IV. Conservative Therapy in Lymphology

Abstract

Manuel Cornely¹, Christian Ure², Anett Reißhauer³, Andrzej Szuba⁴, Jean-Paul Belgrado⁵, Katrin Maennel-Emra⁶, Peter Nolte⁷, Isabel Forner-Cordero⁸, Andreas Mittelbach⁹, Karsten Knobloch¹⁰, Chieh-Han John Tzou^{11, 12, 13}

¹LY.SEARCH gGmbH, Duesseldorf, Germany

²Wolfsberg Lymphology Clinic at the LKH Wolfsberg, Austria

³Charité-Universitätsmedizin, Berlin, Freie Universität Berlin and Humboldt Universität zu Berlin, Germany

⁴Faculty of Medicine, Wroclaw Medical University, Wroclaw, Poland

⁵Lymphology Research and Rehabilitation Unit, Université libre de Bruxelles, Brussels, Belgium

⁶Physiotherapy Maennel-Emra, Neumarkt, Germany

⁷Oedema Center Bad Berleburg, Klinik Haus am Schloßpark, Bad Berleburg, Germany

⁸Lymphedema Unit, University Hospital La Fe, Valencia, Spain

⁹Institute for Physical Medicine and Rehabilitation & Physics Association of the Austrian Health Insurance Fund, Vienna, Austria

¹⁰SportPraxis Prof. Knobloch, Hanover, Germany

¹¹Department of Plastic and Reconstructive Surgery, Department of Surgery, Hospital of the Divine Savior, Vienna, Austria

¹²Faculty of Medicine, Sigmund Freud University Vienna, Austria

¹³TZOU MEDICAL., Lymphology Center, Vienna, Austria

Ten qualified speakers will talk about different aspects of conservative therapy.

Christian Ure, the coordinator of the AWMF's S3 guideline on lymphedema, presents the current status, which is currently at the “work in progress” stage. It is impossible to give a precedent for the literature being reviewed, but the progress to date and the planned milestones can be reported.

Anett Reißhauer provides an overview of the therapeutic challenges in clinical lymphology, from infants and small children to multimorbid patients. Only personalised therapy is possible here, which underlines the complexity of medical care. Reißhauer particularly emphasises the interdisciplinary and interprofessional challenge.

After these introductory explanations, Andrzej Szuba provides insight into the physiology and pathophysiology of the lymphatic system, which is localised in all organs and the central nervous system of the bones.

Its task is immune defence, lipid absorption and regulation of the fluid balance. The functionality of interstitial fluid transport is the responsibility solely of the lymphatic system. Such a central key position is emphasised by the knowledge that a functionally disturbed lymphatic system is found in most known diseases. Disorders of the integrity of the lymphatic vessels and their transport capacity potentiate diseases of the cardiovascular system, intestines, lungs, kidneys, bones and cognitive dysfunction.

Three experts will participate in a panel discussion moderated by Manuel Cornely on “The effect of intermittent pneumatic compression, deep oscillation, and compression on lymph flow and tissue.”

Jean-Paul Belgrado explains the effect of compression on lymph flow and tissue. Every form of impact on the tissue has a common denominator: generating directed forces which act superficially and exert pressure. Pressure profiles, measured over time, show that elastic stockings have only a minor effect on compression. Multi-component bandages build up significantly higher contact pressures, as the materials generate higher amplitudes when muscles under the bandage are actively addressed.

Katrin Maennel-Emra focuses on the effect of deep oscillation on deep tissue, generating oscillation through electrostatic attraction and friction. In a pulsating electrostatic field of 5 to 250 Hertz (Hz), the lymph flow is stimulated, fibrosis is softened, and the vibration has a pain-relieving effect. These effects can penetrate up to 8 cm deep and have a decongestive impact. Deep oscillation supports and intensifies manual lymphatic drainage.

Peter Nolte specialises in the effect of intermittent pneumatic compression (IPC) on venous flow, lymph flow, and tissue. This form of technical compression, ideally applied to the extremities using a 12-chamber-system, supports therapeutic procedures such as manual lymphatic drainage.

