40 Lymphology 41 (2008) 40-44 COMPLETE DECONGESTIVE PHYSIOTHERAPY WITH AND WITHOUT PNEUMATIC COMPRESSION FOR TREATMENT OF LIPEDEMA: A PILOT STUDY G. Szolnoky, B. Borsos, K. Bársony, M. Balogh, L. Kemény Phlebolymphology and Wound Care Unit, Department of Dermatology and Allergology, University of Szeged, Hungary ABSTRACT fatty swelling of the legs (2-4). Arms may also be involved. Edema usually manifests on the Lipedema is a disproportional obesity thighs and buttocks or the upper arms and for which evidence-based treatment is not sometimes has an orthostatic prolongation. currently available. We studied whether Lipedema is often combined with common complete decongestive physiotherapy (CDP) obesity. Lipedematous tissue hardly or never alone or combined with intermittent responds to diet and weight-loss. Lipedema pneumatic compression (IPC) could improve patients often complain of pain upon the treatment outcome in women with palpation that usually worsens with aging. lipedema using a prospective, randomized The other noticeable hallmark is the frequent trial. Eleven patients received CDP (60 min) hematoma formation due to even minor and thirteen CDP (30 min) plus IPC (30 min) traumatic injuries (2-4). once daily in a 5-day-course. Subsequent to Lipedema is accompanied by local drainage, all subjects received multilayered circulatory abnormalities. Excessive fat can compression bandaging, physical exercise and provide low resistance to vessels, and skin care. Treatment efficacy was evaluated lipedema is often associated with superficial by limb volume reduction. Both groups venous insufficiency, although major venous achieved significant reductions in mean lower dysfunction is rarely found (5). Massive extremity volume (p<0.05). The addition of subcutaneous fat is linked with microangio- IPC is safe, although it provides no synergistic pathy, and increased blood capillary benefit to CDP in leg volume reduction under permeability leads to protein-rich fluid these study conditions. extravasation, which can further enhance lymph formation. Therefore, in early stages Keywords: lipedema, manual lymph drainage, of lipedema, increased lymph flow is intermittent pneumatic compression, visualized by lymphscintigraphy. Lymph lymphatic treatment, complete decongestive vessels increase their transport capacity in physiotherapy response to augmented capillary filtration and increasing volume of interstitial fluid Lipedema is a distinct clinical entity first (6). On the other hand, morphologic studies described by Allen and Hines (1). It is a with fluorescent microlymphography display disproportional obesity that nearly always lymphatic microaneurysms and dilated vessels affects women. The main feature is the in the uppermost lymphatic network, indica- bilateral, symmetrical, biker’s hosiery-shaped ting that lymph vessels are also affected (7). Permission granted for single print for individual use. Reproduction not permitted without permission of Journal LYMPHOLOGY. 41 In longstanding lipedema, lymph vessels this application (11,14). The consensus become overworked, and altered micro- document of the International Society of circulation contributes to impaired lymph Lymphology includes pneumatic compression transport capacity and accumulation of pumps as belonging to optional treatments lymph fluid. In advanced stages, lipedema which may be applied as an adjuvant therapy may be combined with lymphedema and to the classical CPT (10). therefore labeled as lipo-lymphedema. High The main goal of the present study was protein and fat concentration of lymph to provide evidence in the treatment of induces a low-grade inflammation and lipedema. In addition, we were also interested subsequent fibrosis leading to non-pitting whether the addition of pneumatic compres- edema characterized by Stemmer’s sign. Pure sion to standard CDP improved the thera- lipedema is not associated with fibrosis (8). peutic outcome in women with lipedema. The experience-based treatment of lipedema is complete decongestive physio- PATIENTS AND METHODS therapy (CDP) due to the lack of evidenced- based treatment (9), and intermittent This prospective study included 23 pneumatic compression (IPC) has been women who had developed bilateral leg applied as adjunctive therapy. CDP for lower lipedema. Patients were first seen at the extremities consists of manual lymph lymphedema outpatient care unit of the drainage (MLD), multilayered compression Department of Dermatology and Allergology. with short-stretch bandages, regular walking Prior to enrollment in the study, each patient exercises, and meticulous skin care (10). was examined to rule out previous deep vein Manual lymph drainage (MLD) is a gentle thrombosis using physical examination and massage technique