Asociación Galega de linfedema, lipedema, insuficiencia venosa crónica y otras patologías: WHAT ARE THE STRATEGIES FOR THE IMPLEMENTATION OF LOW-COST TREATMENT FOR LYMPHEDEMA? - DEVALUING MANUAL LYMPHATIC DRAINAGE (MLD) - Pediatric and Primary Lymphedema - Secondary Lymphedema - Lymphatic Vascular Disease - Best Practices Management Guidelines / Treatment Protocols / Patient Care Pathways / Preventive Medicine / Rehabilitation Stratagies

Lymphedema (LE) occurs due to obstruction of normal lymphatic circulation leading to lymphatic fluid stasis. The lymph build-up results in inflammation, followed by fibrosis and sclerosis, then adipose tissue differentiation, and finally progression to chronic irreversible LE.

In recent years, a number of lymphedema guidelines and protocols have been developed to support health policy guidelines that focus on the implementation of low-budget health management for the treatment of lymphoedema. To achieve this goal, a new treatment concept called “Decongestive Lymphatic Therapy (DLT)” was developed so as to principally limit or exclude Manual Lymphatic Drainage (MLD) carried out by highly specialized therapists.

In many countries lymphoedema care services are scarce, and various strategies are been used in order to justify and implement low-cost alternative treatments, including downplaying conservative treatment (CDT) or undermining the importance of Manual Lymphatic Drainage (MLD). The resulting management approach emphasizes the provision of intensive treatment with MLD only for very severe lymphedema (elephantiasis) and complex cases, thus excluding intervention for patients with mild, moderate, and severe lymphoedema.

Even though the terms “Complete Decongestive Physiotherapy" (CDT) and “Decongestive Lymphatic Therapy" (DLT)" are used synonymously in the medical literature, they are not equivalent and don't represent the same treatment management focus. Read more about the main differences between “CDT” and “DLT” HERE.

Paradoxically, some treatment guidelines, while stating that Manual Lymphatic Drainage (MLD) should only be performed by properly trained professionals, simultaneously detract from MLD and recommend as a good and valid alternative, self-treatment options for the intensive volume reduction phase, even though this has little scientific evidence.

With regard to the objective of discrediting Manual Lymphatic Drainage (MLD), there are confusing research studies that focus on demonstrating its unnecessary inclusion as an essential component of treatment, basing the reports only on the results in terms of volumetric reduction measures, but not taking into account the key functions of MLD. Read more about the principal functions of Manual Lymphatic Drainage HERE.

The following is a list with a sample of conclusions and statements that appear concerning volumetric measurements with regard to Manual Lymphatic Drainage (MLD) published in some studies:

It is difficult to formulate strong conclusions on the long-term benefits of Manual Lymphatic Drainage (MLD) for volume reduction.
Manual Lymphatic Drainage (MLD) adds no further volume reduction to Complete Decongestive Therapy.
The addition of Manual Lymphatic Drainage (MLD) to the standard therapy does not contribute significantly to reducing edema volume.
Manual Lymphatic Drainage (MLD) adds no further volume reduction to Complete Decongestive Therapy.
There is no statistically significant difference in the reduction in limb volume between the MLD groups and the non-MLD groups.
The efficacy of Manual Lymphatic Drainage (MLD) to other therapist interventions needs to be demonstrated, not least because MLD requires specialized training and is labor-intensive compared to other treatments for lymphoedema.
Manual Lymphatic Drainage (MLD) was not associated with any more benefits to standard physiotherapy in lymphedema volume reduction.
Compression Bandaging, with or without Manual Lymphatic Drainage (MLD), is an effective intervention in reducing arm lymphedema volume.
Compression Bandaging on its own without Manual Lymphatic Drainage (MLD) should be considered as a primary treatment option for reducing lymphedema volume.

The following is a sample of conclusions and statements that appear included in some studies to justify the implementation of patient self-treatment instead of clinical management:

Self-management strategies yielded smaller volume reductions but demonstrated that they are more beneficial than doing nothing at all.
Patient self-management may be useful when health professional-based therapies are not accessible or economically viable.
Self-maintenance demonstrated a positive impact on “subjective” limb complaints and quality of life issues.
Low-budget management can be initiated by a health professional or patient with the anticipation of some benefit, even though the evidence to support them is, in some instances, poor.

The following is a sample of comparison trials that are made to justify the suppression of treatment with Manual Lymphatic Drainage (MLD) from treatment protocols:

MLD + standard physiotherapy versus standard physiotherapy alone.
MLD + compression bandaging versus compression bandaging alone.
MLD+ compression therapy versus non-MLD treatment + compression therapy.
MLD + compression bandaging versus SLD + compression bandaging.
MLD + Compression Garments versus Compression Garments + pneumatic pump.
MLD + Compression Garments versus Compression Garment + Self-Drainage (SLD).
MLD + Compression Garments versus Compression bandaging + self-administered simple lymphatic drainage (SLD).