Current studies show that IPK / AIK is equivalent to MLD in pain therapy for illnesses caused by LiDo.

Decongestive lymphatic therapy, performed with intermittent pneumatic compression and bandages, is not inferior to traditional treatment with additional manual lymphatic drainage but also has no influence on reducing undesirable results or on the progression of lymphedema in the maintenance phase.

MLD and pregnancy - what is permitted, what is possible? Andreas Mittelbach focuses on the continuation of conservative treatment of lymphedema during pregnancy. Not only can the demands on therapists and doctors in terms of patient compliance be considerable, but the question also arises as to whether the treatment of lymphedema during pregnancy represents a risk. Lymphedema must be carefully differentiated from the usual oedematous swelling that accompanies pregnancy. Pregnancy is not a contraindication to complex decongestive therapy, but this should be carefully considered by the patient, therapists and doctors.

Karsten Knobloch concludes this topic block on conservative therapy with an explanation of extracorporeal shock wave therapy (ESWT) in lymphology. This treatment can be used for primary and secondary lymphedema, fibrosis, scars and LiDo. The meta-analysis shows that lymphedema-related swelling can be reduced because vascular endothelial growth factors (VEGF-C) increase significantly, lymphangiogenesis is accelerated, and the modulation of TGF-ß has an anti-fibrotic effect. These effects have been demonstrated in a clinical cohort study on lipoedema, cellulite and secondary arm lymphedema following breast cancer.

Number: 19

Current development of the lymphedema guideline: What are the results for the therapy?

Christian Ure

Wolfsberg Lymphology Clinic at the LKH Wolfsberg, Austria

The development of the S3 guideline is currently in the middle of the “work in progress” stage and can therefore not be prejudiced, which is incorporated into the guideline recommendations in the form of literature currently under review. The course to date and the planned milestones of the given time frame (until 03/2026) were presented. A brief insight into the process (and the hurdles) of the current literature research and grade evaluation was presented.

Number: 20

Anett Reißhauer^{1, 2}

¹Charité-Universitätsmedizin Berlin, Germany

²Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany

The lecture provides an overview of the therapeutic challenges in clinical lymphology.

This involves treating infants and small children through to multimorbid, very old patients with lymphedema. Personalized therapy is clearly the focus. This not only shows the complexity of medical care, but also the effort in every respect. Only through a joint effort, of course interprofessional and interdisciplinary, will it be possible to maintain and ultimately expand high-quality therapy for the treatment of lymphedema.

What a person working in lymphology wants for the future, what ideas and wishes there are, will also be considered.

Number: 21

Update on physiology and pathophysiology of the lymphatic system

Andrzej Szuba

Faculty of Medicine, Wroclaw Medical University, Wroclaw, Poland

ORCID Number: 0000-0002-7555-6201

Introduction/Background: The Lymphatic System (LS) is comprised of interstitial fluid and lymph, interstitial space and lymph vessel network, lymphoid cells in organs or freely migrating (lymph nodes, spleen, bone marrow, thymus, lungs, intestines, liver). LS is present in all organs including the central nervous system and bones. Its function includes immune defense, lipid absorption, and fluid balance. LS is solely responsible for interstitial fluid transport. Lymphatic system disorders traditionally included lymphedema, cancer metastasis and immune or inflammatory responses. Recently, lymphatic system involvement was found in the majority of diseases where it was studied, including atherosclerosis, heart failure, Alzheimer dementia, glaucoma, lung diseases and others.

Conclusion: Lymphatic system is an important player in the pathophysiology of any disease.

Disruptions in lymph transport and lymphatic vessel integrity are powerful potentiators of disease, including CVD, inflammatory bowel disease, lung disease, bone disease, cognitive dysfunction, and chronic kidney disease.

Number: 22a

Panel discussion: The effect of intermittent pneumatic compression, deep oscillation and compression on the lymph flow and tissue.

The compression

Jean-Paul Belgrado

Lymphology Research and Rehabilitation Unit, Université libre de Bruxelles, Belgium

ORCID Number: 0000-0001-6774-1725

The notion of compression lies at the very heart of physical treatment aimed at decongesting lymphedemas.