that is a standard and color Doppler ultrasonography of the legs. effective therapeutical tool against various All patients signed a written informed forms of primary and secondary lymphe- consent approved by the Ethical Committee demas. Multilayered compression bandaging of the University of Szeged. plays an important role in the further Patients were randomly enrolled into the reduction of leg volume enhancing the two arms of treatment. The treatment groups continuous pumping mechanism using the were not significantly different from each active involvement of muscle pumps. other in the number of participants (13 and Intermittent pneumatic compression (IPC) 10), mean age and range (51.3 years (32-65 might be a supplementary treatment to MLD years), 50 years (44-80 years)), and mean that mainly affects the improvement of duration time interval from the patient’s first venous flow. The intensive phase of the notice of clinical manifestation to the treatment is followed by the maintenance treatment (9.1 and 10.2 years; all values, phase consisting of the daily use of standard respectively). CDP consisted of 60 minutes of or individually sized compression garments. MLD by Vodder’s method (8) performed by a The use of pneumatic compression is specially trained physiotherapist followed by rather controversial. Earlier use of pneumatic skin care with moisturizers, appropriate compression involved multiple therapeutic foam-padding, and multilayered short-stretch protocols, and inappropriate treatments were bandaging application. Those patients who linked with several side effects (11). Some received additional pneumatic compression studies corroborated their usefulness, while therapy were treated with MLD for 30 others discounted effectiveness. Few schools minutes followed by treatment with Lympha of lymphedema therapy support their utiliza- Press Plus machinery (Mego Afek, Israel) tion as a part of the combined treatment using a long sleeve for another 30 minutes. regimen (12,13), while others are opposed to According to our standard practice, a Permission granted for single print for individual use. Reproduction not permitted without permission of Journal LYMPHOLOGY. 42 maximum pressure of 30 mmHg was applied. ground and hormonal dysfunction (4,8). It is The second group also received the same easily distinguishable from other entities like therapeutical modalities as the first group. lymphedema and phlebedema, and it shows Each patient underwent a 5-day-course of an altered microcirculation pattern of the once daily treatment and all patients fully lymphatic system. Without appropriate completed all components of therapies. After treatment and adequate diet, lipedema is a the cessation of a treatment cycle, patients rapidly evolving disorder that can cause wore standard or individually sized compres- severely limited mobility and can lead to sion grade II or III medical compression associated lymphatic or/and superficial stockings. venous insufficiency. In pure lipedema, the Leg volumes were measured using the amount of transportable interstitial fluid is classical Kuhnke’s disc method (15) and higher compared to non-lipedematous limbs circumferences obtained at 4-cm intervals leading to an increased lymph flow (6). This beginning at the foot and ending at highest increase in flow decreases the ability of the point of the inner thigh. Although not as lymphatic system to handle further excess accurate as the direct or inverse water fluid, and even minor structural alterations displacement model, this is a very good way can cause insufficiency and lymph accumula- to approximate volume and to compare the tion. Superficial venous insufficiency can also volumes over time. Both legs were considered intercede due to the weak connective tissue in limb volume measurements. resistance exerted by enormous fat. In accordance with our experience, the RESULTS most successful therapeutic approach for lipedema is CDP and the crucial part of CDP Measurement of the limb volume is MLD (8). MLD is a technique of gentle reduction is the most common approach massage, which stimulates the lymphangio- to quantify the extent of lipedema and motoric activity. It opens and dilates the evaluate the therapeutic success. In the uninvolved lymph routes and then directs the CDP group, pretreatment mean leg volumes lymph away from the edematous parts and were 17,760.08±4,692.9 (right leg) and reduces the volume of the limb by diminishing 17,976.15±4,960.8 cm3 (left leg) which the persistent lymph. Besides lymph flow reduced to 16,998±4,516.9 (right leg) and improvement, it reduces lymph stasis, 16,866.46±4,474.2 cm3 (left leg) (p=0.0011 increases protein resorption, and softens and 0.001, respectively). In the CDP+IPC fibrosis. Intermittent pneumatic