[decorative logo] Lymphovenous Canada: How effective are pneumatic pumps in treating lymphedema?

A clinician shares her experiences
using pneumatic pumps on patients with lymphedema

Although pneumatic pumps have been used for many years, there has been some debate on their effectiveness. Recent studies suggest that pumps can play a useful role in treating lymphedema, chronic venous stasis ulcers/associated venous insufficiency, and that claims pumps are harmful are highly exaggerated (Cervantes, 2010)1.; (Adams, 2010)2..

A systemic review3. from 2004-2011 on the use of Intermttent Pneumatic Compression (IPC), found that the use of IPC in treating lymphedema is well-founded in the literature. Evidence supported compression ranges in the range between 30 - 60 mmHg, however no clear single Best-Practice guideline for IPC emerged as preferencial. The International Compression Club has also reported on the dearth of IPC research and has called for clinical trials in this area.

Cautions do exist on using pumps. They are not recommended during episodes of inflammatory phlebitis or pulmonary embolism (blood clots). Some researchers (Boris, 1998)4. have suggested that lower limb users may be at risk of developing genital lymphedema while others (Brennan, 1998)5. have warned against using a pump during an infection, metastatic disease and ongoing radiation. As with any treatment, patients should consult with their doctor and/or licensed and reputable health care professionals before embarking on any treatment regime.

Some clinicians in the area have suggested that multi-chamber (segmented) pumps with calibrated pressure gradients are more effective than single chamber pumps without gradient pressure, although an American evaluation undertaken in 2009 with the McMaster University Evidence-based Practice Centre6. (building on an earlier study in 1998 by the Blue Cross Blue Shield Technology Evaluation Center) comparing the efficacy of different types of pneumatic extremity pumps found there was " insufficient evidence to permit conclusions regarding whether the efficacy of lymphedema pumps varied across pump type." The study noted however that therapy-specific adverse effects (not edema) occurred in less than 1% of patients.

A study undertaken by the Faculty of Physiotherapy, University of Physical Education, and Department of Internal Medicine, Wroclaw Medical University 7. notes that: "The present results have not confirmed the presumption, which prevails in the literature, that sequential compression using a multi-compartmental sleeve is more effective than application of a single-compartment sleeve in reducing lymphedema of upper extremity."

The study concluded that:
1. Intermittent pneumatic compression is an effective method to decrease lymphedema of the upper extremities in subjects following treatment of breast cancer independent of cycle type and compression sequence.
2. Changes in number of sleeve chambers induced no significant differences in efficacy of IPC between its various cycles.
3. In the course of the shorter compression cycle, higher efficacy of the IPC procedure has been obtained using the cyclic sequential massage.

Most researchers recommend the use of compression garments to maintain the reduction of edema after pump use. Many suggest conservative treatments such as elevation, exercise, massage and the use of compression garments prior to using extremity pumps.

More objective evidence-based research is clearly called for to determine under what conditions extremity pumps work most effectively on persons who have lymphatic conditions or those with wound care needs/venous insufficiency - particularly given the range of new pneumatic pump designs on the market. Research on these new designs may identify outcomes which are quite different than those of older designs. In addition, outcomes for individuals with upper extremity lymphedema versus lower extremity lymphedema and those with primary versus secondary lymphedema may also vary.

1. Cervantes, C., and Orphey, S. Pneumatic Compression for Venous Stasis Ulcers and the Implications of Lymphedema on Delayed Wound Healing. Today's Wound Clinic, November 2010.

2. Adams, K., Rasmussen J., et al. Direct evidence of lymphatic function improvement after advanced pneumatic compression device treatment of lymphedema, 2 August 2010/Vol. 1, No.1/Biomedical Optics Express.

3. J.L. Feldman, N.L. Stout, A. Wanchai, B.R.Stewart, J.N. Cormier, J.M. Armer. Intermittent Pneumatic Compression Therapy: A Systemic Review. Lymphology 45 (2012) 13-25.

4. Boris M, Weindorf S, Lasinski BB. The risk of genital edema after external pump compression for lower limb lymphedema. Lymphology 1998 Mar;31(1):15-20

5. Brennan MJ. Lymphedema Following the Surgical Treatment of Breast Cancer:A Review of Pathophysiology and Treatment, Journal of Pain and Symptom Management 1992;7:110-116.

