Complete Decongestive Therapy for Treatment of Lymphedema

Complete Decongestive Therapy for Treatment of Lymphedema

20 Seminars in Oncology Nursing, Vol 29, No 1 (February), 2013: pp 20-27 COMPLETE DECONGESTIVE THERAPY FOR TREATMENT OF LYMPHEDEMA BONNIE B. LASINSK...

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Seminars in Oncology Nursing, Vol 29, No 1 (February), 2013: pp 20-27

COMPLETE DECONGESTIVE THERAPY FOR TREATMENT OF LYMPHEDEMA BONNIE B. LASINSKI OBJECTIVES: To summarize current evidence on the management of lymphedema and to provide management recommendations.

DATA SOURCES: Eleven databases, including PubMed and CINAHL from 2004-2011.

CONCLUSION: Complete decongestive therapy (CDT) is effective in reducing lymphedema, although the contribution of each individual complete decongestive therapy component has not been determined. In general, levels of evidence for complete decongestive therapy are mid-level.


FOR NURSING PRACTICE: Oncology nurses and health care providers play key roles in assessing needs and prescribing interventions to support patients with lymphedema from admission to discharge. Reviewing risk-reduction strategies and supporting the patient with lymphedema to continue self-care when undergoing medical treatment empowers patients to be proactive in health maintenance. Identifying potential problems and making appropriate referral to a lymphedema specialist avoids triggering or worsening lymphedema.

KEY WORDS: Lymphedema, systematic review, complete decongestive therapy, manual lymphatic drainage, oncology nursing

YMPHEDEMA (LE) manifests as swelling of the soft tissues resulting from the accumulation of protein-rich fluid in the extracellular spaces, which is caused by decreased lymphatic transport capacity and/or increased lymphatic load. It is classified as either


primary or secondary. Primary LE is the result of lymphatic malformation and can present at birth or many years later. Secondary LE is caused by damage to or removal of lymphatic vessels and/ or nodes during surgery, radiation treatment, trauma, burns, infection; or overload of the

Bonnie B. Lasinski, MA, PT, CI-CS, CLT-LANA: Lymphedema Therapy and The Boris-Lasinski School, Woodbury, NY. Address correspondence to Bonnie B. Lasinski, Clinical Director, Lymphedema Therapy, 77 Froehlich

Farm Blvd Woodbury, NY 11797. e-mail: blasins@ Ó 2013 Elsevier Inc. All rights reserved. 0749-2081/2901-$36.00/0.


lymphatic vessels because of increased lymphatic load from co-morbid conditions that cause edema, such as chronic renal failure, congestive heart failure, liver failure, or chronic venous insufficiency. The most common causes of secondary LE in the Western world are surgery and radiation therapy, which are used to treat cancer. LE most commonly affects the extremities but can occur in the head, neck, torso, abdomen, and genitalia. As LE progresses, fibrocytes and/or adipocytes proliferate in the affected areas, leading to changes in the texture of the skin and subcutaneous tissue and an increased vulnerability to bacterial and fungal infections. The severity of LE is graded using the scale from the International Society of Lymphology: Stage 0 or latent LE, Stage I, Stage II, and Stage III lymphostatic elephantiasis (see Table 1 in article by Bernas elsewhere in this issue).1 The time to the onset of secondary LE after the initial damage to the lymphatic system varies from the immediate postoperative period to months and even years later. It is in this period of ‘‘latency’’ where there is lymph stasis but no apparent clinical swelling that adherence to LE risk-reduction guidelines is critical to avoid triggering events that may incite LE in the person at risk.

