CDT Archives - Lymphedema Therapy Source

The past two months we reviewed compression pumps. Pumps can be an adjunct to therapy maintenance.⁶ But pump use shouldn’t be a standalone plan for lymphedema treatment or maintenance. What is the recommended maintenance program for lymphedema?

Phase I: Decongestive Lymphedema Treatment

First, a person should complete phase I (decongestion) which involves complete decongestive therapy (CDT). CDT is composed of:

manual lymph drainage
multi-layer short-stretch bandaging
skin care
decongestive exercise.

Duration

The duration of this phase depends on the severity of lymphedema. It also depends on the frequency of treatment (which should be daily & bandages should remain on until the next therapy session).⁴ And it depends on comorbidities (such as vein disease, heart failure, renal failure, etc.) being diagnosed & properly treated.⁵

If a person is in stage I lymphedema, CDT generally lasts about 2 weeks. If stage II lymphedema (depending on how advanced within stage II), CDT lasts approximately 4-6 weeks. If stage III lymphedema, CDT may last 6-8 weeks or more (& it’s recommended to be treated several times a day according to Foldi).¹Below is a reference for the stages.

Lymphedema Stages

Stage I (the reversible stage) – It’s caused by accumulation of interstitial (lymph) fluid.² And it’s characterized by pitting edema & reduction in swelling with elevation. There isn’t usually pain in lymphedema,³ but there may be pain in this stage associated with early congestion.
Stage II (the spontaneously irreversible stage) – It’s caused by excess growth of connective (scar) tissue. It’s characterized by fibrosis & fat tissue growth. The swelling becomes more hard & doesn’t go down with elevation. There may be discoloration (brownish discoloration) to the involved tissue.
Stage III (elephantiasis) – It’s caused by the accumulation effect of stage II leading to extensive fibrosis & fat tissue growth. There are deep creases, fungal infections, recurrent cellulitis infections & some people may even become immobile.

In my experience, people get tired of bandaging after 2 weeks. They often seek shortcuts. For example:

– ending therapy before fibrosis is adequately reduced (note: some fibrosis will likely persist if a person initiates therapy during stages II or III of their lymphedema)⁷
– removing bandages before the next session
– using only (1) set of bandages, not washing bandages between sessions for better recoil & compression
– canceling a session here & there, missing consistent daily treatment.

These behaviors impact outcome. Of course, there can also be other “hiccups” during therapy. For example, a pressure wound develops & must be addressed, compression slips down between sessions or gets wet during toileting or bathing. These events are more likely when people aren’t treated as they are in Germany (i.e. inpatient hospitalization with focused, daily lymphedema therapy).⁸ Sometimes things just happen. But these events can prolong phase I & expectations should be clear in advance to avoid added disappointment.

Next month, we’ll pick up with phase II in part 2 of this blog on Lymphedema Maintenance. (References will be cited in that post.)

Reason 3 – Medical Staff or the Patient

In parts 1 & 2, we looked at two reasons CDT (complete decongestive therapy) may not work.

Combined edema & lymphedema

Inappropriate application of CDT (such as leaving one of the four components of treatment out, incorrectly applying technique or inadequate frequency).”

In part 3, we’ll look at the medical professionals & the patient’s role.

(photo by Pexels/Leeloo Thefirst)

Medical Doctors

A doctor may incorrectly diagnose a person with lymphedema, or they may overlook another condition causing swelling that is not lymphedema. And/or these other conditions causing swelling may not have been adequately treated. Additionally, compression garments recommended by a physician may not be the appropriate type or the right compression class.

Therapists

Therapists may also be a reason CDT doesn’t work. First, the therapist may not have actually gotten appropriate training (i.e. they may not have attended a 135-hour lymphedema training course in CDT yet say they “treat lymphedema”). Second, they may have attended an appropriate CDT program to treat lymphedema but may not have sufficient experience. According to Foldi,¹ “Therapeutic success cannot be expected if errors are made in administering the treatment. The necessity of daily treatment has already been noted. Furthermore, we must again emphasize that a … therapist who has just received a certificate authorizing him or her to perform CDT is a novice & needs to get experience.” The text continues, “A “10-year rule” states that it takes approximately a decade of heavy labor to master any field!” The following are listed as the most common errors made by therapists.

Gross technical errors (such as failing to remove a bra which causes constriction)
Failure to treat the patient on a daily basis
Failure to apply bandages properly

Patients

Surprisingly, some patients may cause “artificial lymphedema” through constriction of a tourniquet or other means (& in some cases, deny it for reasons such as disability income). But in most situations (in my experience), failure on the part of a patient is due to non-compliance. Non-compliance can be not showing up for appointments, removing bandages to shower, not performing exercises prescribed, or not wearing a compression garment (including separate daytime & nighttime garments which are typically needed for pure lymphedema).

References
1 Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 281-282. Germany: Urban and Fisher. Foldi, M., & Foldi, E. (2012). Foldi’s Textbook of Lymphology (3rd ed.). Urban and Fisher.

Lymphedema Maintenance (part 1 of 2)

Phase I: Decongestive Lymphedema Treatment

Duration

Lymphedema Stages

Why Would Treatment Not Work (Part 3)

Medical Doctors

Therapists

Patients

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