PNEUMATIC COMPRESSION IN THE TREATMENT OF LYMPHOEDEMA: PREJUDICE OR REASONABLE ANXIETY?
Rovnaya A.V.
To understand how safe pneumocomression is, and whether it should be included in the complex therapy of lymphedema, I was prompted by the last conference in St. Petersburg, where this method was discussed as mandatory for inclusion in the standards for the treatment of lymphedema, as well as many clinics in Russia and the world that actively use this technique, declaring it as the main method of treating lymphedema.
In the classical form, KPFT (Combined Decongestant Physical Therapy) consists of two phases: phase I - elimination of edema, phase II - maintenance and optimization. Each phase is divided into 4 points:
1) Skin Care
2) Manual lymphatic drainage
3) Compression therapy (phase I – compression bandage; phase II – compression knitwear)
4) Physical therapy
The main question is what place pneumatic compression can take in this structure. And will this method be substitute or complementary? When and how should it be applied? What are the possible complications?
Choosing the tactics of treatment, first, we must be guided by the anatomy, physiology of the lymphatic system. If we talk about lymphedema, the pathogenesis of this disease makes us evaluate any method of treatment in terms of safety and effectiveness.
So, if this is a substitute method, then which of those methods that are included in the classical CFT, does it replace? If it is complementary, then complementary to which method is it? Let's look at everything in order.
First, let's remember how manual lymphatic drainage works, what effects it has. And can we pneumatically compress at least one of these effects?
Let me remind you that the main task of lymphatic drainage massage is not to remove swelling from the limb (massage itself can contribute to the care of only a small amount of fluid from the edematous limb, but it cannot cope with edema), but to prepare physiological ways of lymph outflow, through which the fluid displaced by the subsequent pressure of the bandage will reach healthy areas of the lymphatic system, to healthy lymph nodes.
Lymphatic drainage massage increases the absorption of protein-rich fluid and enhances lymphangiomotor skills. This is because the main movement during manual lymphatic drainage on the skin is stretching. Not pressure, but stretching. Due to this action, there is a tension of the anchor filaments and the entry of interstitial fluid into the initial lymphatic capillaries. It also contributes to an increase in pressure in the lymphangions, which enhances lymphoangiomotor skills.
Such a tension of the skin in the process of pneumatic compression can not be created, there will only be pressure, so we will not get the full effects of the entry of intrastitial fluid into the lymphatic system and the enhancement of lymphoangiometrics when using pneumocompression.
Also, a very important point in manual lymphatic drainage is the redirection of fluid flow bypassing the blocked area. If a group of lymph nodes is removed in one area, then the massage is done on the body in the following order (And the lymph nodes of the neck and abdomen are still being prepared before the body): first, the area of healthy lymph nodes is stimulated, then the area of the healthy quadrant is drained, then lympholymphatic anastomosis is worked out . Next, the edematous quadrant is drained, and then the work takes place on the edematous limb. Pneumatic compression, unfortunately, will not be able to perform this drainage sequence on the body, which means that it will not be able to ensure the redistribution of lymphatic fluid current bypassing the blocked area.
The next point is the very effect of manual massage on the skin. It is a great respite for the skin. When the patient removes the bandage, there are traces of bandages and from the imposition of pads. During the massage, the skin receives relief and relaxation. If you remove the bandage and immediately put a person in a pneumatic compression apparatus - this effect, unfortunately, will not be fully realized.
In addition to this, the massage provides relaxing and analgesic effects. Massage helps to create the right "specialist-patient" contact, because so far nothing has replaced just touching a human hand. Most patients with lymphedema have psychological problems, are in a state of chronic stress. And the patient's compliance, the psychological comfort, the confidence in the results, the trust in the specialist increases many times when we do this technique. Of course, machines cannot replace these effects.
As a result, it turns out that pneumocompression cannot replace manual lymphatic drainage on any of the points.
Pneumomassage and compression therapy.
The next method is compression therapy. And here we even hear similar words in the name. Pneumatic compression is not a method of massage, so it is generally incorrect to compare it with massage, but one of the varieties of compression therapy.
Now let's compare the classic compression therapy (bandaging with bandages of a low degree of tenderness, knitting of flat knitting) with pneumatic compression. When it is used, by increasing the pressure in the interstitium, ultrafiltration decreases, the reabsorption of the liquid increases. This happens both when bandaging and when wearing compression knitwear. And this effect may well be provided by pneumatic compression.
Another of the effects of the compression bandage is the creation of a pressure gradient for a certain direction of lymph flow. This is ensured by the correct application of bandages, properly sewn knitwear. If the design of the pneumatic pump is done correctly, this effect will be provided by pneumatic compression (i.e., when the lower chambers inflate with more pressure than the upper ones, and do not happen until everyone is happy).