6. Oremus M, Dayes I, et al. Diagnosis and treatment of secondary lymphedema. McMaster University Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality Technology Assessment, Blue Cross of Idaho MP 1.01.18 Pneumatic Compression Pumps for Treatment of Lymphedema.

7. U. Pilch, M. Wozniewski, A. Szuba, Influence of Compression Cycle Time and Number of Sleeve Chambers on Upper Extremity Lymphedema Volume Reduction During Intermittent Pneumatic Compression, Lymphology 42 (2009) 26-35.

8. Kozanoglu, Erkan, et al, Efficacy of pneumatic compression and low level laser therapy in the treatment of postmastectomy lymphoedema, Clinical Rehabilitation, Vol. 23, No. 2, 117-124 (2009). While both groups were found to benefit from both types of treatment in this randomized trial carried out in Turkey, those receiving laser therapy had better long-term results than those receiving pneumatic compression.

A Retrospective Study of the Effects of the Lymphapress Pump
on Lymphedema in a Pediatric Population

Lymphology 34(2001) 156-165
by A. Hassall, C. Graveline and P. Hilliard,
Dept. of Rehabilitation Services, the Hospital for Sick Children, Toronto, Ont.

This study reported positive results from the use of the Lymphapress pump (LP, Global Medical Imports, Digby, N.S., Canada) studied retrospectively on 16 children with primary or secondary lymphedema of the upper or lower extremities by measuring the volume and circumference of the limbs before and after treatment.

The study notes that clinicians at the Hospital for Sick Children have used the Lymphapress Pump (LP) with no noticeable side effects. They state in the study that although advocates of manual lymph drainage maintain that use of the LP leads to the development of fibrous bands which further impede lymph drainage or produce lymphedema in unaffected limbs, the effectiveness of physiotherapy in the management of lymphedema has not be documented. "No randomized controlled trials in adults or children have been reported. No study of these two therapies has produced statistically significant findings in favour of one over the other."

The study reported that 88% of their subjects experienced no complications directly arising from pump use. The more serious complications of lymphedema, genital and truncal edemas did not appear to be caused by the pump nor did it cause lymphedema in the unaffected limb.

"The boy with bilaterial LE lymphedema and edema of the groin and scrotum was reluctant to discontinue pumping despite these regional swellings, because he had a decrease in infectious episodes while on treatment. It remains unclear whether pumping when these co-morbid conditions are present is harmful."

They conclude by suggesting that more research is needed:

Some flaws with the study are noted in the editorial "Pumps and Lymphedema" (pgs. 150-151) - such as:

Clinical practice guidelines: pneumatic compression pumps

From: Clinical practice guidelines for the care and treatment of breast cancer: 11. Lymphedema Susan R. Harris, Maria R. Hugi, Ivo A. Olivotto, Mark Levine, for the Steering Committee for Clinical Practice Guidelines for the Care and Treatment of Breast Cancer CMAJ 2001;164(2):191-9

One randomized trial has demonstrated a trend in favour of pneumatic compression pumps compared with no treatment. Further randomized trials are required to determine whether pneumatic compression provides additional benefit over compression garments alone. There has been only one randomized trial that has evaluated pneumatic compression pumps for the treatment of lymphedema.

Dini and colleagues35. assigned 80 women with postmastectomy lymphedema to either intermittent pneumatic compression or no treatment. Women in the treatment group underwent a 2-week cycle of 5 pump sessions per week, each session lasting 2 hours, followed by a 5-week break, and then another 2-week treatment cycle. Although the mean decrease in arm circumference in the treatment group was nearly 4 times that in the control group (1.9 cm v. 0.5 cm), the post-test differences between the 2 groups failed to reach statistical significance (p = 0.084), possibly because of the small sample and the large variability in both the initial arm measurements and the circumferential changes within each group (level II evidence).

