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American Cancer Society Lymphedema Workshop
Supplement to Cancer
The Treatment of Lymphedema
Ethel Földi,
Foldiklinik, Fachklinik für Lymphologie, Hinterzarten, Germany.
BACKGROUND. Before the treatment of arm lymphedema after breast carcinoma
treatment with complex decongestive physiotherapy can be initiated, it is mandatory to differentiate between benign and malignant forms (due to relapse) and to
establish the diagnosis of accompanying diseases, if present.
METHODS. In benign lymphedemas, the aim of complex decongestive physiotherapy is to restore the symptom free “Stage 0 of latency” and to maintain fitness for
work. The palliative treatment of malignant lymphedemas results in the amelioration of the quality of life.
RESULTS. The results of treatment depend on the experience of the physician in
clinical lymphology, on the training and dedication of the lymphedema therapist,
and on the compliance of the patient.
CONCLUSIONS. A study concerning gene expression has shown that complex
decongestive physiotherapy influences the pathological alterations of the interstitium in lymphedema patients. Cancer 1998;83:2833– 4.
© 1998 American Cancer Society.
KEYWORDS: lymphedema, complex decongestive physiotherapy, manual lymph
drainage, inflammation.
Presented at the American Cancer Society
Lymphedema Workshop, New York, New York,
February 20 –22, 1998.
Address for reprints: Ethel Földi, Prof., M.D.,
Földiklinik GmbH & Company KG, Fachklinik für
Lymphologie, Rosslehofweg 2-6, 79856, Hinterzarten, Germany.
Received July 2, 1998; accepted August 20, 1998.
© 1998 American Cancer Society
ymphedema is not a symptom, as other edemas are, but a disease,
arising as a consequence of a low output failure of the lymphatic
system. A rational therapy must be based on the knowledge of pathophysiology. Progress achieved in the fields of microcirculation and
molecular biology enables us to understand many aspects of those
morphologic and functional alterations that take place in the tissues
as a consequence of lymphostasis.
Due to the increase in the number of patients suffering from
lymphedema, the importance of clinical lymphology increases world
wide. There are several reasons for this: 1) There are more elderly
people. With age, the force of the lymph pumps decreases, and
lymphedema risk factors, such as heart failure, diseases of metabolism, and arthropathies, arise. 2) The progress in the treatment of
malignancies results in longer remissions and even in more patients
cured; however, as a side effect of the therapies, the cases of lymphedema of the head, limbs, and genitalia increase. The method of choice
for the treatment of lymphedema is complex decongestive physiotherapy (CDP).
CDP must be embedded into comprehensive medical care: the
majority of lymphedema patients suffer from one or even several
accompanying diseases. In addition, the results of CDP depend to a
very high degree on the stage at which the treatment begins. To
prevent harmful side effects, the constituents of CDP often have been
applied in a modified form.
Whether lymphedema is primary or secondary has no relevance
concerning CDP. Along with the question of accompanying diseases,
CANCER Supplement December 15, 1998 / Volume 83 / Number 12
the main problem is to distinguish between benign
and malignant lymphedema: The malignant forms are
caused either by untreated carcinoma or by a relapse
after carcinoma treatment.
CDP is a tetrade: Its constituents are manual
lymph drainage (MLD), skin care, compression, and
remedial exercises. MLD applied in an isolated form is
absolutely inadequate. In the drainage area bordering
the lymphostatic region, mild strokes are applied. The
aim is to stimulate lymphangiomotoric activity. Inside
the lymphedematous region itself, the strokes are applied with more pressure to limber up indurated tissues. Compression bandages are constructed in the
following manner: For skin protection, one pulls on a
cotton sleeve. One inserts upholstering materials with
either a smooth surface or a rugged surface followed
by textile elastic compression bandages.
By using remedial exercises, one activates the
muscle and the joint pumps. The aim of skin care is to
prevent mycotic and bacterial infections. Skin care
starts with hygienic measures. If necessary, disinfective agents are applied; eventually, antimycotics
and/or antiallergics are used. In addition to CDP,
other methods of physiotherapy often are applied to
mobilize joints, to improve the function of the muscle
and joint pumps, to rebuild muscles, or to alleviate
CDP is a two-phase treatment. The aim of phase
one is to mobilize edema fluid and to initiate the
regression of fibrosclerotic tissue alterations. During
phase one, the patients need both mentally and physical rest. Treatment must be applied at least once a
day and, eventually, twice a day. Uncomplicated cases
can be treated as outpatients, and more severe cases
are treated as inpatients. Phase two serves to prevent
the reaccumulation of edema fluid and to continue
the breakdown of the scar tissue.
Phase two is an outpatient treatment. Its main
constituent is compression by elastic stockings or
sleeves. Self-treatment includes skin care and remedial exercises; if necessary, MLD is applied. The intensity of application of the components of CDP in its two
phases depends on the stage of lymphedema at which
the treatment starts and on the nature and severity of
accompanying the disease.
The palliative treatment of malignant lymphedemas consists of the application of phase one of CDP.
In contrast to the treatment of benign lymphedema in
which diuretics have no place whatsoever, in malignant lymphedema, CDP often must be complemented
with diuretics. In contrast to benign lymphedema in
which CDP serves to maintain the patient’s fitness to
work, the role of CDP in the treatment of malignant
lymphedema consists in improving the quality of life.
The prerequisites of successful CDP are the following: 1) What concerns the physician, i.e., knowledge of lymphology and of the pathophysiology of
those diseases that are linked to disturbances of microcirculation. A thorough check-up and therapy of
accompanying diseases are mandatory. 2) Physiotherapists must be trained both by clinical lymphologists
and by experienced physiotherapists. They must have
a deep insight into anatomy and into the consequences of surgical and irradiation therapy of carcinoma. They must be aware of the contraindications of
CDP and its various modifications. 3) The materials for
bandaging and compression stockings, i.e., sleeves
made to measure, must be available in excellent quality. 4) Full compliance of the patient is mandatory. If
the patient is not ready to wear the compression
stockings, then relapse will occur. Also, if CDP fails,
the possibility of self-mutilation, which is by no means
rare, must be taken into consideration.
Unfortunately, there is a world wide ignorance
concerning the clinical symptomatology of lymphedema. Consequently, false forms of treatments are initiated. This statement can be illustrated by an example. A couple of days ago a 32-year-old man was sent
to me. His disease has been initiated by a minor accident involving the right hand while making pizza.
Soon, an elephantiastic, very painful lymphedema of
the right arm arose. Later on, both lower extremities
became lymphedematous as well. The diagnoses of
several doctors and hospitals included lymphedema of
the right arm, chronic pain syndrome, and generalized
reflectory sympathetic dystrophy syndrome.
The treatment consisted in the intrahecal application of morphine with a pump. Amputation of the
arm had been recommended. It was a case of selfmutilation: The young man constricted his limbs with
bands. His motive was to obtain an invalid pension.
I would like to stress that benign lymphedema
does not cause pain, and generalized reflectory sympathetic dystrophy syndrome does not exist. In this
case, CDP will not work; the patient must be entrusted
to a psychiatrist.
It is generally known that the tissue alterations
in lymphedema correspond to a chronic inflammation. In a clinical study not yet published, we have
shown that phase one of CDP of a duration of 4
weeks significantly reduces the gene expression of
CD14, VLA4, TNFR1, and CD44. This means that
CDP reduces or alleviates the chronic inflammatory
process. Our findings provide an explanation for the
regression of the fibrosclerotic tissue in the course
of phase two of CDP.
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