What to Expect During Lymphedema Treatment

John Fuller Beckwith3/11/2024

Complete Decongestive Therapy (CDT) is a collaboration between the Certified Lymphedema Therapist (CLT) and the patient. The best outcomes are achieved when standard guidelines are followed. In the first phase of CDT the therapist does the bulk of the work yet the patient does their part as well. Below is a general outline of what to expect during treatment for lymphedema. CDT is highly effective and the comprehensive nature of this system of treatment is central to its effectiveness.

Frequency of therapy visits/Duration of therapy course

For best results therapy is recommended five days per week and may taper to a lower frequency after several weeks. There are a number of reasons for this: daily treatments allow for consolidation of gains made by the previous treatments; they allow for optimal skin care; as reductions in fluid and fibrosis progress they allow for additional progress that would otherwise be lost to backsliding; contrary to some views, daily treatments are more likely to mean less overall number of visits than when visits are 3 or less times per week; and finally it means the goals of therapy are reached more quickly so the patient spends less time in the bandages and less time in treatment. Of course, it is recognized that important factors may argue against daily treatments. Different levels of severity of lymphedema, transportation, and financial factors, to mention a few, can affect the recommendation. In these cases modifications are made to the recommendations in order to provide the treatment that works best for each individual. Depending on the progression of the lymphedema, most treatments can reach a good outcome within a few weeks. Again, if the frequency of visits is less, the treatment course itself will take many more weeks, even months.

A typical CDT treatment session

Typical CDT treatment sessions last between one to two hours depending on the severity of the lymphedema, the number of body areas involved and perhaps related health issues such as the presence of skin ulcers. Sessions may be shorter than an hour if the lymphedema is in a very early stage or the treatment is almost complete and in the transition to self- care. A typical session includes: removal of bandages; skin care including cleansing the limb, inspecting the skin closely for integrity and changes in the edema/fibrosis/hyperkeratosis and application of moisturizing lotion; a sequence of Manual Lymph Drainage (MLD) done by the CLT customized to the individual case; finally the CLT will newly apply the skilled lymphedema compression bandage with all components and modified as clinically indicated in order to optimize progress. MLD typically takes 30-45 minutes. Most treatment sessions have an ongoing educational component. While progressive treatment sessions may appear the same each visit, the therapist is continually looking at the whole person as well as assessing the changes in the tissue in order to determine appropriate modifications that could be made. The general expectation is that appreciable progress can be made each visit and each week of treatment.

Bandaging

When swelling is present, the goal of the first phase of CDT is to decongest the swelling – reduce it. This requires compression bandaging. Lymphedema compression bandages are a highly skilled and specialized intervention and are adapted to each individual; and are therefore applied by the therapist at each visit. The bandages are meant to be worn 24 hours per day during the in-clinic phase of treatment in order to ensure progress and to be sure that sustained decongestion occurs. If the bandages come off for one reason or another, the edema will begin to return. Of course, the bandages should be removed if they are causing pain or discomfort, but to be effective, they must ultimately stay in place. Your therapist should be able to modify the bandages so they remain comfortable and progress is achieved. Additionally, since the bandages are worn for 24 hours per day, whether on the upper or lower extremity, some compromises to a person’s daily routine may be necessary. For both arm and leg bandages, showering can present a challenge. Some people are able to obtain/create a way to cover the bandages such that the bandages don’t get wet, which allows for regular showering. When not able to do this, many folks are okay to sit by the sink and perform a, “bird bath,” washing the body at the sink. Please be aware that removing the bandages and showering just before coming to a treatment visit is not recommended. If the hand/arm is in the compression bandage, working around running water is definitely a challenge. Additionally, shirts and tops will need to have enough room in the sleeve to allow for the bandage. If it is a leg/foot bandage, slacks or pants may be too narrow to accommodate the bandage so pant legs with more room will be needed. Footwear is often a challenge. Patients in foot/leg bandages may need to procure footwear that accommodates the compression bandage. These potential compromises are again another reason to favor daily treatments so that the time in the compression bandage is shorter.

Compression Garments/Transition to Self-Care

An important element in the first, intensive phase of CDT is preparation for the second, self-care (or optimization) phase of CDT. During phase one, the CLT is taking opportunities to teach the patient about management of lymphedema, the importance of the 4 elements of CDT (compression, MLD, skin care, exercise) and then, as the intensive phase begins to wind down, to customize and impart the plan for self-care. The cornerstone of self-care is the use of compression garments. Garments are the tool for compression during self-care and take the place of the skilled compression bandaging used during the intensive phase. In order to be successful in self-care, most persons need more than one type of compression garment, so we could say each person gets a compression ‘tool box.’ The CLT will discuss and plan with the patient a recommended compression ‘tool box.’ The challenge can be determining payment for the garments, whether by insurance or self-pay. Once that is determined, a method of measurement/fitting for the garments is arrived at and the garments are ordered. They may take a few weeks to arrive. While awaiting arrival of garments, treatment sessions focus on instruction in other aspects of self-care. There will be less frequent clinic visits as the patient takes on more aspects of self-care at home. Once the garments arrive, they are checked for fit, instruction/practice is provided for applying and removing the garments. Before discharge there are generally a few more visits to ensure self-care is going well and to fill in gaps in instruction.