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Lymphedema and Laser Therapy

Lymphedema of the extremities remains a therapeutic challenge. Massage therapists have techniques available to them for treating lymphedema, with promising levels of success. Use of low-intensity laser therapy has also demonstrated effectiveness for this condition and is being used by a growing number of manual practitioners as a primary, and/or adjunct therapy to manipulation and massage.


October 21, 2010
By Fred Kahn MD FRCS (C)

Topics

Lymphedema of the extremities remains a therapeutic challenge. Massage therapists have techniques available to them for treating lymphedema, with promising levels of success. Use of low-intensity laser therapy has also demonstrated effectiveness for this condition and is being used by a growing number of manual practitioners as a primary, and/or adjunct therapy to manipulation and massage.

 This article aims to educate massage therapists on the potential benefits of laser therapy with respect to lymphedema by describing the condition and how it can be addressed using this technology. Although suggestions for combining specific massage techniques with laser therapy are not within the scope of this article, the author suggests that a broader approach to lymphedema, incorporating this technology into practice, could enhance treatment efficacy.

SOME BASIC FACTS ABOUT LYMPHEDEMA
Two types of lymphedema occur – primary and secondary. Primary lymphedema is rare, and results from a congenital abnormality of the lymphatic system. Secondary lymphedema is the most common form and results from the interruption or obstruction of the lymphatic channels. Secondary lymphedema may be categorized as acute or chronic. The acute type is generally secondary to trauma and is easily resolved by conventional methods. The chronic version is a more vexing condition, generally only minimally improved by technologies currently in use, with recurrence when therapy ceases. Most frequently, chronic lymphedema occurs post-mastectomy and following a variety of other surgical procedures that involve disruption of the lymphatic channels and nodes. It also occurs secondary to congestive heart failure, chronic liver disease, thrombophlebitis and gravitational dependency.

AcuteChronic
Objective
• Trauma
• Surgery
• Burns
Subjective
• Thrombophlebitis
• Congestive Cardiac Failure
• Immobilization
• Dependency
• Post Radiation
• Renal Failure
• Hepatic Disease
• Systemic Infection
• Genetic

Figure 1

Conventional Therapies
1. Elevation of extremity above level of heart
2. Variety of compression techniques
     i. Pumps
     ii. Bandages
     iii. Fitted garment
3. Manual procedures
     i. Massage
     ii. Compression

Figure 2

ETIOLOGY
MECHANISM AND PHYSIOLOGY

Edema of the extremities and other anatomical regions results from the abnormal collection of fluids and proteins in the superficial connective tissues. These substances have not been absorbed by the lymphatic system. Their composition consists of transudate from the cells or exudate from the lymphatic and vascular channels. Duration varies from days to years. Chronic lymphedema is characterized by firm induration and cyanosis as arterial compression progresses.

It should be noted that there is no effective drug therapy available. Diuretics are frequently utilized but not recommended for long-term use. The conventional therapies listed in Figure 2 do not, on their own, provide long-term solutions. Outcomes are usually limited, at best, and require prolonged periods of treatment without permanent relief or cure.

Use of low-intensity laser has proven effective to treat this situation and can be used in conjunction with the therapies listed here. The following are case studies demonstrating the use of low-intensity laser alone.

leg.jpg
Left: Initial, pre-treatment. Right: After 10 treatments, mid-calf
circumference equal to left leg.


CASE PROFILE NUMBER 1
80-year-old male
Diagnosis – Chronic lymphedema, right lower extremity.
Duration – Three to four years, progressive in nature.
Etiological factors – Post harvesting long saphenous vein (coronary bypass procedure) and gravitational dependency. Recurrent congestive heart failure
Findings – Initially affected extremity circumference, mid-calf 6 cm greater than opposite side. Non-pitting induration, moderate cyanosis, poor venous filling, no palpable pulse distal to femoral pulse.
Low-intensity laser treatment regimen – Ten one-hour sessions over a four-week period. Treatment was applied over the sympathetic nervous system and locally.
Outcome – No regression or recurrence noted at four months post cessation of treatment.

Outcome
Objective Subjective
Mid-calf circumference same as opposite side Absence of sensation of heaviness, chronic aching
Resolution of cyanosis and induration Activity level restored to normal
Restoration of venous filling and peripheral arterial pulses   
Normal skin temperature   

CASE PROFILE NUMBER 2
58-year-old female
Diagnosis – Chronic lymphedema of left lower extremity with accompanying cellulitis.
Duration – Since 1986, when patient underwent a liver transplant that was precipitated by hepatitis and hepatic failure.
Etiological factors – Thrombophlebitis of deep veins. Anti-rejection medications. Hypoalbuminemia. Gravitational dependency.
Findings – Initially right leg mid-calf circumference was 35 cm. Left leg mid-calf circumference was 43 cm.
Low-intensity laser treatment regimen – Circumferential technique utilized in nine one-hour sessions over three weeks. Therapy was applied locally.
Outcome – Left leg mid-calf circumference – 38 cm. Cellulitis 90 per cent resolved without antibiotics.
(Note: While this article was being written, the patient moved away and was continuing low-intensity laser treatment at another facility.)

leg2.jpg
Left: Initial, pre-treatment. Right: After nine treatments, mid-calf
circumference diminished by five centimetres.


Laser therapy technique for lymphedema
Large surface treatment arrays are applied in a circumferential fashion to the affected areas. In these situations, arterial circulation is compromised; in order to relieve this and enhance reduction of the edema, low-intensity laser therapy may also be applied to the appropriate dermatomes of the spinal column, resulting in a sympathectomy-type effect. This technique can be used in the treatment of edema in both the upper and lower extremities, and accelerates resolution of the pathology and its ensuing complications.

CONCLUSION
Low-intensity laser therapy is effective in the treatment of both acute and chronic lymphedema. In our experience, notwithstanding duration of the condition, the response is rapid, with elimination of the condition in less than four weeks. The therapy is painless for the patient, and very cost effective for both the patient to receive and the practitioner to use. Training for certification in the use of laser therapy is available through a number of channels, with CEU credits offered in various jurisdictions. The treatment can be used on its own or as an adjunct therapy to manipulation and/or massage.


REFERENCES

  • Browse, N., Burnand, Kevin G., and Mortimer, Peter S. Disease of the Lymphatics, Arnold Publishers, 2003.
  • Guyton, A.C., and Hall, J.E. Textbook of Medical Physiology, Tenth Edition, Philadelphia: W.B. Saunders Company, 2000.

Dr. Fred Kahn is a Fellow of the Royal College of Surgeons of Canada and a Diplomate of the American Board of Surgery. He received post-graduate training at the Montreal Children’s Hospital, the Massachusetts General Hospital and Baylor University Medical Centre in Houston, Texas. Currently, Dr. Kahn is the President and Chief Executive Officer of Meditech International Inc., the developer and distributor of the BioFlex Series of Laser Therapy Systems. For more information on Dr. Kahn and Meditech International Inc., please visit http://www.meditech-bioflex.com or call 1-888-557-4004.


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