Many patients who receive a diagnosis of lymphedema will subsequently be prescribed a treatment regimen called complete decongestive therapy (CDT). This therapy (also called Complex Decongestive Therapy) consists of four or more separate, simultaneous approaches to the management of the swelling and lymph fluid accumulation that characterize lymphedema. CDT is considered the gold standard for treatment once lymphedema has progressed beyond stage 1.
This initial, intensive therapy for stage 2 to stage 3 lymphedema is designed to minimize the swelling and discomfort that result from untreated symptoms. Research has shown that this intensive 2-to-4 week program of care can significantly reduce swelling and improve quality of life. These positive results may also continue after treatment has ended. Indeed, the goal is to achieve an acceptable level of control of the patient’s symptoms and then to maintain that level of control.
CDT is also divided into phases. Phase I, also known as Reductive CDT, is focused on reducing the volume of fluid accumulated in the affected limb or body part. It typically involves sessions of manual lymphatic drainage (MLD) 5 days a week. As noted above, this phase may last for as little as 2 weeks, but it may extend to as many as 8 weeks in duration.
Manual Lymphatic Drainage
This is perhaps the most crucial aspect of CDT. This intensive massage technique, performed by a trained specialist, is designed to force lymph out of affected tissues, and back into the circulation. This has the effect of significantly reducing swelling and typically results in significant decreases in the pain and discomfort associated with lymphedema. In fact, in one study of CDT, slightly more than half of the patients who received 2-4 weeks of therapy eventually reported that their pain levels had fallen to zero.
One aspect of this therapy involves the use of graduated compression garments. These medical-grade garments feature compression that squeezes the affected area more tightly at the farthest point from the heart, and less tightly nearer the heart. Thus, a compression sleeve for an arm affected by lymphedema would squeeze the wrist tightly, and this compression force would gradually decrease farther up the arm. This tends to encourage lymph to move out of swollen tissues and to travel back up the arm for recirculation towards the heart.
While CDT itself typically lasts less than a month, the prescription to wear compression wear continuously typically does not end. Rather, it is important to continue wearing such items faithfully, during waking hours, indefinitely in order to maintain the gains made during CDT.
Some patients may be prescribed compression bandages initially. These are specially designed, multi-layer bandages that may feature some elasticity — or not — depending on an individual’s needs and the best advice of a lymphedema specialist. They are ordinarily applied by a medical professional. Patients may be instructed in the proper way to apply and remove them but will be advised to remove them solely for bathing or during manual lymphatic drainage sessions. Eventually, a patient who receives bandaging may “graduate” to wearing an appropriate compression garment instead. These are typically more convenient to don and wear.
Self-Care (Skin and Nails)
Another aspect of CDT involves instruction in proper skin and nail care. Lymphedema patients, especially in the long term — or in cases where control has been less than ideal — may experience adverse changes in the health of the skin in affected areas. Accordingly, it becomes exceptionally important to pay careful attention to the care of the skin. In the case of lymphedema of the arms, legs, hands or feet, the nails must also receive special attention.
During CDT, medical staff typically provide instructions regarding the importance of avoiding damage of any kind to affected skin. This extends to avoiding sunburn, insect bites, and even seemingly minor cuts or scratches. Nails should be kept short and trimmed. And patients are typically instructed to apply skin lotion regularly to help minimize the dryness and cracking that could result in a greater risk of developing local infections.
Therapists will typically provide instruction in mild, appropriate therapeutic exercises designed to help encourage the drainage of lymph from affected tissues. In the past, experts believed exercise might be counter-productive, but we now know that exercise is actually beneficial, especially to the extent that it helps an individual maintain fitness and avoid excess weight gain. Excess body weight is an independent risk factor for the development and progression of lymphedema, and should, therefore, be avoided as much as possible.
Phase II (Maintenance CDT)
During this phase, which will essentially last for the rest of your life, the goal will be to maintain the gains made during your initial, intensive therapy. If it has not already happened, you will be fitted for an appropriate compression garment or garments. You will strive, on your own, to follow a regimen of self-care that includes caring for and wearing your compression garment(s) as directed, every day.
You will also be instructed to continue or progress in your exercise program, and to pay special attention to your skin, and to any changes that may occur in your affected limb or area of the body. You will be instructed to avoid exposure to temperature extremes, sun exposure, etc. In essence, you will learn to live with your condition on a daily basis.
Many patients have discovered that careful vigilance enables them to live essentially normal lives, without experiencing significant progression of their disease.
Finally, it’s important to note that every patient is different. Researchers are investigating these differences, trying to understand why one woman will get lymphedema after having just two underarm lymph nodes removed, for example, while another might have 20 or more nodes removed, yet not develop lymphedema. Some patients may experience relatively few problems with control of their symptoms after initial CDT, while others may experience flare-ups that require a renewed course of intensive treatment.
Thus, you must learn to pay attention to what works best for you and to monitor yourself for any signs of infection, or lymphedema progression. When in doubt, don’t hesitate to contact your lymphedema specialist for help.