Complex physical therapy for the lymphoedematous arm

C O M P L E X P H Y S I C A L T H E R A P Y FOR T H E LYMPHOEDEMATOUS ARM R. G. MORGAN, Judith R. CASLEY-SMITH, M. R. MASON and J. R. CASLEY-SMITH From the

Department of Surgery, Flinder's Medical Centre, Bedford, Henry ThomasLaboratory, Universityof Adelaide and Adelaide Lymphoedema Clinic, Norwood,Australia Complex physical therapy was used in 78 patients with post-mastectomy lympboedema (17 with grade I and 61 with grade 2). This involves: skin hygiene, a special lymphatic massage, compression bandaging and garments, and special exercises which supplement the massage. Two courses of treatment were given, lasting four weeks each, with a year between them. There was a highly significant decrease in the oedema in both grades, with more than 50% removed in the first course of treatment and 50% of the remainder in the second. There was even a small, but very significant decrease during the interval between the two courses. Journal of Hand Surgery (British Volume, 1992) 17B : 437-441

One-third of all patients develop lymphoedema after mastectomy, 15% of these to a moderate or severe degree (Casley-Smith and Casley-Smith, 1986). Even mild amounts of secondary lymphoedema often give rise to pain and disability. Given the incidence of carcinoma of the breast, 1.5% of all women now alive will suffer to some extent from post-mastectomy lymphoedema before they die. To these must be added patients with lymphoedema from other causes. Treatment may involve drugs, physical therapy or surgery. It is widely agreed that adequate physical therapy should be tried before resorting to surgery for lymphoedema (Casley-Smith et al, 1985). Drugs of the benzopyrone group are effective in lymphoedema (CasleySmith and Casley-Smith, 1986; Piller et al., 1988), and even in filaritic elephantiasis (Jamal et al, 1989). However they have a slower effect than good physical therapy. Physical therapy was first used by Winiwarter (1892), but fell out of use, despite the fact that techniques of lymphatic massage were improved in the 1930s by Vodder (1965). Compression garments available at that time were poor, and these are essential to maintain the reduction achieved by physical therapy. They need to be stronger and longer than those used for venous oedema. The promise of surgical improvement may have inhibited the development of physical methods, but the results have been disappointing (Clodius and Gibson, 1982; F61di et al, 1989). Increased understanding of the detailed anatomy, physiology and pathophysiology of the lymphatic system has led to considerable progress in the physical therapy of lymphoedema, both in theory and practice (F61di, 1983, 1984, 1985; F5ldi and Kubik, 1989; F61di et al, 1989). These have now been collected into a regime sometimes called "complex decongestive physical therapy" (F61di 1985). We prefer to call it "complex physical therapy" (CPT), since "decongestive" is misleading in English. Complex physical therapy involves four aspects: (1) skin care and the treatment of any infection; (2) a special form of massage; (3) compression bandaging followed by use of a garment; (4) special exercises which supplement the massage.

The results achieved by this regime have been impressive (Ffldi, 1985; F61di et al, 1989). In 399 patients with no active malignancy, there was a reduction of more than 50% of the oedema in 56% cases, between 25 and 49% in 31% of cases, between 1 and 24% in 8% of cases, and no reduction or an increase in 5% of cases. Three years later, in 177 cases, 54% of cases had maintained the reduction, 35% had a non-significant increase, and 10% had a significant one. FSldi (1984) reports that after three courses, one per year, some patients with lymphoedema can even discard their compression bandages, since their lymphatic function has been improved sufficiently. This report covers the first "~8 lymphoedematous arms treated at the Adelaide Lymphoedema Clinic. The techniques were similar to those used at the F61di clinic, but with an improved exercise regime (Casley-Smith, 1989). Patients and methods

Of the 78 consecutive patients included in this study, 20 had lumpectomy, 24 mastectomy and 34 radical mastectomy. Radiotherapy had been used in all but eight cases. There was no selection except to ensure that there was no active malignancy. Their ages and the duration of lymphoedema are shown in Table 1. The grades used were those defined by the International Society for Lymphology (Casley-Smith et al, 1985). In brief, grade 1 has little fibrosis, pits readily and a substantial reduction can be achieved by simple elevation for some days; grade 2 has much fibrosis, does not pit and elevation causes little reduction. While limbs often vary from one part to another, these grades refer to an average over the whole. Before treatment any infection of the skin was treated. For a single lymphoedematous limb, the massage and Table 1--Ages of patients and durationof lymphoedema(years) Age.

