Lymphovenous Canada: A clinician shares her experiences using lymphedema pneumatic pumps

Once shunned by traditionally trained MLD therapists in favor of a strict regimen of manual massage and bandaging, pneumatic compression is now being integrated into the clinical management of patients, and is being recognized as an effective self-care method for patients at home.

Pneumatic compression provides decongestion of arms, legs and the trunk using a garment (also called an appliance) worn over the treated area. The garment is inflated and deflated in a special pattern that applies both massage and compression, with different brands and models applying various inflation patterns. The pressure is usually adjustable and the amount of pressure, as well as duration and frequency of treatment, is determined by the patient's medical professional. Pneumatic compression is generally used to treat lymphedema and venous insufficiency, as well as traumatic edemas.

Over the past 4 years, Karen Ashforth, MS, OTR, CHT, CLT-LANA, has utilized a wide range of pneumatic compression devices in her treatment of patients with primary and secondary lymphedema at Dominican Santa Cruz Hospital, and recently gave a presentation at the National Lymphedema Network (NLN) 2010 conference on pneumatic compression, the options available and how best to apply them to meet patient needs.

In this interview Karen talks about her clinical experiences using pneumatic compression pumps.

A lot of therapists have been very cautious about using pneumatic compression because pump use has been widely discouraged in CDT training. Many concerns are centered on the extremity-only pneumatic compression (which does a great job of decongesting edema from extremities).

If the lymphatic system in the trunk is damaged it needs treatment as well; otherwise the lymph fluid drained from only the extremity can collect, causing edema at the top of the sleeve, or in the abdomen, genitals, shoulder, chest or back. However, pumps are now available with garments that treat these areas of the trunk as well as the arms and legs by moving fluids around the blockages and decongesting the proximal areas as well as the extremity.

Unfortunately, there are still many therapists who don't realize that pumps are more than single extremity sleeves these days! While many patients benefit from extremity-only sleeves, the ones with torso edema are missing out. I consider these garments essential for patients who have any sort of edema or pooling in the trunk.

What first drew me to check out pumps was one of my patients who was doing a trial with a pump at Stanford University. She had a very positive experience. She had wide-spread edema in all four quadrants and couldn't decongest herself because it was a full-time job. I was really impressed with how well pneumatic compression worked for her on the quadrant that was being treated compared to the rest of her body. That was my entrée: I thought, "Hey, this is really working!"

Before that I shied away from pumps because I had been taught in my CDT training that they were harmful, ineffective and too aggressive- all the myths that everyone has already heard. So I went to the NLN 2006 conference and checked out all the pumps: BioCompression, Flexitouch, and Lympha Press.

After learning more about pneumatic compression I started to use these devices in my clinic and began trialing them with patients. What I found is that the pumps are effective, particularly with patients who have widespread edema or have limited range of motion, strength and endurance. Over the years I have observed that the majority of patients who use pumps at home have a high compliance level.

My colleague Jeanette Workman Cosentino also did a poster presentation at the NLN 2010 conference using a lymphedema home management survey which looked at the tools patients had and the ones they used. She found that patients who had access to pneumatic compression had used it consistently, ranging from daily to several times a week; the patients who relied on MLD were not as consistent.

We have found in our practice that patients are more likely to use a pump for 45-60 minutes while they are watching a movie or reading a book than to spend even 5-10 minutes doing self MLD. I only know of one patient who put her pump in the closet: she didn't have the right type of pump for her condition and she wasn't physically able to use it. In her case, this pump had a complicated set of garments that were too difficult for her to put on and remove.

After I began working with her I trialed a number of adaptive techniques to help her with donning and doffing the garment which still didn't help. I determined that she had swelling in the extremity and not the trunk and I helped her get a more appropriate device, in her case a small extremity-only pump. She is now highly compliant with home pneumatic compression, and she is able to manage her edema and no longer has recurrent cellulitis. Not every pump is effective for every patient. The types of devices and appliances vary greatly in their capabilities, adjustability, comfort and ease of use. It is important to match the patient's needs with the most appropriate system for them.