That is, so far, the score is 2:2.
Also, due to compression therapy, the lumen of the lymphatic vessels decreases, and consequently, the linear speed of lymph flow increases. The same effect occurs when a pump is applied.
In addition to this, a positive effect on the valve apparatus is carried out: the lumen of the vessels narrows, the valve apparatus becomes wealthy. A pneumatic pump can also provide this effect.
Thus, all the first four points work in pneumatic compression.
But compression therapy works most effectively and physiologically in the process of physical movements. Activation of the muscle pump is the strongest mechanism of lymph transport, and this mechanism provides the greatest effectiveness of compression therapy. And this component is absent in pneumatic compression, because in pneumomassage, the person is stationary.
What does this lead to?
The fact is that when a patient is under the influence of compression therapy (bandage or compression knitwear) and makes a movement, i.e. a contraction of skeletal muscles, this ensures the transport of lymph inside the lymphatic system through the lymphatic vessels during all hours of physical activity, even with an incompetent lymphatic system. This becomes possible because when contracted, skeletal muscles shorten in length, but increase in width, and when, from the outside, compression bandages or knitwear create pressure that resists this expansion, the pressure of the contracted muscle will be more transmitted deep into the tissues, into the region of the neurovascular bundle and purely mechanically, due to compression, drains the fluid through the vessels - both the return of blood through the veins and the return of lymph through the lymphatic collectors - in this area ("like squeezing toothpaste out of the tube"). Therefore, due to compression and movements, lymph transport is possible even in the later stages of lymphedema, when the lymphatic vessels have lost the ability to contract independently due to sclerotic processes in their walls. What is most important - I want to emphasize this - the activation of the muscle pump is the physiological mechanism of lymph transport THROUGH the lymphatic system, i.e. lymph, moving from the site of edema, passes its natural way - namely, it is INSIDE the lymphatic system. And with classical compression therapy (bandage / knitwear), she has enough time for this movement - 16-24 hours, i.e. in accordance with the natural temporal and transport abilities (we remember that only 2-3 liters of lymph move per day throughout the body, and the rate of contraction of the lymphangion does not exceed one in 4-6 seconds even at the height of physical activity).
What happens when we use pneumatic compression?
1. There is no skin stretching effect, and lymphatic fluid cannotfully enter the lymphatic bed.
2. No redirection of lymph on the body bypassing blocked areas
3. There is no activation of the muscle pump.
With classical compression therapy (bandage, compression knitwear), the fluid moves mainly inside the lymphatic bed.
When applying pneumatic compression under a sufficiently high pressure for a sufficiently short time, the liquid will be forced to move, but due to the absence of the above effects and conditions, it will NOT move through the lymphatic system, since the transport ability of lymphatic sisiema is not able to transport those hundreds of milliliters of fluid that are in the edematous limb in 20-40 minutes. That is, when applying pneumatic compression, the liquid moves mostly through the intercellular space, through the interstitium, which is not a free cavity or part of the lymphatic system, i.e. the fluid will actually just shift under pressure under the skin to an area where this pressure does not exist (above the end of the pneumocompression sleeve). What consequences can this lead to? If from the intercellular space above the end of the pneumocompression sleeve, the fluid moved from the edematous limb cannot be absorbed there into healthy areas of the lymphatic system (for example, if a large area of the PFA together with the initial lymphatic vessels was damaged during radiation therapy), then edema may form in this area. In addition, it must be remembered that most of the liquid component of lymph can move through the intercellular space, and large protein molecules will remain at the site of edema, which will lead to a sharp increase in the concentration of protein in this place, and therefore increase the risk and intensity of fibrotic processes in the tissue.
That is, the use of pneumocompression can lead to a number of complications, despite the fact that this method is not able to completely replace the effects of classical compression therapy.
Therefore, pneumocompression is a method that can only complement compression therapy, but not replace it.
Application of pneumatic compression.
If this method is used, when and how?
1. Incorporating it into combined decongestant physical therapy to improve or accelerate results. But this question is very controversial. All research data on this topic vary greatly. From the most reliable and understandable studies, the following conclusion can be drawn. In phase number I, a decrease in edema may occur more quickly if pneumocompression is included in complex physical decongestant therapy. At Stanford University, Professor Roxon conducted this study on 23 patients, and showed that within 10 days, the reduction in volume with the addition of pneumocompression was actually twice as high as just classical combined decongestant physical therapy. Accordingly, if there is a patient who requires a month and a half of classical CPFT, then by including pneumocompression in his therapy, this time can be reduced to three weeks. But in practice, everything is very individual. Itis necessary to remember about the possible risks and complications that can be the "price" for the speed of achieving the result. The Association of Lymphologists of Russia, in view of the poor controlled risks, does not recommend the use of pneumocompression at stage 1 of treatment.
