National Lymphedema Network
POSITION STATEMENT OF THE
NATIONAL LYMPHEDEMA NETWORK
By NLN Medical Advisory Committee; Approved by the NLN Board of Directors: 08/10/2006; Review Date: 09/30/2009
TOPIC: TREATMENT
Introduction
Lymphedema (LE) is a chronic condition characterized by the abnormal accumulation of interstitial fluid due to
insufficiency of the lymphatic system. Lymphatic dysfunction may be related to primary malformation of the lymphatic
system, or to secondary causes. The leading cause of LE in the United States today is cancer and its treatment.
The progression of LE is characterized by swelling, as well as changes of the skin and subcutaneous tissue.1 Changes
typically manifest as roughness, dryness, and hardening of the skin.2 Limbs may become grossly enlarged and distorted in
contour with exaggerated skin creases, folds, and lobules.3 Progressive LE may be complicated by medical morbidity
including recurrent tissue infections and non-healing wounds. Functional, psychological, and social morbidity can occur
as well. LE has no cure but can be successfully managed following timely diagnosis with appropriate treatment.
Diagnosis may require evaluation by a physician with expertise in LE and, when indicated, diagnostic testing.
Treatment of LE: Complete Decongestive Therapy (CDT)
CDT is comprised of an initial reductive phase (Phase I) followed by an ongoing, individualized maintenance phase
(Phase II). 4
The primary goals of CDT are to:
1. decrease edema
2. increase lymph drainage from the congested areas5
3. reduce subdermal fibrosis
4. improve the skin condition
5. enhance patient’s functional status6
6. enable the patient to adhere to an independent self-care program
Components of CDT
Manual lymph drainage (MLD), multi-layer, shortstretch compression bandaging, remedial exercise, skin care, education
in LE self-management, and elastic compression garments comprise CDT.7
Frequency and Duration of CDT
Optimally, CDT is performed daily until the reduction of fluid volume has plateaued, often after 3 to 8 weeks.7,8
Therapist Training
Therapists providing CDT should have completed at least 135 hours of training as recommended by the Lymphology
Association of North America (LANA). (See NLN Training Position Paper.) Additional specialty training may be
required for therapists treating facial, truncal, and genital LE, or LE in the context of advanced systemic illness.
Manual Lymph Drainage
Manual lymph drainage is a specialized manual (hands-on) technique which stimulates superficial lymphatic vessels.
MLD may direct lymphatic flow out of congested areas and into functional lymph node basins.
Compression Bandaging
Multiple layers of short stretch bandages are applied to the lymphedematous area(s). Short stretch bandages have limited
extensibility under tension (50%), in contrast to AceR bandages (300%). To achieve an effective compression gradient,
bandages must be strategically applied with low to moderate tension using more layers in the distal, relative to the
proximal, portions of the affected territory(ies).9 Pressure within the short stretch bandages is low when the patient is
inactive, “resting pressure”. Muscle contractions increase interstitial pressure, “working pressure”, as muscles expand
within the limited volume of the semi-rigid bandages. Interstitial cycling between low resting and high working pressures
creates an internal pump that encourages movement of congested lymph along the distal to proximal gradient created by
bandaging. The non-elastic bandage sheath also counters refilling of fluid and reduces tissue fibrosis which further reduces
volume.4
LE Exercises (Remedial Exercise)
LE exercises are beneficial for all patients. Although activity and exercise may temporarily increase fluid load, appropriate
LE exercises may enable the person with LE to resume exercise and activity while minimizing the risk of exacerbation of
the swelling.10 Compression garments or compression bandages must be utilized during exercise to counterbalance the
excessive formation and stasis of interstitial fluid. (See NLN Exercise Position Paper for exercise guidelines.)
Skin and Nail Care
Meticulous hygiene is recommended to decrease dermal colonization with fungus and bacteria. Low pH moisturizers
should be applied to limit dermal desiccation and microbial growth.11 Because of impaired local immunity in a
lymphedematous limb, breaks in the skin may allow entry of bacteria and result in serious infections. (See NLN Position
Paper on Risk Reduction.)
Compression Garments
Following maximal volume reduction with Phase I CDT, patients should be fitted with a compression garment. Properly
fitted garments are essential for long-term control of LE volume.12 Garment style and compression strength should be
prescribed to enhance patient compliance and volume control. Garments should be washed regularly to maximize the
garment’s longevity and effectiveness. Garments must be replaced at regular intervals.
Patient Education
LE is a life-long condition. Patient education in self-management techniques is therefore a critical dimension of effective
treatment. All LE patients should be taught LE risk reduction, self- manual lymph drainage, the importance of skin care,
the signs and symptoms of cellulitis, the proper fit and care of garments, the importance of weight control, and an
individualized LE exercise program. Emphasis on specific LE self-care elements should be adjusted on a case-by-case
basis.