Pumps are useful, but they are not a substitute for MLD. A pump is a machine; a therapist is a human being with eyes and skilled hands. With MLD you can customize treatments using a variety of manual techniques and directional patterns. For instance, for someone who has edema in the shoulders, or has an irregular shaped breast, a pump can be helpful but you are limited to the pump's programming and the types of appliance. On the other hand, if a patient cannot effectively perform self-MLD it can be more cost-effective for the patient to use pneumatic compression than pay for ongoing MLD, particularly since many health insurance providers in the USA and Canada will cover part or all of the cost of these devices. Pumps are also helpful for patients who cannot self-apply bandages. A pump is particularly useful for patients who are not mobile.

I like to use both MLD and pneumatic compression when I treat patients in the clinic. If I have a patient with a problem area which is not draining, or areas of "woody" fibrosis, I like to get my hands on it, work with it using all my manual skills, and then use pneumatic pressure to further decongest the area. I find it important to perform trials with pumps in the clinic if the patient is a candidate for home pneumatic compression, so I can make sure that the patient will be successful in using this treatment at home.

Contraindicators for pneumatic compression use:
Therapists should be aware that there are also contraindications to pneumatic compression use, just as there are to MLD, such as in cases of:

• Active malignancy (although compression can be used in providing comfort in terminal illness)
• Unhealed fracture or high potential for fracture (such as severe osteoporosis)
• Unresolved DVT (Deep Vein Thrombosis)
• Acute Infection
• Uncontrolled CHF (Congestive Heart Failure)
• Severe arteriosclerosis or other ischemic vascular disease
• Pulmonary Embolism
• Inflammatory Phlebitis
• Pregnancy (avoid compression over abdomen)

Specific contraindications can vary by device, for instance, a pump with only an extremity sleeve should not be used if swelling is present in the trunk (axilla, breast, chest, abdomen, hips, or genitals). In these cases a torso garment (pants or jacket) should be used. I haven't found any significant difference between benefits to patients with primary lymphedema versus secondary lymphedema- both get similar results.

It is important for patients to know that pneumatic compression isn't a single "magic bullet" to treat lymphedema. Once patients have been decongested by MLD or pneumatic compression, it is essential to have some type of bandaging system or compression garment to contain that result and to prevent a rapid refill.

The amount of pressure that I use is determined by a patient's condition and tolerance. I generally start with lower pressures of 20-40 mm Hg and customize compression programs depending on each patient. In general I find the use of lower pressures can work well with Stage 1 and some patients with Stage 2 lymphedema, and I use higher pressures (50-80 mmHg) when I need to treat specific areas of lymphostatic fibrosis. I rarely use pressure over the torso that is higher than 40 mmHg range.

I'm aware that patients and therapists can be leery of pumps because of a concern for tissue damage with pneumatic compression, but considering that the amount of compression of water at the ankles (while standing in a pool at shoulder depth) exceeds the amount of pressure used with most pumps, this fear is unwarranted.

Our clinic is very active in development of new lymphedema equipment and we have done research and Beta testing with a number of companies, including BioCompression, Lympha Press, JoviPak, Farrow Medical Innovations, MediUSA, RianCorp, CircAid, The Lymphedema Sleeve Company and Peninsula Medical. Additionally, we have been collecting data on pneumatic compression devices and appliances that our patients have used both in the clinic and at home, and it's helped us develop protocols for pneumatic compression treatment. We continue to use a variety of different types of devices and appliances depending upon patient need, tolerance and insurance reimbursement.

We are excited to be getting a bioimpedance device and see this as an opportunity to measure changes that occur with lymphedema treatment. There has been some work in Australia looking at bioimpedance and fibrosis and I'm interested in tracking that data to see if we can strengthen that correlation. That could be very valuable and could potentially increase our ability to describe and measure fibrosis in the clinic. I'm also very interested in measuring the effectiveness of different types of pneumatic compression with this new tool.

My colleague Jeanette is going to be looking at recurrent cellulitis and the effectiveness of lymphedema treatment and pneumatic compression on lowering incidence- so we hope to have some really good data on that in the future.

There is a great need for evidence-based research in lymphedema treatment, and I would encourage clinicians to collect data on their treatment methods and outcomes and consider writing a case study as a first step. Many clinicians think research is limited to institutions, but there is a great need for clinic based studies to support our practice. That's a great way that we can share information with each other, which ends up helping our profession as a whole.