SYSTEMATIC REVIEW SUMMARY FOR MANAGEMENT OF LE A team of clinicians and researchers reviewed the current literature on complete decongestive therapy (CDT) on behalf of the American Lymphedema Framework Project. The objectives of the American Lymphedema Framework Project are to provide evidence of the best practice of LE care, to assist in establishing guidelines for the management of LE, and to increase awareness of this condition in the United States and worldwide through an extension of the International Lymphoedema Framework’s Best Practices Document.2 Altogether, 99 articles related to LE treatment were reviewed. Twenty-six studies met inclusion criteria for individual studies.3-28 In addition, one article that did not meet study size inclusion criteria,29 along with 14 review articles30-43 and two consensus documents1,2 were included. Information on study design/objectives, participants, outcomes, intervention, results, and study strengths and weaknesses was extracted from each article. Study evidence was categorized according to the


Oncology Nursing Society Putting Evidence into Practice level of evidence guidelines after achieving consensus among all authors. The level of evidence for each study was assessed using the research grading system from the Oncology Nursing Society Putting Evidence into Practice level of evidence guidelines (Table 1).44 Fifteen articles were scored as ‘‘Likely to be effective’’ (according to Putting Evidence into Practice classification).3-17 Two articles were scored as ‘‘Benefits balanced with harm.’’18,19 Ten articles were scored as ‘‘Effectiveness not established.’’20-29 Based on these findings, the following clinical implications were developed.

COMPLETE DECONGESTIVE THERAPY Complete decongestive therapy is currently recognized as the standard of care in LE treatment.1,42,45 Ideally, the initial intensive phase of CDT is performed daily until maximal volume reduction and normalization of tissue texture is achieved.45 CDT consists of: 1) an average of 60 minutes of manual lymph drainage (MLD) – a specialized gentle massage to stimulate the lymphatic system; 2) multilayer, short-stretch compression bandaging (CB) with foam or layers of fabric padding of the affected limbs – also known as multilayer limb bandages or CBs; 3) exercises to enhance lymphatic pumping; 4) meticulous skin care of the affected areas; and 5) fitting of appropriate compression garments to maintain the reductions achieved through treatment. Head and neck, truncal, and genital LE present unique challenges for the application of compression. Patient education in self-care, risk reduction, and the importance of adherence to daily exercise, selfMLD, and compression garment wear are critical for successful long-term treatment outcomes.46,47 Manual Lymph Drainage The original manual techniques known as MLD were developed in 1936 by Emil Vodder. The four basic hand strokes used in MLD consist of intermittent, gentle pressure applied directly on the skin to stretch the very small initial lymphatics, increasing lymphatic vessel contraction, and lymph drainage from the affected area.4 MLD has been shown to stimulate lympholymphatic or lymphovenous anastomoses,31,45 as well as providing symptom reduction not achieved by compression alone or the other components of CDT.9,19,23,24,26,27 This finding was demonstrated in a study that compared



TABLE 1. Putting Evidence into Practice (PEP) Weight of Evidence Classification Schema Weight-of-Evidence Category Recommended for practice

Likely to be effective

Benefits balanced with harms

Effectiveness not established



Effectiveness is demonstrated by strong evidence from rigorously designed studies, meta-analyses, or systematic reviews. Expected benefit exceeds expected harms.


Effectiveness has been demonstrated by supportive evidence from a single rigorously conducted controlled trial, consistent supportive evidence from well-designed controlled trials using small samples, or guidelines developed from evidence and supported by expert opinion. Clinicians and patients should weigh the beneficial and harmful effects according to individual circumstances and priorities. Data currently are insufficient or are of inadequate quality.






Effectiveness unlikely

Not recommended for practice

Lack of effectiveness is less well-established than those listed under not recommended for practice.


Ineffectiveness or harm is clearly demonstrated, or cost or burden exceeds potential benefits.