All the therapeutic tools, among them manual lymphatic drainage, intermittent compression therapy, elastic stocking or multi-component bandages, have as a common denominator the generation of directed forces, which applied to the surface of the tissues exert pressure on them.

Generally, these pressures are often expressed in static terms. Time dimension associated with the variation of these pressures is generally overlooked. The main reason for this is that, until recently, only a few laboratories equipped with suitable pressure sensors had access to these data in real time and over long periods.

Today, technology offers practitioners wireless pressure sensors which can be placed under the compression elements, providing real-time pressure profiles, i.e. not just the pressure values at a given point in time, but also the variation in these pressures over time. These affordable devices provide measurements in mm Hg with very satisfactory reliability. The resolution is around 1mm Hg, with a stability of around 24 hours.

For example, measurements taken under elastic stockings indicate that (regardless of the activity of the muscles beneath them), the compression varies very little and oscillates from 2 to 4 mm Hg around the base pressure (the pressure recorded when the subject is lying down and not moving).

Under multi-component bandages, the baseline pressure recorded immediately after bandaging can be three to four times higher than that recorded under compression stockings. However, this pressure falls very quickly to less than 50% of the baseline pressure after just ½ hour.

The difference observed in the pressure profile is that multicomponent bandages made with suitable foams and bands generate large amplitudes of pressure variation when the subject is actively contracting the muscles under the bandage. This variation in pressure produces a significant and measurable massage which ultimately leads to the decongestive effect.

Number: 22b

Panel discussion: The effect of intermittent pneumatic compression, deep oscillation and compression on the lymph flow and tissue.

The deep oscillation

Katrin Maennel-Emra

Physiotherapy Maennel-Emra, Neumarkt, Germany

Introduction/Background: Deep oscillation is a unique, patented, electromechanical therapy method.

Using electrostatic attraction and friction, the treated tissue segment is made to vibrate pleasantly through all layers.

An electrostatic attraction occurs when a semiconductor (vinyl layer in the form of gloves or coating on a hand applicator) is attached between 2 electrodes and then an electrical voltage is applied.

During treatment, both the therapist and the patient are connected to the therapy device.

Material and Methods: For the application, the therapy device builds up a pulsating electrostatic field with oscillations between 5 and 250 Hz.

The therapist moves the hand or hand applicator with little pressure over the area of the patient's skin to be treated.

As a result, the underlying tissue is electrostatically attracted and dropped again.

Results: The lymphatic flow is stimulated, fibrosis is softened, and the vibrations have a pain-reducing effect.

Hernandez et al. (2010) were able to demonstrate a penetration depth of the depth oscillation of up to 8 cm with diagnostic ultrasound.

Deep oscillation has been successfully used as an adjuvant therapy in numerous clinics around the world for more than 30 years in early post-operative aftercare, including for breast cancer.

Numerous studies prove the effectiveness of the method.

A de-odematising effect could be demonstrated in various RCTs.

Groups with MLD+ deep oscillation, versus MLD alone, were examined.

(Jahr et al. 2008, Boisnic et al. 2013 clin. and ex vivo, Kashilska et al. 2015, Teo et al. 2016)

In studies by Gasbarro et al. 2006, Gao et al. 2015, Teo et al. 2016, Hernandez et al. 2018, an antifibrotic effect was also demonstrated by ultrasound.

Conclusion: Deep oscillation should be understood as an additional treatment option for manual lymphatic drainage.

It is intended to intensify therapy in a supportive way, but not to replace MLD.

Number: 22c

Panel discussion: The effect of intermittent pneumatic compression, deep oscillation and compression on the lymph flow and tissue.

The intermittent pneumatic compression (IPK)

Peter Nolte

Oedema Center Bad Berleburg, Clinic - Haus am Schlosspark, Bad Berleburg, Germany

Background: The treatment of venous and lymphatic reflux diseases is complex and, when comparing the recommendations, always describes the context of an absolutely necessary compression therapy. This compression therapy is often accompanied by various supportive therapy methods such as manual lymphatic drainage (MLD) and intermittent pneumatic compression (IPK), synonymously also referred to as apparatus intermittent compression therapy (AIK).