Modifications and Individualization of CDT
CDT programs should be individualized based on the presence of concomitant medical conditions. Patients with wounds,
musculoskeletal problems, adhesive scars, or post-radiation fibrosis causing limited mobility of the involved area or areas
adjacent to the swelling, may require adjunctive therapeutic interventions in addition to CDT.13-15
Alternative nonelastic compression devices are often helpful adjuncts to simplify nighttime compression. These devices
may enhance Phase II CDT effectiveness in persons who are unable or unwilling to apply traditional short-stretch
compression bandages. In selected cases, they may be useful during Phase I treatment in combination with short-stretch
bandaging.
Pressotherapy (Intermittent Pneumatic Compression, “Compression Pump”)
Pressotherapy is not a component of conventional CDT. Pressotherapy may be used as an adjunct to CDT.16
Pressotherapy involves insertion of the lymphedematous extremity into a multi-cell inflatable appliance, which is attached
to an air compression pump. Sequential inflation and deflation of the cells creates a distal to proximal compression wave
that moves the water component of the lymph and interstitial fluid out of the affected territory. There is a two-phase pump
that creates a proximal to distal gradient (preparation phase) and a distal to proximal gradient (drainage phase) to simulate
MLD.
Pressotherapy can decrease capillary filtration, thereby decreasing lymph formation. Pressotherapy does not accelerate
lymph return 17 and does not enhance the removal of the excess protein component of lymphatic fluid. Potential
complications of pressotherapy include displacement of the edema to the proximal limb, adjacent trunk and/or genitalia. A
fibrosclerotic ring may develop above the proximal end of the pump appliance, further obstructing lymphatic flow. The
use of a pump should be supervised by a trained therapist or healthcare provider experienced in lymphedema management.
Pump pressures generally range from 30-60 mmHg.
NLN Treatment Position Paper, Page 2 of 6
Approved 8/10/2006. Review date: 8/10/2009
Surgical Treatment of LE
The surgical treatment of LE has been advocated in a few specific circumstances to reduce the weight of the affected limb,
to help minimize the frequency of inflammatory attacks, to improve cosmesis, and to potentially reduce the risk of
secondary angiosarcoma.18-21 However, the surgical treatment of LE is not curative. The potential benefits of surgery
need to be weighed against the risks, which are related to the extent of the procedure, the individual medical needs of the
patient, and the expertise of the surgical team. There are two basic types of surgical procedures used for the treatment of
LE: 1) excisional operations, including debulking 21, 22 and liposuction,23 and 2) lymphatic reconstruction.24-28 Most
reports of the outcomes from surgical treatment for LE are drawn from the experience of a single institution or group of
surgeons and focus on small numbers of patients with insufficient objective outcome data and long-term follow-up. In
general, surgical treatment is associated with significant risks and does not eliminate the need for compression garments.
29-31
Pharmaceutical Approaches
LE should not be exclusively treated with drugs or dietary supplements. Diuretics may be harmful.32 Dehydration of soft
tissues with diuretic therapy may increase interstitial protein concentration and secondarily potentiate inflammation and
tissue fibrosis. Diuretics may be indicated in LE associated with systemic conditions (e.g. anasarca), but this must be
medically assessed on a case-by-case basis.
Benzopyrones, such as Coumarin and Hydroxyethylrutin and flavonoid derivatives such as Diosmin have been tested in
research studies.33-37 The United States and Australia abandoned the use of oral Coumarin due to liver toxicity and
inconsistent efficacy.36 Trials with hydroxyethylrutin demonstrate improved skin softening. Daflon 500 (a combination
of Diosmin and Hesperidin) is used widely in the equatorial regions of the world to treat LE. The benefit appears to result
from the reduction of microvascular permeability38,39 and increased thoracic duct pumping.40 However, these mechanisms
have only been verified in animal models to date.
Natural supplements
Studies indicate potential benefit from American horse chestnut. The effects may be mediated by reducing venous
capillary permeability.41,42 There are also studies demonstrating mixed benefits of selenium in radiation-associated LE.41-
43 Bromalain is a natural diuretic found in fresh pineapple.44-47 It appears to have an anti-inflammatory and diuretic effect
that may have a beneficial impact.48,49 Further investigation of these and other supplements is necessary.
Conclusion
LE is a chronic condition characterized by the abnormal accumulation of interstitial fluid due to insufficiency of the
lymphatic system, either as a primary or a secondary disorder. Diagnosis of LE may require evaluation by a physician with
training and expertise in LE. Sometimes special diagnostic testing is needed. CDT is the current international standard of
care for managing LE. The efficacy of CDT is supported by large case series demonstrating a tight temporal association
between the initiation of Phase I CDT and limb volume reductions of 50-70%, enhanced cosmesis, and reduced incidence
of cellulitis.1,3,7,50-52 Chronic or gradually progressive lymphedema for intervals up to 30 years or more prior to the
initiation of CDT consistently respond to Phase I therapy. Patient adherence during Phase II CDT preserves the volume
reduction.7,52 The literature establishes an emphatic causal relationship between CDT and lasting LE volume reduction.