At least two multisite, well-conducted, RCTs with at least 100 subjects Panel of expert recommendation derived from explicit literature search strategy; includes thorough analysis, quality rating, and synthesis of evidence One well-conducted RCT with <100 patients or at one or more study sites Guidelines developed by consensus or expert opinion without synthesis or quality rating

RCTs, meta-analyses, or systematic reviews with documented adverse effects in certain populations Well-conducted case control study or poorly controlled RCT Conflicting evidence or statistically insignificant results Single RCT with at least 100 subjects that showed no benefit No benefit and unacceptable toxicities found in observational or experimental studies No benefit or excess costs or burden from at least two multisite, well-conducted RCTs with at least 100 subjects Discouraged by expert recommendation derived from explicit literature search strategy; includes thorough analysis, quality rating, and synthesis of evidence

Abbreviation: RCT, randomized controlled trial. Reprinted with permission by the Oncology Nursing Society.44

intermittent pneumatic compression and MLD for post-mastectomy LE. Both interventions reduced swelling, but subjects reported a decrease in the feeling of heaviness and tension in the swollen arm/hand with MLD but not with intermittent pneumatic compression.36 The evidence from the systematic review showed the value of MLD when combined with CB in treating LE.8,12,14,15,22,24,26,27,31 The evidence did not support using MLD alone for the purpose of limb volume reduction independent from CDT. However, Moseley et al,39 reported that MLD alone did contribute to improvement in self-reported symptoms when used in the palliative care setting.2,42

In a summary, of 3 years of treatment data collected from patients with LE after breast cancer treatment (n ¼ 168), breast edema reduction was noted when MLD was performed.10 Others have suggested that MLD may be the best intervention possible for LE of the head and neck, genital, or breast, as well as in palliative care situations when compression by bandaging or garments is not well tolerated or not possible.2,42 Compression Bandaging Multilayer, short-stretch CBs applied to the lymphedematous extremity following MLD help maintain the edema reduction achieved through the lymphatic drainage.45,46 CB creates an increase


in interstitial tissue fluid pressure and lymph uptake to prevent the refill in the tissue spaces that have been cleared by MLD.45 Short-stretch CBs exert a relatively low restingpressure on the limb at rest and are less likely to impinge into the limb at skin folds or joints than more elastic long-stretch bandages typically used for sprains or sport injuries. Conversely, when the limb is in motion and muscles are contracting, short-stretch CBs maintain their integrity as the muscles contract against the bandages and provide a semi-rigid support structure for the muscles to contract against (high working pressure), enhancing lymph pumping/flow and venous flow, reducing capillary filtration, resulting in further edema reduction.41,45 One study compared CB followed by compression garments versus compression garments alone to treat limb LE. Volume reductions for the group receiving CB followed by wearing compression garments were double that of the group wearing only compression garments,4 highlighting the importance of knowing the efficacy of available treatment options for patients with LE who may be prescribed a compression garment as the sole ‘‘treatment’’ for their LE. Following the initial treatment course of CDT, most individuals wear a compression garment during the day to maintain adequate compression on their lymphedematous limb(s). The evidence reviewed for the systematic review on adherence with nighttime CB and daytime compression garment wear suggests that maintenance of LE reductions achieved through CDT is directly correlated with level of adherence to compression.15,19,22,46 Knowledge of a patient’s individual LE management program, including the type of compression garments worn, duration of wear, and exercises/ self-MLD regimen provides valuable information to assist oncology nurses to incorporate these selfcare activities into an individualized nursing care plan. This information guides the oncology nurse in formulating a patient discharge plan in terms of need for home care assistance or referral to a LE specialist for assessment of possible modifications to compression garments/exercises as needed.

APPLICATION OF EVIDENCE TO THE CLINICAL SETTING Consider the following patient scenarios involving risk or presence of cancer-related LE. A 60-year-old woman who is a 10-year survivor


