Clinical Use of Graded Negative Pressure in Leg Lymphedema Therapy

Introduction, Objectives, and/or Purpose: The standard of care for conservative treatment of leg lymphedema is complete decongestive therapy (CDT), which involves compression, manual lymphatic drainage, skin care and exercises. Therapists can modify treatment interventions using new advancements such is the use of negative pressure during manual lymphatic drainage to assist the clinician with lymphatic stimulation and tissue mobilization to decongest the limb. A device allowing for a therapist to direct the specific amount of pressure pull, gives a therapist a way to quantify and adjust the pull on the tissue. We provide information on the use of CDT with and without the inclusion of a graded negative pressure device in the treatment of leg lymphedema. To reduce fibrosis, ideally tissue would be mobilized in all directions for remodeling. Theoretically, the use of graded negative pressure mobilizes tissue in a direction not possible with the more common positive pressure techniques.
This case describes lymphedema therapy episodes of care provided to a 71-year-old male with a history of bilateral lower extremity lymphedema and morbid obesity. The patient had undergone laparoscopic weight loss surgery having initially lost weight to later return to his pre-surgical weight one year later. Additional co-morbidities include depression, osteoarthritis in the ankles and knees, as well as balance impairment causing significant functional difficulties with walking, stair gait, and donning and doffing his shoes and socks independently.
The patient initially presented to a local lymphedema clinic in September 2020 with pain and severe fibrosis in his legs. Since this initial presentation, he has undergone three episodes of conservative lymphedema therapy followed by a fourth clinical assessment. The purpose of this case is to reveal the outcome trends of CDT with and without graded negative pressure in the treatment of bilateral leg lymphedema with onset likely induced by obesity, underlying vascular insufficiency and sedentary lifestyle.

Methods: The patient was treated t a lymphedema therapy clinic by the same therapist for 3 different episodes of physical therapy to manage his chronic lymphedema that spanned from September 2020 to December 2021 and then a follow-up single reassessment visit in April 2022. Table 1 indicates the dates and summary of CDT therapy interventions for the episodes of care along with the single follow-up assessment that did not result in need for further lymphedema therapy. Each episode of care involved decongestion using compression bandages, exercise, skin care and manual lymphatic drainage. Manual treatment techniques involved manual lymphatic drainage and hands on techniques (positive pressure) to address fibrosis of the tissue, especially in the lower legs. Once the graded negative pressure (GNP) device was available at the clinic, the therapist incorporated the GNP device to further soften fibrosis and decongestion the tissue. At the start and end of each episode of therapy, the therapist obtained volumetric measurements via circumferential tape measure and calculating the limb volume. Additionally, the patient provided pain levels via a 0-10 Visual Analog Scale (VAS), and the patient completed two functional questionnaires, Patient Specific Functional Scale (PSFS) and Lower Extremity Functional Scale (LEFS).

Results: In the first episode of care without inclusion of GNP in the therapy application, the patient was seen for 14 visits showing reduction in limb volume (see Table 1). He experienced a positive reduce of lymphedema decongestion and reduced pain in the limbs. His second and third episodes of care incorporated the use of GNP and involved 7 visits and 15 visits respectively, all with continued and sustained reduction in leg pain. The patient’s weight was stable throughout this period, and as noted by his volumetric measurements, each of the three episodes of care started with similar right and left leg volume and experienced similar limb volume reduction at time of discharge, however with use of GNP, the therapist noted less time in reducing limb volume as compared to without use of GNP during therapy visits. It is important to note that despite the third episode of care being 15 days like 14 days during the first episode of care, the therapist opted to extend the third episode of care to continue to monitor the patient’s self-management until the patient obtained and learned how to self-don and doff his proper compression garments before therapy discharge. This was the reason for the patient’s relapse in swelling in between the 2nd and 3rd episodes of care, yet the therapist noted that by visit 8 in the third episode of care, the patient had obtained sufficient limb volume reduction comparable to previous episodes of care. Additionally, the therapist noted through palpation the ease of softening tissue with mechanical assistance and the ability to quantify tissue pressure pull through readings from the GNP device compared to non-quantifiable positive pressure techniques to-date. Lastly, the evaluation in April 2022 revealed that the patient did not need continued skilled care, thus a fourth episode of care was not initiated. Throughout all this time, the patient reduced in limb volume, was better able to self-manage his legs once obtaining and learning how to don and doff his compression garments, experienced reduced and sustained pain relief from his legs, however his reported functional questionnaires do not reveal clinically significant changes though minor improvements in his function at this time.

Conclusion(s): Patient improved in reduced limb volume and pain for all lymphedema therapy episodes of care, however there was a reduced amount of time by essentially half the number of visits when the therapist incorporated graded negative pressure as a component of complete decongestion therapy to soften tissue fibrosis and stimulate lymphatic clearance. Furthermore, tailoring of therapy to address patient’s impairments and limitations aides in improved self-management of chronic lymphedema and any associated pain. Potential future steps for this patient would be water therapy, nutritional care, and a long-term support for self-initiated exercise to optimize patients’ quality of life and function.