Consultant – Orthopaedic Surgeon
Speciality interests include:
Lower extremity: trauma, sports surgery, knee, patella dislocation, tendon problems, foot and ankle surgery, and the management of degenerative joint disease in younger patients.
Visiting on Sep 21-22, 2019Request an Appointment
Complete Decongestive Therapy (CDT), also called complex lymphatic therapy, is considered as standard care for many types of lymphedema (swelling caused by a compromised lymphatic system, LE) management. The four components of CDT are manual lymphatic drainage (MLD), compression therapy, lymph-reducing exercises and skin care. CDT is usually initiated as two phases: phase 1, the intensive CDT, indicated for moderate to severe lymphedema, and phase 2, the modified CDT, for mild or moderate lymphedema. In phase 1, the goal is to reduce the swelling through MLD and compression bandaging. The therapist also instructs the patient on good skin care practices to ensure the skin remains healthy and free of infection and prescribes specialized lymph-reducing exercises. In phase 2, after the limb is sufficiently reduced in volume, the patient is then fitted with a compression garment. The goal of this phase is to maintain the volume reductions achieved in phase 1 through self-administered compressive therapy, lymph-reducing exercises, and self-lymphatic drainage.
Manual lymphatic drainage
Manual lymphatic drainage is a specialized manual therapy based on the anatomy of the lymph system. It is a gentle massage technique that reduces swelling by stimulating resorption of lymph by the lymph capillaries and improving fluid removal from congested areas and thus helping to drain the lymph into functioning lymph vessels and lymph nodes. The ability of MLD to reduce lymphatic swelling has been well demonstrated.
Compression therapy helps to reduce the fluid by decreasing its formation and preventing lymph backflow into the areas that surround the cells (interstitial space). Compression also assists the pumping action of muscles by creating a resistance against which muscles can work. This is called the “muscle pump” effect.
In phase 1 of the CDT, the compression therapy is usually done using multi-layered compression bandaging. In phase 2 it is designed to maintain the volume reductions from the first phase, which may be achieved by using a compression sleeve or custom-fitted garment, that is worn during the day. Compression garments should be replaced every 4 to 6 months, or when they begin to lose their elasticity.
Lymph-reducing exercises aim specifically at promoting lymph flow and reducing swelling. These exercises involve active, repetitive, non-resistive motion of the involved body part and, always done with compression on the involved extremity. The compression allows the muscles to contract against resistance creating a more effective “muscle pump” which enhances lymphatic and venous return.
Studies demonstrate that slow, progressive resistance exercise with weight-lifting is likely to be effective in reducing the risk of lymphedema symptoms and progression, and in increasing overall strength in breast cancer survivors. Studies examining aerobic and resistance combination exercises also report no increase in LE and appear safe. Finally, a growing body of evidence suggests that exercise does not exacerbate or trigger BCRL.
Rehabilitative and exercise interventions have shown benefit to patients with BCRL; however, programs must be structured according to the abilities of each patient, with close monitoring to ensure safety and standardization.
People with BCRL are at increased risk of skin inflammation and infection because the swelling from BCRL stretches the skin, putting it at increased risk of injury. Furthermore, the high protein content of lymphatic fluid serves as a medium where bacteria may thrive, causing a skin infection known as cellulitis. Cellulitis can spread to deeper tissues and/or systemically through the body.
The skin care education includes hygiene, moisturizing, keeping the skin supple and protected from breaks and tears, avoidance of constriction from blood pressure cuffs and the use of pH-neutral creams or lotions to discourage bacterial colonization.
Additional patient education should also include nutritional information and strategies to promote optimal weight management as another means of preventing lymphedema development and progression.
CDT showed an effective reduction in lymphedema, pain, and a significant improvement in function and should be administered by a speciality- trained therapist with the goal of reducing swelling and fibrosis in the affected area.