Grade I Grade 2

437

Duration

Number

Mean

SD

Mean

SD

17 61

53.2 55.4

11.4 11.6

0.84 4.41

0.97 4.03

438

bandaging take about an hour. This is repeated five days out of seven for an average of four weeks. Most of the reduction occurs in the first one to two weeks. The massage is based on the concept of emptying the central regions first, to give the lymph from the periphery somewhere to go. First the lymphatics are emptied in the adjacent trunk and the two quadrants which border it, then the draining lymph nodes are emptied (if they still exist), and finally the limb is massaged. The lymph is moved proximally and, across lymphatic watersheds, into the nearest normally-drained lymphotomes (F61di and Kubik, 1989). The proximal region of the limb is always cleared first, then the massage is extended distally; effleurage which starts at the distal end, and attempts to push the lymph into the unemptied, proximal regions, is ineffective (F61di, 1984). Once a plateau in the reduction has been reached, the next two or three weeks' massage concentrates on enlarging the collateral lymphatics linking the obstructed lymphotomes to normal ones. In some patients, the movement of lymph along such enlarged collaterals becomes visible to the eye. Lymphatic massage was administered for 30 to 45 minutes, five days of the week. All patients performed exercises, specially designed to supplement the massage, every day for 30 minutes. Compression bandages were used at all times except during massage, and were also changed once over the weekend. Initially Tubigrip (Seton, UK) was used, but this proved far too weak to hold the reduction. Much better results were achieved using the low-elastic Comprilan (Beiersdorf, Germany) applied over padding (Artiflex Soft, Beiersdorf) and an undergauze (Tricofix, Beiersdorf). The treatment course usually lasted four weeks, but was extended by a few days in difficult cases. At the end of the course, patients were fitted with carefully measured compression garments, either ready-made (Sigvaris, Ganzoni, Switzerland), or made-to-measure (OPAL or Second-Skin, Australia). If the hands were swollen, compressive gloves or mittens were used (Jobst, USA; OPAL or Second Skin, Australia). It is necessary for the garments to apply compression of the order of 40 to 50 mmHg. Two additional therapies were used in some patients (oral benzo-pyrones or compression with a column of mercury). However the numbers using these are not yet sufficient to allow meaningful analysis, and they will not be discussed further. 51 of the 78 patients were available for re-examination and remeasurement about one year after the first course of complex physical therapy. 18 of these had a second course, which as identical to the first, and the remaining patients declined this, being satisfied with their improvement. Those patients who did have a second course tended to be those who were left with rather more residual oedema after the first course and the intervening period. Although measurements of circumference were made at least once a week to guide the therapist, we only report the initial and final measurements, together with those of the normal arm. These were made at the widest part of

T H E J O U R N A L OF H A N D S U R G E R Y VOL. 17B No. 4 A U G U S T 1992

the hand, the narrowest part of the wrist, and every 10 cm proximal to this. The volume of the arms has been estimated from these figures, using the formula for a truncated cone, taken from the radii of its two ends and the distance between them. This has been shown to be an accurate method of calculating the volume of a limb (Stranden, 1981). The normal limbs were measured similarly and the alterations in individual relative volumes were used to express the results. The amount of oedema was estimated, comparing the lymphoedematous limb to the normal one, in each case at various periods. The means are the results of calculations for each individual patient. The significance of differences of the means was evaluated using paired t-tests. Results