At present it is unclear to what degree deviation from the intensive and integrated approach that is the hallmark of CDT,
will compromise LE treatment outcomes. It is recognized that such deviations may be imposed by provider, patient, and
third party payer constraints. Means do not exist to accurately identify which LE patients will be most adversely affected
by changes in the intensity or components of CDT. A variety of alterations have been formally proposed, however, their
impact remains undetermined.17 It is therefore recommended that CDT alterations be instituted on a case by case basis
under the supervision of an experienced LE therapist or lymphologist with the goals of preserving volume reduction,
preventing medical comorbidity, and enhancing patient adherence and comfort.
NLN Treatment Position Paper, Page 3 of 6
Approved 8/10/2006. Review date: 8/10/2009
References
1. Casley-Smith, J. (1995). Alterations of untreated lymphedema and its grades over time. Lymphology, 28, 174-
185.
2. MacLaren, J. (2001). Skin changes in lymphoedema: pathophysiology and management options. Int J Palliat
Nurs, 7, 381-388.
3. Yasuhara, H. (1996). A study of the advantages of elastic stockings for leg lymphedema. Int Angiol, 15, 272-277.
4. Foldi, E. (1989). The lymphedema chaos: a lancet. Ann Plast Surg, 22, 505-515.
5. Ferrandez, J. (1996). Lymphoscintigraphic aspects of the effects of manual lymphatic drainage. J Mal Vasc, 21,
283-289.
6. Weiss, J. (2002). The effect of complete decongestive therapy on the quality of life of patients with peripheral
lymphedema. Lymphology, 35, 46-58.
7. Ko, D. (1998). Effective treatment of lymphedema of the extremities. Arch Surg, 133, 452-458.
8. McNeely, M. (2004). The addition of manual lymph drainage to compression therapy for breast cancer related
lymphedema: a randomized controlled trial. Breast Cancer Res Treat, 86, 95-106.
9. King, T. (2001). Physical properties of short-stretch compression bandages used to treat lymphedema. Am J
Occup Ther, 55, 573-576.
10. McKenzie, D. (2003). Kalda AL. Effect of upper extremity exercise on secondary lymphedema in breast cancer
patients: a pilot study. J Clin Oncol, 21, 463-466.
11. Vaillant, L. (2002). Infectious complications of lymphedema. Rev Med Interne, 23, 403-407.
12. Yasuhara, H. (1996). A study of the advantages of elastic stockings for leg lymphedema. Int Angiol, 15, 272-277.
13. Mallon, E. (1994). Ryan TJ. Lymphedema and wound healing. Clin Dermatol, 12, 89-93.
14. Macdonald, J. (2001). Wound healing and lymphedema: a new look at an old problem. Ostomy Wound Manage,
47, 52-57.
15. Lund, E. (2000). Exploring the use of CircAid legging in the management of lymphoedema. Int J Palliat Nurs, 6,
383-391.
16. Szuba, A. (2002). Decongestive lymphatic therapy for patients with breast carcinoma-associated lymphedema. A
randomized, prospective study of a role for adjunctive intermittent pneumatic compression. Cancer, 95, 2260-
2267.
17. Miranda, Jr., F. (2001). Effect of sequential intermittent pneumatic compression on both leg lymphedema
volume and on lymph transport as semi-quantitatively evaluated by lymphoscintigraphy. Lymphology, 34,135-
141.
18. Campisi, C. (2003). Peripheral lymphedema: New advances in microsurgical treatment and long-term outcome.
Microsurgery, 23, 522-525.
19. Gloviczki, P. (1999). Principles of surgical treatment of chronic lymphoedema. International Angiology, 18, 42-
46.
20. Vignes, S. (2002). Role of surgery in the treatment of lymphedema. Rev. Med Interne, 23, 426-430.
NLN Treatment Position Paper, Page 4 of 6
Approved 8/10/2006. Review date: 8/10/2009
21. Miller, T.A. (1998). Staged skin and subcutaneous excision for lymphedema: a favorable report of long-term
results. Plastic & Reconstructive Surgery, 102,1486-498.
22. Kim, D.I. (2004). Excisional surgery for chronic advanced lymphedema. Surgery Today, 34, 134-137.
23. Brorson, H. (2003). Liposuction in arm lymphedema treatment. Scand J Surg,92, 287-95.
24. Koshima, I. (2000). Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the
upper extremities. J Reconstr Microsurg, 16, 437-442.
25. Baumeister, R.G. (2003). The microsurgical lymph vessel transplantation.Handchir Mikrochir Plast Chir, 35,
202-209.