Goal: Indisputable effectiveness of IPK/AIK can be deduced based on the recommendations in various guidelines for the use of this instrumental therapy. In particular, reference should be made here to the variance of indications for alleviating the symptoms by improving the flow properties and reducing oedema as well as pain therapy.

Method: Comparison of the statements of the professional societies in consensus on the use of IPK/AIK in the guidelines published in Germany.

Results: In Germany, IPK/AIC is widely used in the treatment of lymphedema for supportive oedema reduction. Current studies show that in pain therapy for lipoedema, IPC/AIC is equivalent to MLD and is therefore a far more economical therapy option.

However, it has been shown that the use of IPK/AIK can be used in an interdisciplinary manner due to its effectiveness in a number of other indications.

Number: 23

Physical therapies in the decongestive treatment of lymphedema: A randomized, non-inferiority controlled study

Isabel Forner-Cordero

Lymphedema Unit, University Hospital La Fe, Valencia, Spain

ORCID Number: 0000-0003-2778-037X

Introduction:

Objective: To assess whether the treatment with intermittent pneumatic compression plus multilayer bandages is not inferior to classical trimodal therapy with manual lymphatic drainage in the decongestive lymphedema treatment.

Material and Methods:

Study Design: Randomized, non-inferiority, controlled study to compare the efficacy of three physical therapy regimens in Decongestive Lymphatic Therapy.

Participants: 194 lymphedema patients, stage II-III with excess volume >10% were stratified within upper and lower limb and then randomized to one of the three treatment groups. Baseline characteristics were comparable between the groups.

After DLT, garments were prescribed (flat-knitted, custom-made, ccl2 UL, and ccl3 LL).

End-point: Percentage reduction in excess volume (PREV).

Relative-volume change

Progression: RVC > 10%.

Results: All patients improved after treatment. The global mean of PREV was 63.9%, without significant differences between the groups. The lower confidence interval of the mean difference in PREV between group B and group A, and between group C and group A were below 15%, thus meeting the non-inferiority criterion.

Most frequent adverse events were discomfort and lymphangitis, without differences between groups. A greater baseline edema, an upper-limb lymphedema and a history of dermatolymphangitis were independent predictive factors of worse response in the multivariate analysis.

Global mean RVC was 1.95%, 4.2% and 5.76% at 1, 6 and 12months after the end of DLT, respectively, without differences between groups.

The rate of progression was 28.7% without differences between groups.

Conclusion: Decongestive lymphatic therapy performed only with IPC plus bandages is not inferior to the traditional trimodal therapy with MLD. This approach did not increase adverse events and didn't have any effect on the progression of lymphedema during maintenance phase.

Number: 24

Accounts of experiences in care during pregnancy and patients with infants

Andreas Mittelbach

Institute for Physical Medicine and Rehabilitation & Physikoverbund, Austrian Health Insurance Fund, Mein Gesundheitszentrum Neubau, Vienna, Austria

Introduction/Background: Continuation of conservative therapy for known lymphedema is indicated during pregnancy. There is evidence for the increased occurrence of swelling — particularly of the lower extremities — during pregnancy, and therefore compression therapy is recommended. However, as additional stress is placed on the body during pregnancy and after childbirth, there are risk factors that must be considered by medical professionals during treatment via complex decongestive therapy. Beyond the medical risks, there is also a greater demand on therapists and physicians to ensure patient compliance.

Despite these specific circumstances, robust literature on the subject is sparse to nearly non-existent. Risk factors during pregnancy and the postpartum period are well-researched. The side effects, risks, and contraindications of complex decongestive therapy are also outlined in guidelines. However, in scientific studies, these topics rarely overlap.

Results: Critical considerations in this therapeutic context involve accurately differentiating types of edematous swelling, evaluating impacts on vital parameters, notably blood pressure, and monitoring immune system modulation, which may lead to allergic or inflammatory responses. Furthermore, the elimination of potential environmental confounders within the therapeutic setting is essential to optimise patient compliance.

