Management of Lymphedema
The recommended management plan for lymphedema should include complete decongestive therapy (CDT) as the primary treatment approach, consisting of manual lymphatic drainage, compression therapy, exercise, skin care, and education for self-management. 1, 2
Diagnosis and Assessment
- Assess patients for symptoms of lymphedema including swelling, heaviness, and numbness to facilitate early diagnosis 3
- Perform physical examination to evaluate for fibrosis, pitting, and overall tissue quality, including the Stemmer sign test 3
- Use circumferential measurement or bioimpedance analysis (BIA) to diagnose and monitor lymphedema 3
- Regular examination is required even among patients without lymph node dissection (e.g., en-bloc-resection, bowel resection) 1
Treatment Algorithm
Step 1: Initial Management and Referral
- Refer patients with clinical symptoms or swelling suggestive of lymphedema to a specialized therapist knowledgeable about lymphedema diagnosis and treatment (physical therapist, occupational therapist, or lymphedema specialist) 1, 4
- Early detection and intervention are critical as lymphedema may be reversible or more effectively managed with early physiotherapy 1, 4
Step 2: Complete Decongestive Therapy (Phase I)
Implement complete decongestive therapy consisting of: 2, 5, 6
- Manual lymphatic drainage (MLD)
- Short-stretch compression bandaging
- Decongestive exercise
- Skin care
- Patient education
The principle of treatment is decongestive therapy with physiotherapy and compression therapy that must be regularly repeated to maximize treatment effect 1
CDT has demonstrated mean reductions in limb volume of 42-44% in the short term 7
Step 3: Self-Management (Phase II)
- Transition patients to home-based self-management with appropriate education 5, 6
- Self-management includes continued compression therapy, skin care, exercise, and self-manual lymphatic drainage 5
- Long-term follow-up shows sustained volume reductions of 38-41% when patients adhere to self-management protocols 7
Risk Reduction and Prevention
Counsel patients on risk reduction strategies: 1, 4
- Weight management for patients who are overweight or obese
- Regular physical activity
- Infection risk minimization
- Prompt treatment of infections with antibiotics
Supervised, progressive resistance training is safe and may be beneficial for patients with lymphedema or at risk for developing it 4, 8
Advanced Treatment Options
- If conservative treatment is not sufficient, consider referral for microsurgical procedures, which have shown to be an effective treatment method 1
- Intermittent pneumatic compression (IPC) devices may be used as an adjunctive therapy, particularly for home management 5
Special Considerations
- For neuropathy associated with lymphedema, consider supportive care such as physiotherapy, physical activity, referral to podiatrists, patient education (adequate footwear), acupuncture, and support in daily activities 1
- For pain management related to lymphedema, vitamin B supplementation can be considered, and patients with chronic pain may be referred to a neurologist 1
Common Pitfalls to Avoid
- Delaying treatment can lead to progression of lymphedema and increased risk of complications 4
- Using diuretics is generally ineffective for lymphedema management 4, 8
- Contrary to historical advice, complete avoidance of physical activity and heavy lifting with the affected limb is not necessary; supervised progressive resistance training has been shown to be safe 1, 8
- Poor patient compliance with time-consuming, technique-dependent home care regimens can result in losing gains achieved in the clinic 5
By following this comprehensive management approach, patients with lymphedema can experience significant reduction in swelling, improved function, and enhanced quality of life.