of a right-sided breast cancer that was treated with a lumpectomy and axillary lymph node dissection is hospitalized for the treatment of a deep vein thrombosis (DVT) in her left leg that requires intravenous heparin therapy. Following the standard risk-reduction guidelines, the intravenous line should be placed in the left arm and the right arm should not be used for finger sticks or blood pressure, if possible, because the right upper extremity is at risk for LE, even though the lymph node dissection was performed 10 years earlier. In addition, this patient is also now at risk for LE in her left leg, which can occur in the setting of post-thrombotic syndrome. A review of the signs and symptoms of LE with the patient, which can develop secondary to venous insufficiency or post-thrombotic syndrome in the leg, will assist the patient in seeking medical assessment early if symptoms occur to avoid further complications. Patients with lower-extremity LE hospitalized with DVT are often unsure of whether or not to apply CBs/garments to their affected leg. Partsch et al41 reported that CB (50 mmHg) in the bedbound patient and compression stockings (23-32 mmHg) in the ambulatory patient reduced the incidence of post-thrombotic syndrome and also relieved pain and swelling. Shrubb and Mason43 reviewed studies on DVT and LE and concluded that it was reasonable to continue compression in patients with LE and DVT to avoid worsening of the LE, as well as the associated physical and psychological problems. The oncology nurse can initiate a dialogue with the treating physicians and LE specialist regarding whether and when this patient should have CBs/garments applied to the limb being treated for DVT. Addressing this in the nursing care and discharge plans provides the patient with resources for follow-up, reducing the risk for additional complications post- discharge. If the same patient presented with LE in her right upper extremity, it would be important to know how she manages her LE. Does she wear a compression glove and sleeve regularly? Does she use a different device for night compression? Does she bandage her right hand/arm at night with short-stretch CBs? Does she need assistance with this while in the hospital? Does she perform self-MLD? Has she experienced a worsening of her swelling recently? Does she need to contact her LE specialist to be reassessed during and/or after this hospitalization? This information should be included in her nursing care plan. Providing



support and helping the patient to review her selfcare program, as well as assisting the patient with referral to a LE specialist if needed, may prevent acute worsening of the patient’s LE while she is hospitalized for an unrelated problem. Encouragement should be provided for the patient to check the skin of the affected limb(s)/torso twice daily for any cuts, abrasions, signs of redness, heat, or increased swelling that could signal the onset of an infection (cellulitis/lymphangitis) requiring antibiotic treatment, unrelated to the primary diagnosis of DVT. Meticulous skin hygiene in the at-risk/affected limbs should also be stressed to avoid infection for people with LE who have impairment in their immune function. People with LE may have alterations in skin integrity, increasing their infection risk. If they are receiving chemotherapy, this further reduces their ability to fight infection. Hospital staff must assist patients and visitors to be vigilant with infection control practices to reduce the risk of nosocomial infections. While waterless cleaners are convenient, their high alcohol content can dry the already fragile skin of a limb with LE. Patients with LE should also be reminded to avoid washing their affected limb(s) with either very cold or hot water and when toweling dry, and to use the towel to massage the skin gently in the direction of lymphatic flow.48 Another consideration is that moisturizer should be within easy reach at the bedside as supple skin is less likely to chap and crack, which could allow bacteria to enter a break in the skin and cause an infection in the limb at risk for or with LE.1,2 Patient teaching regarding a skin care routine will ensure that appropriate moisturizer is applied to the at-risk or affected limb(s). If the patient needs assistance, follow the anatomy and principles of MLD in CDT, apply the moisturizer with gentle pressure from distal to proximal on the extremity, stroking in one direction from the periphery to the proximal part of the limb (see Fig. 1). Patients with or at risk for lower extremity LE should be reminded not to walk barefoot at any time to reduce the risk of injury/infection of the feet or toes. Proper toe and foot hygiene is essential for individuals with or at risk for lower extremity LE. People with lower extremity LE are often unaware that they have cracks in the skin between their toes from fungal infection that are often the cause of a seemingly ‘‘unexplained’’ cellulitis infection. Individuals who are obese may develop fungal maceration in the skin

FIGURE 1. Moisturizer is applied in the direction of lymph flow, from distal to proximal.