These studies and trials do not mention the possible serious and irreversible side effects that may arise in the short or long term, if Manual Lymphatic Drainage (MLD) is not included during the application of compression therapy in the process of reducing the volume of the oedematous limb, such as the possibility of lymph displacement to previously unaffected areas.

Many lymphedema-related healthcare management studies are only cost-saving non-investment strategy tools. It should be borne in mind that the annual health expenditure for the treatment and maintenance of lymphoedema adds far less in comparison to the cost of treatment for many chronic diseases, and even so, many national health systems do not treat or are undertreating lymphedema.

Early detection and preventive treatment (Preventive Medicine) can reduce overall costs by keeping affected limbs at minimal volumes and other co-morbidities and complications before they become chronic.

For the purposes of the above discussion, some basic and important concepts relating to the treatment of lymphoedema are detailed below:

Manual Lymphatic Drainage (MLD) is part of the conservative treatment known as Complex Decongestive Therapy (CDT). The five components of the Initial Phase I are skin care, manual lymphatic drainage (MLD), multilayer compression bandaging, decongestive exercises, and patient education.

It must be taken into account that the isolated application of individual components is not recommended and, that treatment without Manual Lymphatic Drainage (MLD) does not represent "Complex Decongestive Therapy (CDT).

There is a big difference between the terms "Complex Decongestive Physiotherapy" (CDT) and "Decongestive Lymphatic Therapy" (DLT).

The term "Compression Therapy” is used to describe the compression part of lymphedema therapy, whether it is bandaging or a custom-fitted garment. Edema volume reduction is principally achieved by compression, and wrapping with a low-stretch bandage is the major component of the intensive volume reduction phase.

Isolated compression therapy of the extremities, particularly in those with lymphoedema also affecting the quadrants of the trunk, may increase swelling at the root of the extremity and may even lead to genital lymphoedema.

Manual Lymphatic Drainage (MLD) should always be applied before the compression phase and is not intended to be a stand-alone treatment option. MLD as a stand-alone treatment is used when treating body parts that are not conducive to sustained compression (e.g., face, breast, genitalia, and trunk).

The main functions of Manual Lymphatic Drainage (MLD) are aimed at lymph vessel and lymph node drainage; rerouting of lymph into nonobstructed lymphatics; development of accessory lymph collectors; improvement of lymphatic contractility; and prevention of the displacement of lymph fluid to adjunct areas when lymphatic edema is submitted to compression therapy (bandages/compression pumps) for volumetric reduction.

It must be kept in mind that the primary role of Manual Lymphatic Drainage (MLD) is "NOT" for volumetric reduction.

IMPORTANT NOTICE

Lymphedema is a serious chronic and progressive disease due to an organic disability. The clinical treatment of lymphedema is neither a cosmetic nor an aesthetic treatment. The treatment of lymphedema is to control its progression and alleviate the symptoms related to dysfunction of the lymphatic circulatory system. To prevent and avoid serious complications associated with treatment, such as the possible displacement of edema to previously unaffected areas when compression therapy is applied for volume reduction, patients should use highly specialized and experienced therapists. Professional qualification and instruction delivered remotely online are not the same as live hands-on practical instruction in the clinical training and certification of lymphedema therapists, similar to all other rehabilitation, medical, and surgical training programs, and especially for developing the necessary manual skills to treat a disease as complex as lymphedema.

Patients should also take special care when choosing a "Multidisciplinary Center of Reference for Lymphedema", as not all countries and centers provide the same treatment options. The best choice is a center of reference that provides “Complete Decongestive Therapy (CDT)”, which is recognized as the “Gold Standard” treatment for lymphedema.

Read more about what is the best treatment option for Lymphedema HERE.

Read about what are the principal functions of Manual Lymphatic Drainage HERE.

Read about what are the main differences between the two principal lymphedema treatment protocols HERE.

REFERENCES

(Click on the texts to read the research articles)

SCIENTIFIC SOCIETIES

German Scientific Society Guideline: Diagnostics and Therapy of Lymphoedema.

PATHOPHYSIOLOGY

CUTANEOUS COMPLICATIONS

INFECTIOUS COMPLICATIONS

CELLULITIS / DERMATOLYMPHANGIOADENITIS

TUMOURS

PAIN

TREATMENT

COMPRESSION GARMENTS

DISABILITY

DISFIGUREMENT

QUALITY OF LIFE

PSYCHOSOCIAL IMPACT

PEDIATRIC LYMPHEDEMA

LYMPHATIC FILARIASIS / PODOCONIOSIS

BLOOD VASCULAR SYSTEM

sábado, 4 de febrero de 2023