Conclusion: Administering complex decongestive therapy during pregnancy is feasible but necessitates meticulous attention to specific procedural nuances. Collaborative exchange of clinical experiences among therapists and physicians specializing in conservative lymphedema management is therefore paramount. Systematic data collection on this patient subgroup is recommended to support the development of standardized care protocols and promote adherence to therapeutic regimens.

Number: 25

Abdominal lymphedema

Christoph Ausch

Chirurgie am Küniglberg,Vienna, Austria

Not submitted

Number: 26

Extracorporeal shockwave therapy in lymphology

Karsten Knobloch

SportPraxis Prof. Knobloch, Hannover, Germany

Introduction/Background: Extracorporeal shockwave therapy (ESWT) uses acoustic wave to elicit a biological response via mechanotransduction. This systematic meta-analysis seeks to evaluate all experimental and clinical studies on ESWT on the lymphatic system for indications like primary & secondary lymphedema, lipoedema, cellulite and fibrosis/scarring.

Material and Methods: A standardized search with the following search terms was done: #lymphedema #shock wave therapy #cellulite #fibrosis #lymphangiogenesis within the MEDLINE, EMBASE, PubMed, and the Cochrane Library. According to the PRISMA recommendation for systematic meta-analysis the relevant data were extracted and analyzed in detail.

Results: 54 full papers were identified based on the aforementioned search terms. In animal experiments in a lymphatic rabbit ear model focused ESWT (12 sessions, 0.09mJ/mm²) improved lymphatic vascular endothelial growth factor (VEGF-C) significantly and reduced ear swelling. Focused ESWT accelerates lymphangiogenesis and exerts antifibrotic effects by modulation of the TGF-ß-pathway. Clinically, a cohort study in 2005 in 26 lipoedematous females with cellulitis found that focused ESWT (0.016mJ/mm², 1000 shots, 3–6 sessions) reduced lipoedema and improved the extent of cellulitis significantly. Of note, the more ESWT sessions were applied, the better the elasticity. In ESWT in cellulitis, 12 clinical studies (with 5 randomized-controlled trials) have been published, which will be presented separately in a metaanalysis. In secondary lymphedema of the upper extremity in breast cancer and axillar lymphonectomy, both radial and focused ESWT have been reported to be successful in swelling reduction and pain improvement. Bae & Kim from South Korea reported a 37% reduction of arm swelling after 4 focused ESWT sessions (0,056mJ/mm² electrohydraulic focused ESWT, 2000 shots). Cebicci from Turkey highlighted radial ESWT with 12 sessions as successful in secondary lymphedema with 31% improvement of swelling.

Conclusion: In lymphology, extracorporeal shockwave therapy (ESWT) improves lymphangiogenesis by VEGF-C-stimulation, facilitates swelling reduction and clinically reduces pain.

Number: 27

Workshop: ICG-guided decisions and visualization of lymphedema

Jean-Paul Belgrado

Lymphology Research and Rehabilitation Unit, Université libre de Bruxelles, Belgium

ORCID Number: 0000-0001-6774-1725

The lymphatic system is invisible to the human eye because of its transparency. After an intradermal injection of highly diluted ICG, the superficial lymphatic system draining the injected area appears visible, thanks to a dedicated infrared camera.

The workshop aims to show in real time, on two volunteers, one affected with lymphedema and one without, typical steps of ICG lymphography exam. Based on observable evidence, we will show and discuss: the diffusion of the dye from the injection point, the lymph progression in normal and pathological conditions, the contingencies of lymphangion valves and other characteristics of updated knowledge of lymphatic physiology and physiopathology.

Impress your eyes: In this workshop you will see the superficial lymphatics and the lymph flow in real time on normal and pathological condition. Invisible lymphatics becomes visible, thanks to Indocyanine green (ICG) lymphography. It can be used in the diagnosis of lymphedema and for the planning of surgical therapy and also for the physical treatment.

Topics

ICG lymphography provides specific dynamic images to help diagnose lymphedema.

Dynamic testing of the physiology of the superficial lymphatic collectors

Clinical cases of primary and secondary lymphedema observed under the eyes of ICG lymphography.