July - Sept 2013: CDT

LymphLink Question Corner - Archived From July- Sept 2013

By:  Joachim E. Zuther, CI, CLT-LANA
Academy of Lymphatic Studies, Sebastien, FL

Q: What is Complete Decongestive Therapy (CDT)?

A: Complete decongestive therapy, sometimes referred to as complex decongestive therapy, or combined physical therapy is the internationally recognized “gold standard” treatment system for the vast majority of patients affected by lymphedema. 

Backed by long standing experience, CDT has shown to be safe and effective as the standard therapy for lymphedema.

Applied correctly by a skilled LE therapist, CDT shows excellent long-term results in both primary and secondary LE. 

The swelling in lymphedema is caused by an accumulation of protein and water molecules in the tissue and results from the inability of the lymphatic system to perform one of its basic functions, the removal of water and protein from the tissues of a certain portion of the body. This insufficiency can be caused by developmental abnormalities of the lymphatic system (primary LE), or damage to the lymphatic system such as the removal or radiation of lymph nodes in cancer surgery, or infection of the lymphatic system (secondary lymphedema). Lymphedema most often affects the extremities, but can also be present in the head and neck, trunk, or external genitalia.

In order to reduce the swelling it is necessary to re-route the lymph flow - to include excess protein and water molecules - around the blocked area(s) into more centrally located healthy lymph vessels. This goal is achieved by a combination of different treatment modalities, all of which are integral components of CDT.

Q: What are the Components of CDT?

A: Elements of CDT include manual lymph drainage, compression therapy, decongestive exercises, and skin care.

Manual lymph drainage (MLD): This gentle manual treatment technique, based on four basic strokes, is designed to have an effect on fluid components and lymphatic structures located in superficial tissues, such as the skin and subcutis. LE almost exclusively manifests itself in the subcutis, and the techniques of MLD are ideally suited to gently re-route the flow of lymph around blocked areas.

Compression therapy: Utilizing proper treatment techniques, lymphedema can be reduced to a normal or near normal size. However, existing LE damages the elastic fibers in the skin, and even after decongestion, the skin elasticity may never be regained completely. This can result in re-accumulation of fluid and external support of the affected body part is therefore essential. Depending of the phase of the treatment compression is provided by padded short-stretch bandages, compression garments, or a combination of both. 

Decongestive exercises: Unlike the heart in the blood circulatory system, the lymphatic system does not have an active pump to propel lymphatic fluid back into the bloodstream. Effective lymph flow depends on sufficient muscle and joint activity, especially if the functionality of the lymphatic system is compromised. Decongestive exercises consist of active, non-resistive and repetitive protocols, which should be customized by the LE therapist and/or physician to meet individual goals for patients affected by LE. The stage and type of lymphedema, specific restrictions and limitations of joint and muscle activity, as well as additional medical conditions need to be considered.

Ideally, decongestive exercise protocols are performed two to three times daily for about 10-15 minutes, and the patient should rest with the affected limb elevated for at least 10 minutes following the exercises. Decongestive exercises are most effective if performed while the patient wears compression garments or bandages.

Individuals affected by lymphedema of the leg benefit greatly from an exercise program including diaphragmatic breathing exercises. The downward and upward movement of the diaphragm in deep abdominal breathing is an essential component to support the sufficient return of lymphatic fluid back into the bloodstream. The movement of the diaphragm, combined with the outward and inward movements of the abdomen, ribcage, and lower back, also promotes general well-being, peristalsis and return of venous blood back to the heart.

Skin and nail care: Patients who already have, or had lymphedema are susceptible to infections of the skin and nails. Lymphedematous tissues are saturated with protein-rich fluid, which serves as an ideal nutrient source for bacteria and other pathogens. Lymphedematous skin also tends to be dry and may become thickened and scaly, which increases the risk of skin cracks and fissures. The skin represents the first line of defense against foreign invaders and is usually impermeable to bacteria and other pathogens. However, any defect in the skin such as burns, chafing, dryness, cuticle injury, cracks, cuts, splinters, and insect bites can present an entry site for pathogens or infectious agents and cause infection. The process of inflammation may not only worsen the symptoms of LE by increasing the swelling, but can also develop into a serious medical crisis. The basic consideration in skin and nail care is therefore the prevention and control of infections, which includes proper cleansing and moisturizing techniques with the goal of maintaining the health and integrity of the skin. Suitable ointments or lotions formulated for sensitive skin, radiation dermatitis and lymphedema should be applied before the application of LE bandages while the patient is in the decongestive phase of the treatment. Once the limb is decongested and the patient wears compression garments, moisturizing ointments should be applied twice daily. 

Frequently therapists are asked if it is possible to effectively treat lymphedema using only one or two components of CDT. The clear answer is “no”. LE requires a systematic approach, and each of these components is ideally suited to treat and manage the symptoms associated with lymphedema. Successful treatment of lymphedema would not be possible without the combination of individual benefits of all components of CDT.

Q: What are treatment goals in the two phases of CDT?

A: Successful lymphedema treatment is performed in two phases. In phase one, also known as the intensive or decongestive phase treatments are administered by trained lymphedema therapists on a daily basis until the affected body part is decongested. 

The duration of the intensive phase varies with the severity of the condition and averages two-three weeks for patients with lymphedema affecting the arm, and two-four weeks for patients with lymphedema of the leg. In extreme cases the decongestive phase may last up to six to eight weeks and may have to be repeated several times.

The end of the first phase of CDT is determined by the results of measurements on the affected body part, which are taken by the therapist. Once measurements approach a plateau, the end of phase one is reached and the patient progresses seamlessly into phase two of CDT, also known as the self-management phase, which is an ongoing and individualized part of CDT. In this second phase the patient assumes responsibility for maintaining and improving the treatment results achieved in phase one. 

During the intensive phase, the patients are instructed in the individual components of self-management, which include a skin care regimen, home exercises, self-manual lymph drainage and the application of compression garments for daytime use.