2. Application in Phase II "Maintaining Results". This is currently the safest and most reasonable use of pneumatic compression, because the liquid component of edema is no longer there, namely, freely moving fluid is the basis of most possible complications of pneumocompression (edema eliminates in phase number I). And the task of phase II is to maintain the result so that fluid does not accumulate. In the same Stanford University, studies were conducted -two groups of patients were compared: in one there was a wearing of compression knitwear, and the use of e pneumocompression (1 time per day), and in the second groupe patients only wore knitwear. Usually, after six months, the jersey begins to stretch, loses its compression class, and the volumes begin to increase slightly - by one to two centimeters. The above studies have shown that if the patient was pneumocompressed, then the edema did not increase by a single centimeter. And this is the most rational use of pneumocompression.
But at the same time, if we use it, no matter at what stage, lymphatic drainage massage is first done precisely so that the fluid does not rise above the site of application of pneumocompression. And after the procedure, in any case, compression therapy is used. That is, if after applying a pneumocompression pump you do not create pressure (neither bandages nor knitwear), then, of course, the liquid will simply descend back.
Here are examples of some research on the subject.
D. Dini et al conducted a study and showed that if pneumatic compression was used by itself, then it showed no significant effectiveness.
Karin Johannsson from Lund University showed that the volume reduction when using manual lymphatic drainage alone (without subsequent compression) was 15%, and the use of pneumatic compression (without subsequent compression therapy) reduced swelling by only 7%. But both figures are very low, so to remove swelling, it is still necessary to use compression therapy in the form of a bandage or knitwear.
W.I. Olszewski has probably done the most interesting research on pneumatic compression, and the results are very disconcertible. But it definitely showed well what design these pumps should have, if they are still used. The problem is that there are a huge number of their options on the market, but only one will work for the lymphatic system.
First, there must be a sufficiently high pressure.
Secondly, the time of inflation, that is, the speed at which the camera inflates, should be long enough – 50 seconds.
Thirdly, there should be a lot of cameras – at least 8-12. And a very important point is that distal cameras should not deflate as all proximal ones are inflated. Only then will the correct gradient be created. And also proximal areas should be closed. For example, if we use pneumocompression on the arm, it should be a full vest so that the fluid does not stand in the chest area. For the lower extremities, these should be pants that cover both the groin and the abdomen up to the chest, and the contralateral limb. This will protect against possible complications.
Complications.
Many patients come to me for consultations and treatment. Of these, many patients before they came to me were treated for lymphedema in various clinics with the help of pneumatic compression (either in a monovariate, or as part of a set of procedures). I myself do not use this method. And of those patients, complications after the application of pneumatic compression were observed in more than half. The following complications were noted:
1. Swelling of the body area and "fibrous rings".. When only the sleeve or only the stocking is used in pneumoompression, the liquid moves in the interstitium to the place where this product ends, and there it can remain. Because the outflow paths have not been prepared, and after a while there is a stagnation of fluid and fibrosis processes develop quite strongly. Ifyou look at the literature data on this type of complication, they are most fully described and proven in the dissertation of Jesim Bokür.
2. Swelling of the genitals. I've had 7 of these cases, and it's not an easy situation, because when the swelling has moved to the genitals, it's much harder to work with it than with swelling of the limb. In the literature, the data are very different. For example, Boris et all. showed in his work the presence of this type of complication in 43% of cases! And Wigg et all., on the contrary, did not confirm such a complication.
3. Swelling of the opposite limb. I also observed 4 such cases. This is due to the presence of anastomoses, with an increase in pressure immediately above the affected limb, the edema can pass to another with the appropriate anatomy (we are talking about the lower extremities, of course). Again, these literature contradict each other.
4. Chylothorax. Such a case in my practice was an isolated one. I suspect that radiation therapy originally resulted in damage to the chest and pleura. That is why the interstitial fluid withthe increase in pressure in the arm received such easy access to the pleural cavity. And this was proved during the puncture: the patient, after three sessions of pneumocompression, accumulated 2 liters of fluid in the pleural cavity. She was urgently hospitalized. and doctors subsequently confirmed that there was lymph in the pleural cavity.
