The lymphatic system is a one-way system that originates from the interstitial spaces and collects substances that cannot be absorbed by the circulatory system. It transports lymph fluid from the tissues and drains it into the venous circulation. It can be thought of as a cleansing system that collects cellular and tissue waste, filters harmful cells like bacteria, and returns the fluid to circulation. Lymph fluid contains water, proteins, fats, microorganisms, extravascular blood cells, lymphocytes, and even cancer cells. Therefore, it has a close relationship with the immune system.
Lymph Nodes
Lymph nodes are stations where harmful substances from lymph fluid, which flows from under the skin, are filtered. They produce antibodies and lymphocytes. Lymph nodes are mostly found in the intestines, head and neck region, underarms, and groin area.
Lymphedema
Lymphedema occurs when the lymphatic circulation is disrupted due to congenital or acquired causes, leading to the accumulation of protein-rich interstitial fluid either generally or in specific regions. It can develop after trauma, venous diseases, surgery, infections, or cancers. Lymphedema usually presents with asymmetrical involvement. It can be unilateral or, if bilateral, one side is more swollen than the other.
Lymphedema is classified into three stages. In the early stages, the swelling is softer. When pressed with a finger, a temporary indentation remains in the skin, a condition known as pitting edema. In the later stages, known as elephantiasis, the tissues become harder, skin color changes occur, and other skin problems emerge. As the tissue becomes firmer, it no longer leaves a pitting effect. The earlier physiotherapy interventions are initiated, the more successful the outcomes will be. Compression devices are ineffective in the first and second stages of lymphedema and may even harm the lymphatic system.
Goals of Complex Decongestive Physiotherapy
- Reduction of lymphedema volume and maintenance of the reduction
- Prevention or reduction of fibrotic tissue formation
- Prevention of potential complications
- Improvement in the cosmetic and functional aspects of the affected limb
- Enhancement of venous return
- Reduction of pain
- Decrease in sympathetic response while increasing parasympathetic response
- Improvement in quality of life
Complex Decongestive Physiotherapy (CDP) Consists of Two Phases
Phase 1:
Includes skin and nail care, manual lymphatic drainage, multilayer bandaging, and an exercise program. The goal in this phase is to reduce swelling. It is applied 5 days a week for 3-4 weeks. Each session lasts 45-50 minutes and consists of manual lymphatic drainage, skin care, and bandaging. Circumferential measurements are taken at the beginning and weekly thereafter to monitor the reduction in swelling. Once the swelling reduction plateaus, the patient moves on to Phase 2.
Phase 2:
The aim of Phase 2 is to maintain the gains achieved in Phase 1. Compression garments tailored to the patient’s measurements help maintain volume. At night, self-bandaging or night compression garments prevent re-swelling. Exercises are adjusted for Phase 2 and taught to the patient. Lifelong exercise and breathing techniques are essential for these patients. These prevent muscle weakness caused by reduced movement due to swelling and support circulation by acting as a pump through muscle contractions during exercise.
A patient diagnosed with lymphedema by a specialist should attend follow-up sessions at 1, 3, and 6 months after manual lymphatic drainage and decongestive physiotherapy. Circumferential measurements, muscle testing, and normal joint mobility assessments are repeated. If the patient consistently performs exercises and wears compression garments daily, they can maintain their condition without swelling. Compression garments should be replaced every 9 months to 1 year. The patient should avoid anything that could increase the risk of infection throughout life. Personal hygiene should be meticulously maintained, and risk factors such as insect bites and walking barefoot on soil should be avoided.
Lipedema
Lipedema is a chronic and progressive fat tissue disorder characterized by an abnormal increase in subcutaneous fat tissue, especially in the legs. Due to structural impairments, tissue elasticity decreases, and the return of fluid to the lymphatic system diminishes, leading to fluid accumulation in the fat tissue. It presents with symmetrical involvement and is generally painful. Hormonal factors and genetic predisposition play a role in its development. It may appear during puberty or pregnancy even in the absence of prior symptoms. Swelling decreases and symptoms improve with rest. Lipedema can coexist with lymphedema and venous insufficiency.
Treatment for lipedema also begins with manual lymphatic drainage and bandaging. Once drainage stabilizes, compression garments are introduced. Unlike in lymphedema, compression devices may be effective in lipedema management.
Manual Lymphatic Drainage and Decongestive Physiotherapy in Post-Surgical Recovery
Manual lymphatic drainage and decongestive physiotherapy should also be applied after liposuction or aesthetic surgeries to enhance the success of the intervention and minimize the risk of recurrence.
In both lymphedema and lipedema, as well as after surgical interventions, compression garments alone may not be sufficient without proper drainage. It is essential to first reduce swelling before prescribing compression garments.
Canan ÖZKAN
Physiotherapist