The progress of the first course of complex physical therapy is illustrated for a typical patient (Fig. 1). " Considerable reductions in the volumes of both her arm and forearm were achieved in the first three days, when only the trunk was being massaged, and not the arm or forearm. During this initial period the arm was of course bandaged, but massage was concentrated on the anterior and posterior aspects of the quadrant of the trunk adjacent to the lymphoedematous arm, the contralateral axilla and the ipsilateral inguinal region. Thus the banked-up lymph in the arm was given somewhere to go. Most of the reduction happened in the first ten days, with a smaller reduction containing through the remaining two-thirds of the course. During this time the therapist concentrated on opening and enlarging collaterals to carry lymph from the lymphotomes whose drainage was restricted to those with normal drainage. Upon these new pathways depends the ultimate success of the treatment. The results of the first course of complex physical therapy are shown in Table 2 and Figure 2. Both grades of lymphoedema were very significantly reduced. It was encouraging that those with grade 2 lymphoedema had even greater reductions than those with grade 1. These differences between the grades were highly significant (0.001 to 0.0001>P) and they are shown separately. Thus, the greater the oedema, the more it was reduced. All calculations were performed on each individual and then combined as the means shown in the Tables. Hence these means often differ from those obtained by performing the same calculations on the various mean results given in the table: e.g. in Table 2 the percentage alteration in oedema for grade 1 (-103.1%) is much greater than that which would be obtained by simply dividing the difference in lymphoedema/normal (-14.3%, in the line above) by the mean amount of oedema (120.9%-100%) derived from the initial percentage lymphoedema/normal (two lines above). This difference is particularly striking since many grade 1 arms were actually reduced to less than the normal arm. The most spectacular of these went from 102% to 92% of

PHYSICAL THERAPY OF LYMPHOEDEMA

439

60% % 50%

N

84iiiiiiiiiiiiiiiiii i

40%

0

r 30% m

a

...................... ~...................... . . . . . . . . . . . . . .

20%

I lO%

......................................................................................................................................................

0%

Normal 0

Fig. 1

...................... ~......................... ~........................

Days 5

10

15

20

25

30

Daily arm volumes of a typical patient aged 51, who had suffered from grade 2 post-mastectomy lymphoedema for 5.5 years. During the first three days the upper and lower arms were not massaged at all, yet their volumes reduced greatly; this is because the massage of the body adjacent to the lymphoedematous arm, the contralateral axilla and the ipsilateral inguinal region provided room for the banked-up l y m p h in the arm. It can be seen that most of the reduction occurred in the first 10 days. After this time, m u c h lesser reductions were achieved. However this period is vital for the ultimate success of the therapy in the opening-up of new collaterals.

Intermediate

Period

% 50% N 40% 0

r

3O%

iiii!ili i!filial filli lil

rn 20% a I lo%

"

"

~

- i - 0

Normal --

0 Fig. 2

10

20

30

n

40

50

60

M e a n values for all patients over 13 months. The upper set of lines (squares) refer to grade 2 lymphoedema, the lower (circles) to grade 1. The results of the first and second courses are shown in solid lines, on the left and right respectively, and those of the intermediate periods in dashed lines. The numbers of patients are shown for each period, together with the significances of the percentage alterations in oedema. Because lesser n u m b e r s of patients were in each succeeding group, their initial values are different from the final ones of the preceding group. It can be seen that well over half of the initial oedema was lost in the first course, that this loss was not only maintained but slightly increased during the intermediate period, and that half of the remainder was again lost during the second course.

440

THE JOURNAL OF HAND SURGERY VOL. 17B No. 4 AUGUST 1992

Table 2--Results of first course of complex physical therapy

Grade 1 (n= 17) Mean

SE

2292 2779 2458 - 322

172 237 222 60.2

Initial % lymphoedema/normal Final % lymphoedema/normal Difference in lymphocdema/normal (%)

120.9% 106.6% - 14.3%

3.75% 2.79% 2.94%

{95% confidence interals} % alteration in oedemab {95% confidence intervals}

{ - 8.54% to - 20. l~o} - 103% 1.96% { - 9 9 . 3 % to - 107~o}

Normal arm (ml) Initial lymphoedema (ml) Final lymphoedema (ml) Difference (ml)