5. Acceleration of fibrous processes. If, when applying pneumocompression, the liquid component mainly moves, and the protein remains in place, then the fibrosis processes go faster, and this is very noticeable. I hadpatients whose lymphatic edema was very fresh, stage 1I according to ISL, no more than 2-3 months. Usually in the first six months in the first stageand the edema in KFAT is removed completely, and the density of the tissue there does not change at all. But if the patient before that, in these first six months, pneumocompression was done, then the swelling was small, but very dense, and the difference in the thickness of the PFA was already clearly noticeable and persisted even after KFPT. This was noted in 12 patients. The data of the literature again contradict each other: M. Földi confirms this complication, Wigg, Rickson, etc. - do not confirm.
6. Damage to the capillaries, up to the formation of ecchymoses. Observed in 3 patients. Perhaps it was associated either with the choice of too high pressure on the device, or with an individual tendency to capillary fragility.
What is particularly alarming is that several people received complications when pneumocompression was included in the KFPT.
A large-scale study was conducted by Casley Smith: 1500 patients went through this study, and 150 people (that is, 10%) had early complications with the use of pneumocompression.
When can pneumatic compression give an advantage?
1. When the patient cannot get KFAT. For example, due to the lack of a specialist in his city and the inability to go somewhere for treatment. If in this case you are inactive, then the swelling will progress. Then you can buy a pneumocompression pump and use it to keep the swelling in an acceptable state.
2. Paralysis. With paralysis, one of the main mechanisms of lymph transport - a muscle pump - will not work. Compression therapy in this case will not have the effect that we get when the patient moves. Therefore, the use of pneumocompression therapy is justified here.
3. Limited time for treatment. For example, a patient may only come for treatment for two weeks. As mentioned above, when using pneumocompression in conjunction with KFPT, it is possible to reduce edema in a shorter time. But you need to remember about the risk of complications and carefully weigh the pros and cons. Lichbut I'm not prepared to expose the patient to such risks. Let me remind you that in the Feldi clinic in Germany, in the Lympha clinic in Moscow, in the Center for Lymphology in Kazan, this method is also not used.
4. The lack of the possibility of constant compression therapy in the phase of maintaining the result, that is, the inability for one reason or another to wear compression knitwear or continue bandaging. In this case, between "nothing" and pneumocompression, it is better for her to choose pneumocompression.
5. Addition to compression knitwear in the phase of maintaining the result. In order not to lose a centimeter of the removed during treatment, in addition to the constant wearing of compression knitwear, pneumatic compression can be applied, because the liquid component is no longer present - it was removed with KFPT. There should be no complications here, because there is not a large amount of fluid moving along the interstitium.
If, for one reason or another, we say "yes" to pneumocompression in any of the above cases, we should always remember that, like any method of treatment, this also has contraindications when it cannot be used. These are:
1. Decompensated heart failure, cardiac edema
2. Pulmonary embolism
3. Deep vein thrombosis without treatment
4. Infectious diseases of the skin and PFA
5. Venous infectious and inflammatory diseases (thrombophlebitis) without treatment
I must emphasize that excellent results in the elimination of edema can be achieved WITHOUT the use of pneumocompression, but only with a properly conducted KFPT by specialists who are fluent in it. Let me remind you that in the world's leading clinic for the treatment of lymphedema - Feldi Clinic - this method has not been used and is not used until now. In all (albeit, so far small) Russian clinics, highly specialized in the treatment of lymphedema, pneumocompression is not used. My colleagues, leading experts on CFPT from other countries (Brazil, Malta, Turkey, Greece, Romania, etc.) also achieve excellent results in their patients without pneumocompression.
If we return to the question asked at the very beginning is the anxiety justified when using pneumocompression for the treatment of lymphedema or is it bias, the answer is obvious - there are reasons for concern. Because the effectiveness is much lower than that of KFPT, and the safety is not only not proven, but even on the contrary, there is numerous evidence of complications due to the use of this method.
Also, alarming are the data of researchers that are too contradictory to each other. And do you know why the results of different authors are so different from each other? Because all the authors in their studies used different design pumps from different manufacturers for different amounts of time with different degrees of pressure and number of chambers. Obviously, such studies cannot be compared with each other. In order to obtain such research data, so that they can be used to draw conclusions that can be trusted, the parameters of the devices used in the studies should be the same. And I very much hope that soon we will be able to conduct such a multicenter study on the basis of clinics in the Russian Federation and will be able to find out under what conditions the use of pneumocompression will give the best results with minimal risk of complications.
If we do not have such data, and the above grounds to fear the possible risks of pneumocompression are, this method should not be included in the standards for the treatment of lymphedema, because we should not forget the basic principle of medicine - "do no harm", and only the method of treatment whose safety we will have enough evidence can be officially recommended for use.