26. Olszewski, W.L. (1988). The treatment of lymphedema of the extremities with microsurgical lympho-venous
anastomoses. Int Angiol,. 7, 312-321.
27. Abalmasov, K.G. (2003). Lymphedema of the extremities: prospects of microsurgical treatment. Angiol Sosud
Khir, 9, 66-79.
28. Campisi, C. (1998). Frontiers in lymphatic microsurgery. Microsurgery,18, 462-471.
29. Vignes, S. (2003). Quantitative evaluation and qualitative results of surgical lymphovenous anastomosis in lower
limb lymphedema. J Mal Vasc, 28, 30-35.
30. Koshima, I. (2003). Long-term follow-up after lymphaticovenular anastomosis for lymphedema in the leg.
Journal of Reconstructive Surgery, 19, 209-215.
31. Lee, B.B. (2005). Contemporary issues in management of chronic lymphedema: Personal reflection on an
experience with 1065 patients. Lymphology, 38, 28-31.
32. Mortimer, P.S. (1997). Therapy approaches for lymphedema. Angiology, 48,87-91.
33. Casley-Smith, J. (1993). Treatment of lymphedema of the arms and legs with 5, 6 benzo-a-pyrone. New England
Journal of Medicine, 329, 1158-1163.
34. Casley-Smith, J. (1993). Treatment of filarial lymphodema and elephantiasis with 5, 6 benzo-a-pyrone
(coumarin). British Medical Journal, 307, 1037-1041.
35. Loprinzi, C. (1999). Lack of effect of coumarin in women with lymphedema after treatment for breast cancer.
New England Journal of Medicine, 340, 346-50.
36. Taylor, H. (1993). A double blind clinical trial of hydroxyethylrutosides in obstructive arm lymphodema.
Phlebology, 8, 22-28.
37. Mortimer, P. (1995). A double-blind, randomized parallel-group, placebo-controlled trail of 0-( -hydroxyethyl)-
rutosides in chronic arm oedema resulting from breast cancer treatment. Phlebology, 10, 51-55.
38. Kendall, S. (1993). Effects of hydroxyethylrutosides on the permeability of microvessels in the frog mesentery.
British Journal of Pharmacology, 110, 199
-206.
39. Bouskela, E. (1999). Effects of diosmin-hesperidin on increased microvascular permeability in the hamster
cheek pouch. International Journal of the Microcirculation: Clinical and Experimental, 14, 79.
NLN Treatment Position Paper, Page 5 of 6
Approved 8/10/2006. Review date: 8/10/2009
40. Cotonat, A. (1989). Lymphangogue and pulsatile activities of Daflon 500 mg on canine thoracic lymph duct.
International Angiology, 8, 15-18.
41. Ody, P. (1993). The Complete Medicinal Herbal. (p. 181). New York: Dorling Kindersley.
42. Leung, A. (2003). In The Encyclopedia of Common Natural Ingredients (pp. 304-306). Hoboken, NJ: Wiley-
Interscience.
43. Hoffman, D. (1997). Herbal Phytotherapy and the Elderly. MNIMH Web site: http://www.Healthy.net, 1-5.
44. Cirelli, M. (1962). Treatment of inflammation and edema with bromelain. Delaware Med J, 34,159-167.
45. Seligman, B. (1969). Oral bromelains as adjuncts in the treatment of acute thrombophlebitis. Angiology, 20, 22-
6.
46. Schafer A. (1985). Plasma inhibition of platelet function and of arachidonic acid metabolism. J Clin Invest, 75,
456-461.
47. Kelly, G. (1996). Bromelain: a literature review and discussion of its therapeutic applications. Altern Med Rev, 1,
243-257.
48. Munzig, E. (1995). Bromelain protease F9 reduces the CD44 mediated adhesions of human peripheral blood
lymphocytes to human umbilical vein endothelial cells. FEBS Lett, 351, 215-218.
49. Gaby, A. (1995). The story of bromelain. Nutr Healing, 3, 4-11.
50. Boris, M. (1997). Persistence of lymphedema reduction after noninvasive complex lymphedema therapy.
Oncology, 11, 99-109.
51. Lasinski, B. (2002). Comprehensive lymphedema management: results of a five- year follow-up. Lymphology,
35, 301-305.
52. Morgan, R.G. (1992). Complex physical therapy for the lymphoedematous arm. J Hand Surg, 17, 437-441.
© 2006 National Lymphedema Network, Inc. (NLN).
Permission to duplicate this handout as-is, in its entirety, for educational purposes only; not for sale.
All other rights reserved. For reprint permission, please contact the NLN office at 510-208-3200 or nln@lymphnet.org.
NLN Treatment Position Paper, Page 6 of 6
Approved 8/10/2006. Review date: 8/10/2009
Document Outline
