eNews Online - October 2004 Edition

eNews Online
October 2004 Edition

This Lymphedema eNews is being generated through your request from our website.

Combined Modality Treatment of Lymphedema using the ReidSleeve and the BioCompression/Optiflow System

In this lymphedema eNews, I will discuss our recent results using a combination of the ReidSleeve with the BioCompression pump and Optiflow insert to treat lymphedema. We tested a combination of these two approaches because of the possibility of enhancing treatment for both the acute and chronic components of lymphedema. The results demonstrate that the combination of these two approaches can significantly enhance the treatment of lymphedema.

Lymphedema is a complex problem. Obstruction of lymphatic flow results in retention of interstitial fluid within the tissue leading to swelling. Retention of interstitial fluids and associated proteins results in a chronic inflammatory process that leads to the changes characteristic of lymphedema. This includes thickening and discoloration of the skin, loss of tensile strength of elastic fibers and accumulation of adipocytes and subcutaneous fat. Therefore, removal of the accessible interstitial fluid is an important first step in the treatment of lymphedema. However, to achieve optimal results the excess lipid must be removed, the abnormal accumulation of fibroblasts and thickened layers of skin have to resolve and the tensile strength of elastic fibers needs to be restored. The abnormal proliferation of fibroblasts, keratinocytes (skin cells) and adipocytes (fat cells) is due to stress on the tissue and effective remodeling of the skin and subcutaneous tissues requires minimization of the stress on these tissues. To achieve the optimal interstitial pressure that will facilitate removal of excess interstitial fluid and to minimize stress on recovering tissues, we have used the ReidSleeve in combination with the BioCompression/Optiflow system.

The ReidSleeve provides gentle compression using a multitude of high and low compression points. Normally, lymphatic fluid is propelled forward by the arterial and muscle pumps. Lymphatic vessels are squeezed by the expansion and recoil of the arterial system contained within the same connective tissue sheath. Similarly, the compression of lymphatic vessels by expansion and contraction of muscles during movement propels lymphatic fluid forward. The resilient foam used in the ReidSleeve models the compressi on normally applied to the lymphatic system by the expansion and recoil of the arterial system and the intermittent compression of the muscle pump. Minimizing the stress on the subcutaneous tissues is critical for long-term improvement and to assure minimal stress on the recovering tissue, soft foam is used at the lowest pressure necessary to achieve reduction of interstitial edema. Excess pressure not only adds increased stress to the tissue but also can lead to compression and obstruction of functioning lymphatic vessels.

We have used a ReidSleeve Optiflow insert inside of the gradient, sequential, pneumatic compression pump sleeve to achieve optimal interstitial pressure. The intermittent compression of the sequential pneumatic pump can augment the massaging effects of the muscle pump. Furthermore, the sequential pneumatic pump can be adjusted to optimize the interstitial pressure. The system is designed to provide a baseline compression of approximately 4 to 6 mmHg pressures. This level of compression is consistent with v enous pressure. During inflation, the pressure exerted increases smoothly and gradually to a peak pressure that can be adjusted to the patients needs. The peak pump pressures were increased in increments of 5mmHg to achieve reduction in lymphedema without causing the sensation of congestion or discomfort in the extremity.

The ReidSleeve was used nightly, the BioCompression/Optiflow system was used for 2 periods of 60 minutes during the day and level II compression sleeves were used for the remainder of daytime wear. The results from this study demonstrated marked reduction of lymphedema of the upper and lower extremity of patients with moderate to severe lymphedema refractory to other treatments. Patients with upper extremity lymphedema demonstrated a 25% reduction at 4 weeks, 50% reduction at 16 weeks and 80% reduction at 28 weeks (Fig. 1).

Fig. 1. Effect of Combined Treatment with ReidSleeve and BioCompression/Optiflow. 16 patients with refractory lymphedema were followed for 36 weeks following initiation of treatment using the Duke protocol. The percent reduction in lymphedema was determined by subtracting the volume of the unaffected extremity from the volume of the affected extremity leaving the amount of excess volume. A 100% reduction would result in normalization of the volume of the affected extremity.

A plateau in response can be seen between weeks 4 and 8 among these patients. The initial rate of reduction was 6.2% per week (Fig. 1). Following a leveling off or plateau period, further reductions are observed, however, the rate of reduction is 3.1% per week. Further reductions in lymphedema and improvements in skin tone and color were achieved over the course of treatment. The slower rate of improvement with visual improvement in the skin tone and texture is consistent with gradual resolution of the tis sue abnormalities associated with lymhedema and demonstrates that the use of this system provides adequate control of lymphedema without causing increased stress on the tissue. The rate of response appears to decrease during the later months of treatment; however, this is due to patients achieving their treatment goals and going into maintenance therapy and off study.

Reductions in excess of 100% are noted in some patients. We have consistently noted that after effective control of lymphedema, the affected extremity can be smaller than the unaffected extremity. This appears to be due to atrophy of the musculature of the affected extremity.

Linear regression analysis was performed to demonstrate that treatment with the ReidSleeve BioCompression/Optiflow system leads to long-term reduction in lymphedema. In this analysis each patient is evaluated over time during treatment. If the treatment is effective and if the effect is maintained, continual reduction in edema would be observed. The graph below shows that many patients have significant improvements during the early phases of treatment (Fig. 2). However, this analysis also demonstrates that there is a consistent improvement in lymphedema with time after initiation of treatment. 50% reduction in lymphedema is seen at approximately 16 weeks. By approximately 60 days some patients had achieved reductions in excess of 90% and by 28 weeks the average reduction was 80%. The response to treatment is highly significant (p<0.001).

Fig. 2. Scattergram of the effect of the ReidSleeve Biocompression/Optiflow System. Linear regression analysis demonstrates progressive decrease in lymphedema with time of treatment.

During the initial phase some patients had worsening lymphedema. These exacerbations were transient and due to secondary causes common among patients with moderate to severe lymphedema including infections. When treated for the infections, these patients were put back on treatment with compression. By 3 to 4 months after initiation of treatment with the ReidSleeve BioCompression/Optiflow system, marked improvement in lymphedema was observed in nearly all patients.

The combination of the ReidSleeve with the BioCompression/Optiflow system can provide effective therapy for lymphedema. By effectively treating interstitial edema and by avoiding unnecessary stress on the tissues during the plateau phase, tissue repair was enhanced. The changes in skin tone and color became visibly evident. The repair of tissue provided a basis for further improvements in the subsequent weeks and months.

Similar results were observed for patients with lymphedema of the lower extremity. I will address this in the next eNews.

Tony Reid MD Ph.D