Grade 2 (n=61) Sign

Mean

SE

Sign

*

2175 3317 2665 - 652

60.7 1l 3 94.0 51.5

**

*

153.2% 122.6% - 30.6~

3.37% 2.40% 2.45~0

{ - 25.8% to - 35.4%} -60.2% 1.21% { - 57.8% to -62.6%}

**

a The significance of the difference of a value from zero is shown after certain results; * 0.001 > P> 0.0001 ; ** 0.0001 > P. Wl'hesewere calculated from individual values ofoedema/normal and so their results can differ from the difference in lymphoedema and from difference in lymphoedema/ normal.

normal, i.e. a reduction of - 10% of the lymphoedematous arm compared with the normal, but of -417% of the oedema. By contrast, the worst case went from 216% to 199%: reductions of - 17% of the lymphoedematous arm/ normal and - 14% of oedema. However, the criterion by which the effect of any treatment for lymphoedema must be judged is the longterm result. It can be seen that the reductions achieved in the first course of complex physical therapy carried on for the next year (Table 3). There was a very significant decrease in the percentage of oedema of both the grade 1 and grade 2 patients. It was evident that Tubigrip is quite unsuitable as a compression garment since seven early patients with grade 2 lymphoedema had a 16% increase (SE 6.1%) using this, which was significantly worse than the results for the remaining patients (0.01 > P > 0.001). These are omitted from Table 3. Patients who had a second course tended to be those with less good results from the first course, or who had worsened over the intermediate period. This can be seen

from initial measurements in Table 4. However those with grade 2 lymphoedema had very significant percentage reductions. There were only two who had grade 1 so, while their reductions were similar, statistics could not be applied. Using the grade 2 figures one can conclude that over 50% of the oedema is removed in the first course, that this is largely maintained by the compression garment over the next year, and that over 50% of the remaining oedema is removed by the second course of CPT. Discussion Our results confirm those reported by F61di (1985) and F61di et al. (1989) and have been shown to last over a period of 12 months. The poor results using Tubigrip during the intermediate period reinforce how important it is to have adequate compression garments. We have found it essential to insist that the garments be worn at night. Because muscular contraction is all that powers

Table 3--Intermediate period, after complex physical therapy

Grade 1 (n=9) Mean

SE

2006 2092 2172 80.0

165 159 154 113

% lymphoedema/normal at start % lymphoedema/normal at 12 months Difference in lymphoedema/normal (~o)

104.8% 101.8% - 3.00%

2.87~o 3.36% 2.08%

{95% confidence intervals} ~o Alteration in oedema b {95% confidence intervals}

{1.08% to - 7.08~o} -33.8~o 5.39% { - 23.2% to - 44.4%}

Normal arm (ml) Lymphoedema at start (ml) Lymphoedema at 12 months (ml) Difference (ml)

Grade 2 (n=35) Sign

Mean

SE

Sign

n.s.

2148 2680 2648 - 32.1

68.2 117 115 49.1

n.$.

n.s.

124.1% 123.1% - 1.05~0

2.66~o 3.21~o 1.40~o

n.s.

*

{1.69~o to - 3.79~,} -9.63% 1.86% { - 5.98% to - 13.3%}

a The significance of the difference of a value from zero is shown after certain results; n.s. : P > 0.05; * 0.001 > P > 0.0001. bThese were calculated from individual values ofoedema/normal and so their results can differ from the difference in lymphoedema and from difference in lymphoedema/ normal.

PHYSICAL THERAPY OF LYMPHOEDEMA

441

Table 4---Results of second course of complex physical therapy

Grade 1 (n= 2) Mean

SE

2318 2631 2533 - 97.9

59.0 131 103 28.1

Initial % lymphoedema/normal Final % lymphocdema/normal Difference in lymphoedema/normal (%)

113.4% 109.3% - 4.19%

2.78% 1.67% 1.11%

{95% confidence intervals} % alteration in oedemab {95% confidence intervals}

{ - 2.01% to - 6.37%} -30.8% 0.89% { - 29.1% to - 32.5%}

Normal arm (ml) Initial lymphoedema (ml) Final lymphoedema (ml) Difference (ml)

Grade 2 (n= 16) Siga

Mean

SE 119 164

2480 n.s.

