauma, infection, venous insufficiency, and lipedema.

Most often noted in the extremities, lymphedema may affect any body part that has sustained damage to the lymphatic system. At times of extreme swelling, patients with lymphedema may experience functional limitations and social isolation.

“Complete Decongestive Therapy is the most effective treatment for lymphedema and includes manual lymph drainage, skin care, exercise, patient education, and compression wrapping/garments,” says Joelle Grossman, PT, MEd, CLT-LANA (certified lymphedema therapist, Lymphology Association of North America). Grossman trained with Guenter Klose, CI, CLT-LANA, and is the PT supervisor of the Regional Rehabilitation Center at Montrose Memorial Hospital in Colo.

Treatments that have traditionally been used for patients following lymph node excision are now emerging as options for patients with orthopedic involvement. “I find that orthopedic injuries and acute surgical cases respond amazingly well to [lymphedema] treatment approaches,” notes Loraine Lovejoy-Evans, PT, DPT, CLT-Földi. Lovejoy-Evans completed her CLT training with Drs. Michael and Ethyl Földi in Germany, and owns Independence Through Physical Therapy in Sequim, Wash. She is also an adjunct faculty member at the University of Puget Sound in Tacoma.

Stimulating venous return

Although the lymphatic system in any extremity may be affected, the lower extremities present with a special problem due to the gravitational pooling effect of fluids. As in the arms, blood pressure in the lower extremities is influenced by changes in position and can be measured with a blood pressure cuff.

“When upright, the calf venous pressure increases from 8 mmHg [in supine] to 108 mmHg. This increased venous pressure causes the veins to dilate, blood velocity slows, and blood volume increases. Capillary pressure [also] increases, greatly forcing more fluid into the interstitium, creating a greater load for the lymphatics,” Grossman explains. “With exercise, however, the venous leg pump reduces the pressure to 25 mmHg and encourages improved venous return; [in other words], diminished pooling and swelling. The degree to which pressure changes occur depends on cardiovascular status, sociodemographic factors, and cigarette smoking,” she says.

Pairing exercise with compression garments also is beneficial. “The compression on the limb from garments provides pressure externally, while the muscle pump provides internal pressure; the lymphatics are then encouraged to reabsorb fluid and move it proximally. With garments on the limb, walking and exercise can dramatically improve the effect of the limb compression,” Lovejoy-Evans says.

Monica Sety, OTR/L, CMLDT (certified manual lymph drainage therapist), at CarePartners South Clinic in Asheville, N.C., agrees. “Compression bandages and garments are an essential part of controlling lymphedema in the extremities,” she says. “Without compression, the limb will fill back up with fluid and/or not maintain reductions achieved through therapy. The compression creates the appropriate interstitial pressure in order for the system to pump efficiently.”

A fitting occupation

Because of the efficacy of external compression on distended tissues, therapists who complete lymphedema certification or management courses usually become certified compression garment, or stocking, fitters. People without medical training can become certified stocking fitters, although their training is usually brief and company-sponsored.

Compression garments and stockings are available custom-fit or over-the-counter. “If the problem can be caught early when there is minimal to moderate edema present, then [over-the-counter stockings] may well be adequate; however, when edema has been present for a long time, there is significant congestion or fibrosis present, and skin mobility is significantly limited due to the failure of the lymphatic system … [In these cases the] patient will more likely require custom-fitted compression stockings,” Lovejoy-Evans notes.

Compression garments are usually dispensed according to diagnosis or indication, such as postsurgical swelling, venous ulcers, hypertrophic scars, orthostatic hypotension, or lymphedema. “These diagnoses dictate the compression required to minimize [or] prevent circulatory stasis and, therefore, swelling. However, one must also consider [the patient’s] ability to don the garments [and the] fabric type and appearance to ensure compliance with use,” Grossman explains.

Regarding online or catalog shopping for compression garments, Grossman notes, “The Internet is very competitive in this market with all styles, sizes, and compressions available. However, quality varies and there are many types of fabric to choose from. A fitter with some experience can provide valuable assistance in choosing a garment that will be comfortable, fit well, and be utilized effectively. For some, a custom garment is the best choice.”

But compression garments and stockings are just one aspect of CDT. “While compression therapy does not change the pathophysiology of the circulatory/lymphatic systems, it is very effective in reducing the venous hypertension that leads to lower extremity swelling,” Grossman emphasizes. “It is critical to understand the etiology of the problem and the stage of the disease process in order to achieve good results. CDT is the most effective treatment for lymphedema and many types of swelling, [but] of course, patient education and compliance is the ultimate goal for long-term positive outcomes.”

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Rosalyn Wasserman, PT, DPT, is a medical writer for the Gannett Healthcare Group. To comment on this story, send e-mail to pteditor@gannetthg.com.

© Copyright 2009 Gannett Healthcare Group