Complete Decongestive therapy is also called Combined, Complex or Comprehensive Decongestive Therapy. All refer to the same method known as CDT. CDT is the main treatment for lymphedema. Experts who treat lymphedema consider CDT the “gold standard” of treatment. CDT has been shown to be safe and effective. CDT consists of an initial reductive phase (Phase I) followed by a maintenance phase (Phase II). In Phase I, the main goals are reducing the size of the affected part and improving the skin. After Phase I, the person with lymphedema needs to continue into Phase II, an ongoing, individualized self- management phase to make sure the gains of Phase I are maintained long term.
Effects of CDT are to:
Components of CDT
Manual lymph drainage (MLD), multi-layer, short-stretch compression bandaging, remedial exercise, skin care, education in LE self-management, and elastic compression garments comprise CDT.
Frequency and Duration of CDT
Optimally, CDT is performed daily until the reduction of fluid volume has plateaued, often after 3 to 8 weeks.
Therapist Training
Therapists providing CDT should have completed at least 135 hours of training as recommended by the Lymphology Association of North America (LANA). (See NLN Training Position Paper.) Additional specialty training may be required for therapists treating facial, truncal, and genital LE, or LE in the context of advanced systemic
illness.
Manual Lymph Drainage Manual lymph drainage is a specialized manual (hands-on) technique which stimulates superficial lymphatic vessels. MLD may direct lymphatic flow out of congested areas and into functional lymph node basins.
Compression Bandaging
Multiple layers of short-stretch bandages are applied to the lymphedematous area(s). Short-stretch bandages have limited extensibility under tension (50%), in contrast to AceR bandages (300%). To achieve an effective compression gradient, bandages must be strategically applied with low to moderate tension using more layers in the distal, relative to the proximal, portions of the affected territory(ies). Pressure within the short-stretch bandages is low when the patient is inactive, “resting pressure”. Muscle contractions increase interstitial pressure, “working pressure”, as muscles expand within the limited volume of the semi-rigid bandages. Interstitial cycling between low resting and high working pressures creates an internal pump that encourages movement of congested lymph along the distal to proximal gradient created by bandaging. The non-elastic bandage sheath also counters refilling of fluid and reduces tissue fibrosis which further reduces volume.
LE Exercises (Remedial Exercise)
LE exercises are beneficial for all patients. Although activity and exercise may temporarily increase fluid load, appropriate LE exercises may enable the person with LE to resume exercise and activity while minimizing the risk of exacerbation of the swelling. Compression garments or compression bandages must be utilized during exercise to counterbalance the excessive formation and stasis of interstitial fluid. (See NLN Exercise Position Paper for exercise guidelines.)
Skin and Nail Care
Meticulous hygiene is recommended to decrease dermal colonization with fungus and bacteria. Low pH moisturizers should be applied to limit dermal desiccation and microbial growth.11 Because of impaired local immunity in a lymphedematous limb, breaks in the skin may allow entry of bacteria and result in serious infections. (See NLN Position Paper on Risk Reduction.)
Compression Garments
Following maximal volume reduction with Phase I CDT, patients should be fitted with a compression garment. Properly fitted garments are essential for long-term control of LE volume. Garment style and compression strength should be prescribed to enhance patient compliance and volume control. Garments should be washed regularly to maximize the garment’s longevity and effectiveness. Garments must be replaced at regular intervals.
Patient Education
LE is a life-long condition. Patient education in self-management techniques is therefore a critical dimension of effective treatment. All LE patients should be taught LE risk reduction, self- manual lymph drainage, the importance of skin care, the signs and symptoms of cellulitis, the proper fit and care of garments, the importance of weight control, and an individualized LE exercise program. Emphasis on specific LE self-care elements should be adjusted on a case-by-case basis.
Modifications and Individualization of CDT
CDT programs should be individualized based on the presence of concomitant medical conditions. Patients with wounds, musculoskeletal problems, adhesive scars, or post-radiation fibrosis causing limited mobility of the involved area or areas adjacent to the swelling, may require adjunctive therapeutic interventions in addition to CDT.
Alternative non-elastic compression devices are often helpful adjuncts to simplify nighttime compression. These devices may enhance Phase II CDT effectiveness in persons who are unable or unwilling to apply traditional short-stretch compression bandages. In selected cases, they may be useful during Phase I treatment in combination with short-stretch bandaging.
Pressotherapy (Intermittent Pneumatic Compression, “Compression Pump”)
Pressotherapy is not a component of conventional CDT. Pressotherapy may be used as an adjunct to CDT.16 Pressotherapy involves insertion of the lymphedematous extremity into a multi-cell inflatable appliance, which is attached to an air compression pump. Sequential inflation and deflation of the cells creates a distal to proximal compression wave that moves the water component of the lymph and interstitial fluid out of the affected territory. There is a two-phase pump that creates a proximal to distal gradient (preparation phase) and a distal to proximal gradient (drainage phase) to simulate MLD.
Pressotherapy can decrease capillary filtration, thereby decreasing lymph formation. Pressotherapy does not accelerate lymph return 17 and does not enhance the removal of the excess protein component of lymphatic fluid. Potential complications of pressotherapy include displacement of the edema to the proximal limb, adjacent trunk and/or genitalia. A fibrosclerotic ring may develop above the proximal end of the pump appliance, further obstructing lymphatic flow. The use of a pump should be supervised by a trained therapist or healthcare provider experienced in lymphedema management. Pump pressures generally range from 30-60 mmHg.