The experience with lymphedema pumps has also been reported in a number of level V studies.36,37,38,39,40,41,42 The results have been mixed. These studies were limited by their small samples, mixed populations (arm and leg edema), lack of control groups and lack of outcome measures that assessed symptoms such as pain and heaviness. In one study pneumatic compression produced a reduction in lymphedema volume that was 18% greater than the reduction produced by elastic compression;41. in another study no difference was detected between elastic compression and pneumatic compression.36.

No comparative studies have been published to determine the most effective pumping time, pressure levels or kind of pump. There is a suggestion,44. but not unanimous agreement,43. that sequential, multichambered pumps are more effective than monochambered pumps. The former produce a linear pressure wave from distal to proximal portions of the limb that reduces the tendency of fluid to collect in the hand. There are several commercially available pumps, ranging in complexity and cost. Most pumps used by therapists, clinics and consumers are complex and cost several thousand dollars. Pump therapy is contraindicated in the presence of active infection or deep vein thrombosis in the limb.

35. Dini D, Del Mastro L, Gozz A, Lionetto R, Garrone O, Forno G, et al. The role of pneumatic compression in the treatment of postmastectomy lymphedema. A randomized phase III study. Ann Oncol 1998;9:187-91.
36. Bertelli G, Venturini M, Forno G, Macchiavello F, Dini D. An analysis of prognostic factors in response to conservative treatment of postmastectomy lymphedema. Surg Gynecol Obstet 1992;175:455-60.
37. Kim-Sing C, Basco VE. Postmastectomy lymphedema treated with the Wright linear pump. Can J Surg 1987;30:368-70.
38. Pappas CJ, O'Donnell TF. Long-term results of compression treatment for lymphedema. J Vasc Surg 1992;16:555-62.
39. Klein MJ, Alexander MA, Wright JM, Redmond CK, LeGasse AA. Treatment of adult lower extremity lymphedema with the Wright linear pump: statistical analysis of a clinical trial. Arch Phys Med Rehabil 1988;69:202-6.
40. Raines JK, O'Donnell TF, Kalisher L, Darling RC. Selection of patients with lymphedema for compression therapy. Am J Surg 1977;133:430-7.
41. Swedborg I. Effects of treatment with an elastic sleeve and intermittent pneumatic compression in post-mastectomy patients with lymphedema of the arm. Scand J Rehabil Med 1984;16:35-41.
42. Richmand DM, O'Donnell TF Jr, Zelikovski A. Sequential pneumatic compression for lymphedema. Arch Surg 1985;120:1116-9.

Decongestive Lymphatic Therapy for Patients with Breast Carcinoma-Associated Lymphedema: A randomized, prospective study of a role for adjunctive Intermittent Pneumatic Compression, Cancer 2002; 95:2260-7 Andrzej, S., Achalu, R., Rockson, S.

In this study, Intermittent Pneumatic Compression (IPC) was assessed as a component of the initial therapeutic regimen for newly treated patients with breast cancer-related lymphedema. Twenty-three patients who had not been previously treated for lymphedema were randomized to receive either decongestive therapy (DLT) alone or DLT with daily adjunctive IPC.

Patients with stable, treated, breast-cancer related lymphedema were also assessed in the maintenance phase of therapy. Investigators looked at the safety and efficacy of adjunctive intermittent pneumatic compression (IPC) for the acute decongestive therapy of post-mastectomy lymphedema. 23 patients were randomized into two groups: the first which received decongestive lymphatic therapy (DLT) which included manual lymph drainage, bandaging and exercise daily and IP; and the second which received IPC 30 minutes daily at 40-50 mm.

Twenty-seven patients were randomized either to DLT alone, or to DLT coupled with IPC. In both studies, objective assessment included serial measurement of volume by water displacement, tissue tonometry to assess elasticity of the skin and goniometry to measure joint mobility.

During initial treatment, the IPC to standard DLT, yielded an additional mean volume reduction of 45.3% vs. 26%). During maintenance DLT alone, there was a mean increase in volume, with DLT and IPC, there was a mean volume reduction. In both studies, IPC was tolerated well, without detectable adverse effects on skin elasticity or joint range of motion.

Conclusion: When IPC is used adjunctively other, established elements of DLT, it provides an enhancement of the therapeutic response. IPC is well tolerated and remarkably free of complications.

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