Complex Decongestive Physiotherapy (CDP)
Complex Decongestive Physiotherapy (CDP) was developed in Europe by Dr. Emil Vodder, over a quarter of a century ago, just prior to World War II, in the1930's. Complex Decongestive Physiotherapy consists of three integral components consisting of manual lymph drainage (MLD), vasopnuematic compression and compression bandaging. Complex Decongestive Physiotherapy is performed by a licensed therapist certified as a manual lymph drainage therapist (CMLDT) under the supervision of a licensed physician. CDP is an accepted standard of care throughout Europe and is taught at the Vodder School in Walchsee, Austria, under the direction of Dr. Ingrid Kurz and Hildegard Wittlinger, and in Germany, under the direction of Dr. Etelka Foldi. Here at the Lymphedema & Wound Care Institute, our therapists are certified in both the Vodder and Foldi technique through The American Academy of Lymphatic Studies or the Norton School of Lymphedema Management. CDP is the most effective treatment for lymphedema available today.
Manual Lymph Drainage (MLD)
Manual lymph drainage (MLD) is a method of massage therapy. Its application in the treatment of lymphedema has garnered the attention of physicians and therapists worldwide. MLD differs from traditional massage in that it focuses on connective tissue rather than muscle tissue. MLD applies a “milking” action and/or “pumping” motion at a much gentler pressure than other massage techniques.
Each treatment begins by clearing the chain lymph nodes and lymphatic channels down through the neck to the connection of the jugular and subclavian veins where the lymphatic system joins the venous system. The MLD therapist works with light slow controlled strokes in a spiral and circular direction and in distal and proximal directions. The massage begins at the top of the affected extremity, clearing the pathway closest to the body first, then continues down the limb with the same distal to proximal motions.
Each stroke consists of three parts increasing pressure, decreasing pressure, no pressure. These three components create a pumping effect. The skin is gently moved to stretch and stimulate the lymph vessels. Control of the applied pressure is extremely important, so as not to inhibit the blood and lymph flow. MLD stimulates and increases the outflow of lymph fluid (water, protein, and cellular components) from the tissue. Left untreated, the accumulated protein leads to the development of fibrotic edema (hardening of the skin).
MLD stimulates a weakened lymphatic system by pushing the stagnant fluid to be reabsorbed through the venous system, and helps develop collateral channels through which the lymph fluid can begin to flow.
MLD is the treatment of choice in conjunction with other treatment modalities such as sequential gradient compression pumps and compression garments.
Pneumatic compression pumps are designed to assist in the moving of venous and lymphatic fluid when the vessels are impaired. Peristaltic pneumatic compression will propel the fluid through the body mechanically allowing it to be excreted normally, without the use of diuretics. Diuretics are contraindicated in the treatment of lymphedema as lymphatic fluid is comprised of water, protein and fat. Although diuretics may eliminate water, the protein and fat are left behind and will develop into fibrotic tissue.
Pneumatic compression pumps may only be used under a physicians order. The pump may be supervised in the facility in conjunction with other treatment modalities. The physician may also order the pump for permanent home use, however the physician must prescribe the treatment pressure, frequency and duration of use.
Compression Bandaging Systems
Compression bandaging for lower extremity and compression strapping for upper extremity lymphedema patients are primarily used in the decongestive phase of Complex Decongestive Physiotherapy. Consisting of a short-stretch compression these bandages are textile-elastic; the braided cotton fibers used in the production process are woven specially to achieve a certain degree of elasticity. Two different qualities of pressure can be distinguished in compression therapy: the working pressure and the resting pressure. Resting pressure is pressure that the bandages exert on the tissue at rest without muscle contraction, it has a permanent pressure and its value depends on the amount of tension used at the time of its application. Relative in the determination of these pressure qualities are the types of bandage, the number of layers, and the condition of the material (age), because bandages can lose some of their elasticity over time and with repeated use and cleaning.
Short-stretch bandages employ a very low resting pressure on the tissue and the vascular system. The risk of tourniquet effect are therefore relatively low as long as a specially trained individual applies the compression wraps correctly.
The high working and low resting pressure qualities of short-stretch bandages make them the preferred compression bandage in the management of lymphedema.
Compression Hosiery, Stockings & Sleeves
Compression hose for lower extremity and compression sleeves for upper extremity counteract the pull of gravity on the veins. Gradient compression support (stocking or sleeve) is made of a special low stretch fabric that provides added gradient compression. Compression support are available in ready to wear sizes, or depending on the size and severity of the patient, can be custom made to order.
Compression garments are generally uncomfortable if worn while the affected extremity is swollen and will do nothing to correct the underlying lymphedema, therefore, they should only be fitted at the end of the intensive phase (Phase 1) of treatment, when the extremity has been decongested to normal or near normal size. The use of high quality and appropriate compression garments is essential for the long-term management of lymphedema and to have the maximum effect must be worn daily and should be replaced every six months. For hygienic reasons it is appropriate to have two sets of garments. Compression garments are not recommended for nighttime use (compression orthotics are the appropriate modality for nighttime use when sleeping).
The compression support (stockings or sleeves) come in various amounts of pressure that is prescribed by the physician to maintain edema reduction following Complex Decongestive Physiotherapy (CDP).
Compression support is a vital part of the treatment program.
Diet, Nutrition and Exercise
Lymphedema management requires that proper diet, nutrition and exercise are integral in maintaining edema reduction. Diets high in salt, fat and preservatives may cause an new onset of lymphedema. Diagnostic testing, including an oxygen uptake test, is performed to test the metabolic rate and monitor the caloric intake, this helps to determine a proper diet and nutrition plan as well as monitor patient compliance.
Wound Care Management
Wound care dressings including UNNA boots and other topical wound care dressings are applied in conjunction with compression therapy to assist in the healing of decubitus ulcers, venous stasis ulcers and other chronic non-healing wounds.