folds under the breasts, below an abdominal pannus, or in the groin. The oncology nurse is poised to review the importance of skin inspection, foot and toe hygiene, and to suggest referral to a podiatrist for assessment of fungi such as tinea pedis and onchomycosis, as well as to stress the importance of taking the full dose and course of antibiotics prescribed for cellulitis, both oral and topical (if prescribed) to avoid recurrence of infection. The signs and symptoms of cellulitis or infection (redness, swelling, pain, warmth of skin, sometimes accompanied by fever and chills) should be reviewed with the patient. If future episodes of cellulitis occur, patients should seek immediate medical attention and delineate the areas of redness on their skin to mark the borders of the infection (see Figs. 2 and 3). Observing the regression or progression of the area of redness (as well as reduction in fever, pain, acute swelling) will help medical staff to monitor the efficacy of the prescribed antibiotic treatment. These simple strategies empower patients to be an active partner in their own care. Occasionally, lymph fluid may leak from the skin (lymphorrhea) or from blisters/pimples on the skin that erupt during


FIGURE 2. Cellulitis in a patient with breast -cancer lymphedema in the left upper extremity. Progression of infection is marked in black. an episode of infection. Adhesive, even from paper tape, can further damage delicate skin, so care should be taken to secure any gauze or dressings on the affected area taping the gauze to itself, not to the patient’s skin. Patients who have undergone surgical treatment and/or radiation therapy to the pelvis (eg, gynecologic and urologic tumors) may develop blisterlike papules on the skin of their genitals, buttocks, or inner thighs. These papules may also leak lymphatic fluid if they open, leaving a portal of entry for bacteria that often causes a cellulitis infection. These infections can be difficult to resolve, given the moist environment of the perineum and the high risk for contamination from fecal bacteria. Many patients who have these

FIGURE 3. Cellulitis in a patient with lymphedema of the left lower extremity, secondary to pelvic node dissection to treat ovarian cancer. Cellulitis was triggered because of cracks between the toes associated with tinea (fungal) infection.


papules often suffer in silence because they are embarrassed and show them to their health care providers only if they are asked. Checking for these papules should be a routine part of skin inspection in the patient who is at risk for LE secondary to surgery or radiation in the groin, pelvis, or lower abdominal region. The patient may present for another reason, months or years after initial treatment for cancer, perhaps for an acute bowel obstruction related to scar tissue from cancer treatment or for dehydration related to radiation-induced colitis. Whatever the reason for the admission, the focus may not be on extremities or genitals per se. The astute clinician can identify this potential problem and assist the patient with proper perineal cleansing by providing a peri bottle to rinse the area after voiding or a bowel movement to avoid breaking the papules from friction from wash cloths or paper towels, reducing the risk for infection. Special care should be taken with the bedpan after each use and sanitizing wipes should be available for the toilet seat if the patient shares a bathroom with another patient. Although there are no studies examining the efficacy of education in proper hygiene and skin care in the patient with LE, LE practitioners continue to emphasize this component of CDT with their patients and report anecdotal evidence of reduction in the frequency and severity of cellulitis in patients with a history of recurrent cellulitis before undergoing CDT.49

CONCLUSION Evidence from the systematic review concluded that CDT is effective and has a positive impact on the quality of life in patients with varying severities of LE, whether early or late onset, and in patients with active cancer, in the palliative care setting. Continued compression of the affected area is required to maintain treatment results. The effects of CB are enhanced by adding MLD, which has been shown to provide symptom relief and reduction in breast and truncal LE. The contribution of each individual component of CDT to achieving good outcomes is not clear and further research is needed to determine optimal treatment protocols and home programs to maintain or improve treatment outcomes. The oncology nurse plays a key role in assessing the oncology patients’ function, critical care needs, and planning interventions needed to support the



patient from the time of admission to discharge. As frontline educators of oncology patients and their families, nurses play a critical role in supporting these patients at risk for or living with LE by recommending risk-reduction strategies and (where applicable) adherence to self-care programs, particularly wearing their prescribed compression garments and performing their lymphatic exercises and self-MLD and referring to a LE specialist when indicated. Fortunately, more people are cancer

survivors and living many years, but with a lifelong risk of developing LE from surgery and/or radiation treatment to regional lymph node basins. The oncology nurse has the opportunity to utilize the practical applications of the evidence for CDT when intervening in the continuum between surgery and/or radiation and end of life, and can assist patients in reducing their risk for LE or minimize worsening of pre-existing LE while they receive needed medical care.

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