duration (2–3 days to 4 weeks), depending on the practitioner
(93–96).
Pneumatic compression, with and without physical therapy,
has been shown to decrease lymphedema (97,98). In one study
(95), an intensive 4-week multimodal treatment program—
consisting of massage, sequential pneumatic compression, and
compression bandaging, along with patient education in selfmanagement
skills of bandaging, massage, and exercise—for
patients with lymphedema secondary to breast cancer treatment
decreased the degree of lymphedema and the need for physical
assistance and increased the perceived comfort and strength of
the extremity and quality of life. Although intermittent pneumatic
compression is often used, a number of issues about its use
remain to be resolved, including the optimum amount of pressure,
the most efficacious treatment schedule, and whether maintenance
therapy is needed after the initial reduction of edema
(83). In addition, a consensus statement (99) recommends that
the use of compression pumps be avoided in the absence of a
multidisciplinary treatment program for lymphedema.
Complex physical therapy (also known as complex decongestive
therapy, complex lymphedema therapy, multimodal
physical therapy, complex decongestive physiotherapy, and
complete decongestive physiotherapy), which consists of skin
care, manual lymphedema treatment, exercises, and compression
wrapping, followed by a maintenance program and psychosocial
rehabilitation, has been recommended as a primary treatment by
consensus panels (74,83,100) and is an effective therapy for
lymphedema unresponsive to standard elastic compression
therapy (87,101–106). Complex physical therapy resulted in
some volume reduction of the affected extremity in 95% of 399
patients (50% reduction in 56% of patients, 25%–49% reduction
in 31%, and 1%–24% reduction in 8%), 54% of whom
maintained the therapeutic result at 3 years (87).
Surgical interventions, although rarely used, include liposuction,
superficial lymphangiectomy, fasciotomy, and microsurgical
lymphatico-venous anastomoses (107,108).
Many authorities, including two consensus panels (21,99),
advocate the use of a multidisciplinary treatment program for
lymphedema management. For example, Brennan and Miller
(83) advocate a treatment plan that includes addressing infection,
limitations in range of motion, impairment in activities of
daily living, and psychological issues in addition to providing
therapies aimed at reducing the amount of edema.
The literature seems to be clear on the efficacy of nonpharmacologic
treatment. While the exact measure of outcomes of
nonpharmacologic treatment for edema varies from study to
study, most studies have used some variation on the percentage
of reduction in limb volume or circumference and show fairly
dramatic improvement with reductions of 15%–75% in volume
or circumference. Although not all of the studies differentiated
grades of edema, every indication is that both more and less
severe cases showed improvements.
The largest number of studies described the efficacy of complex
physical therapy, although all were cohort studies that
evaluated patients before and after therapy. The three randomized
control trials each evaluated a different mode of therapy and
studied fewer than 100 patients. There is clearly a need for large
randomized control trials to determine the relative efficacy of
interventions (both individually and in combination), the optimal
timing for the institution of various treatment modalities, and the
effect of treatment on disease progression (99).
duration (2–3 days to 4 weeks), depending on the practitioner(93–96).Pneumatic compression, with and without physical therapy,has been shown to decrease lymphedema (97,98). In one study(95), an intensive 4-week multimodal treatment program—consisting of massage, sequential pneumatic compression, andcompression bandaging, along with patient education in selfmanagementskills of bandaging, massage, and exercise—forpatients with lymphedema secondary to breast cancer treatmentdecreased the degree of lymphedema and the need for physicalassistance and increased the perceived comfort and strength ofthe extremity and quality of life. Although intermittent pneumaticcompression is often used, a number of issues about its useremain to be resolved, including the optimum amount of pressure,the most efficacious treatment schedule, and whether maintenancetherapy is needed after the initial reduction of edema(83). In addition, a consensus statement (99) recommends thatthe use of compression pumps be avoided in the absence of amultidisciplinary treatment program for lymphedema.Complex physical therapy (also known as complex decongestivetherapy, complex lymphedema therapy, multimodalphysical therapy, complex decongestive physiotherapy, andcomplete decongestive physiotherapy), which consists of skincare, manual lymphedema treatment, exercises, and compressionwrapping, followed by a maintenance program and psychosocialrehabilitation, has been recommended as a primary treatment byconsensus panels (74,83,100) and is an effective therapy forlymphedema unresponsive to standard elastic compressiontherapy (87,101–106). Complex physical therapy resulted insome volume reduction of the affected extremity in 95% of 399patients (50% reduction in 56% of patients, 25%–49% reductionin 31%, and 1%–24% reduction in 8%), 54% of whommaintained the therapeutic result at 3 years (87).Surgical interventions, although rarely used, include liposuction,superficial lymphangiectomy, fasciotomy, and microsurgicallymphatico-venous anastomoses (107,108).Many authorities, including two consensus panels (21,99),advocate the use of a multidisciplinary treatment program forlymphedema management. For example, Brennan and Miller(83) advocate a treatment plan that includes addressing infection,limitations in range of motion, impairment in activities ofdaily living, and psychological issues in addition to providingtherapies aimed at reducing the amount of edema.The literature seems to be clear on the efficacy of nonpharmacologictreatment. While the exact measure of outcomes ofnonpharmacologic treatment for edema varies from study tostudy, most studies have used some variation on the percentageof reduction in limb volume or circumference and show fairlydramatic improvement with reductions of 15%–75% in volumeor circumference. Although not all of the studies differentiatedgrades of edema, every indication is that both more and lesssevere cases showed improvements.The largest number of studies described the efficacy of complexphysical therapy, although all were cohort studies thatevaluated patients before and after therapy. The three randomizedcontrol trials each evaluated a different mode of therapy andstudied fewer than 100 patients. There is clearly a need for largerandomized control trials to determine the relative efficacy ofinterventions (both individually and in combination), the optimaltiming for the institution of various treatment modalities, and theeffect of treatment on disease progression (99).
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