2191 2876 142 - 396

81.9

n.s.

132.7% 113.8% 18.9%

5.36% 3.43% 3.58%

*

Sig~

{11.9% to - 25.9%} -58.6% 2.21% { - 54.3% to 62:9%}

,The significanceof the differenceof a value from zero is shownafter certain results; n.s. : P> 0.05; *0.05> P>0.01 ; **0.001> P > 0.0001 ; ***0.0002 > P. bThesewerecalculatedfrom individualvaluesofoedema/normaland so their resultscan differfromthe differencein lymphocdemaand from differencein lymphocdema/ normal.

the initial lymphatics, and mostly powers the coUecting lymphatics, the relatively motionless time of sleep is the time when the garment is most needed to prevent swelling. If it feels too tight at night, a lower grade, or slightly larger, garment can be worn just for sleeping. Compliance is extremely important, and patients must be frequently encouraged by the therapist. They need to be continually reminded that they do have a limb which has poor lymphatic drainage and that any infection or trauma can make it much worse. They need to be encouraged to always wear the compression garment, and to renew it as necessary every few months, at least for the first year, until the new dimensions are established. They must be encouraged to continue with the special exercises and skin care. Finally, it was interesting to observe that ten lymphoedematous limbs were reduced to less than the normal limb. This has been noted by others (F61di, personal communication). Dominance was equally distributed and was therefore not the reason. The lymphoedematous arm is commonly used less than the other one, which might cause muscle wasting. On the other hand, the muscles also drain through the same set of lymph nodes (although not the identical nodes) that drain the superficial tissue. Lymphoedema of the latter, caused by interference with the set of nodes, would be likely to cause lymphostasis of the muscles also, with its attendant lack of oxygen and poor cellular function (Casley-Smith and Casley-Smith, 1986). However, the strong fascia would prevent real swelling. Hence concomitant lymphostasis of the muscles is a feasible alternative explanation. This needs to be explored by isotope lymphography since, if it exists, special procedures could be probably introduced to treat it.

Acknowledgements We are mostgrateful for the enthusiastic hard work by a number of therapists, particularly by D. H. Hall, MAPA, R. G. Heddle, MAPA and D. K. Milne, MAPA. We are also most grateful for financial and other support from the Lymphoedema Association of Australia.

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und Physiotherapeuter: mit Anhang, Praktische hinweise fftr die Physiotherapie. Stuttgart, Gustav Fischer, 1989. JAMAL, S., CASLEY-SMITH, J. R. and CASLEY-SMITH, JUDITH R. (1989). Effects of 5,6 benzo-[a]-pyrone (coumarin) & DEC on filaritic lymphoedema & elephantiasis in India: Preliminary results. Annals of Tropical Medicine and Parasitology: 83: 287-290. PILLER, N. B., MORGAN, R. G. and CASLEY-SMITH, J. R. (1988). A double-blind, cross-over trial of O-~-hydroxyethyl)rutosides (benzo-pyrones) in the treatment of lymphoedema of the arms and legs. British Journal of Plastic Surgery, 41 : 20-27. STRANDEN, E. (1981). A comparison between surface measurements and water displacement volumetry for the quantification of leg edema. Journal of the Oslo City Hospital, 31 : 153-155. VODDER, E. 0965). Lymph drainage ad modem Vodder. Eine neue Behandlungsart in der Chirotherapie zu aesthetischen, prophylaktischen und kurativen Zwecken. Aesthetic Medicine: 14: 190-191. WINIWARTER, A. Die Elephantiasis. In: Deutsche Chirurgie, Stuttgart, Enke, 1892: 23. Accepted:16March1992 Dr J. R. Casley-Smith,The HenryThomasLaboratory,Universityof Adelaide,Box 498 G.P.O.,Adelaide,S.A.5001,Australia. 9 1992TheBritishSocietyfor Surgeryofthe Hand