The use of Low Level Light Therapy in the management of Head and Neck Lymphoedema

Abstract

The use of low level light therapy in the treatment of head and neck oedema L ow level laser therapy (LLLT) has been used in conjunction with other therapies such as intermittent pneumatic compression, manual / medical lymphatic drainage (MLD) and kinesiotaping for the treatment and management of limb lymphoedema. Evidence from practice and small scale studies demonstrates that LLLT can greatly influence outcomes and improve quality of life (QoL) in these groups of patients (Piller and Thelander, 1998). However, these studies have been conducted specifically on breast cancer-related lymphoedema (BCRL) of the arms. This article aims to provide evidence for the benefits if its wider use including its role in the holistic care of a patient with head and neck oedema and the benefits observed by inclusion of LLLT as initial treatment for those with this type of oedema. What is lymphoedema? Lymphoedema is defined as a chronic progressive disease, which can manifest as a swelling of any part of the body different criteria to ascertain the presence of oedema in patients who had received radiotherapy. Deng et al (2011) show that, due to the difference of the anatomical structures assessed, the incidence of head and neck oedema ranged from 12% to 54%. By contrast, Weissleder and Schuchhardt (2008) state that the incidence of head and neck oedema following bilateral neck dissection was between 30% and 60%, with head and neck oedema occupying 2% of the caseload at a local lymphoedema service (Rüger, 1993). When examining statistics for cancer type, oral cancers are 15 th

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Practice development
Journal of Lymphoedema, 2013, Vol 8, No 1 35
Natalie Lee, Jane Wigg, James D Carroll
e use of low level light therapy in the
treatment of head and neck oedema
Low level laser therapy (LLLT)
has been used in conjunction
with other therapies such as
intermient pneumatic compression,
manual / medical lymphatic drainage
(MLD) and kinesiotaping for the treatment
and management of limb lymphoedema.
Evidence from practice and small scale
studies demonstrates that LLLT can greatly
inuence outcomes and improve quality of
life (QoL) in these groups of patients (Piller
and elander, 1998). However, these
studies have been conducted specically
on breast cancer-related lymphoedema
(BCRL) of the arms.
is article aims to provide evidence for
the benets if its wider use including its role
in the holistic care of a patient with head
and neck oedema and the benets observed
by inclusion of LLLT as initial treatment for
those with this type of oedema.
What is lymphoedema?
Lymphoedema is dened as a chronic
progressive disease, which can manifest
as a swelling of any part of the body
dierent criteria to ascertain the presence
of oedema in patients who had received
radiotherapy. Deng et al (2011) show that,
due to the dierence of the anatomical
structures assessed, the incidence of head
and neck oedema ranged from 12% to 54%.
By contrast, Weissleder and Schuchhardt
(2008) state that the incidence of head
and neck oedema following bilateral neck
dissection was between 30% and 60%, with
head and neck oedema occupying 2% of the
caseload at a local lymphoedema service
(Rüger, 1993).
When examining statistics for cancer
type, oral cancers are 15th in the 20 most
common cancers in the UK, with 6236
cases reported in 2009, of which 2272 were
laryngeal (Cancer Research, 2012). Cancer
Research (2012) states that, between 2005
and 2009, 67% of patients survived more
than 5 years aer diagnosis, highlighting an
increased risk to the patient of secondary
complications, such as lymphoedema
(Deng et al, 2011).
Head and neck lymphoedema has a
huge impact on QoL; patients will oen
e focus of this article is to present evidence supporting the use of low level laser therapy (LLLT) as
a specialist treatment for patients with head and neck oedema. Information obtained from a critique
of relevant literature will be utilised to discuss the treatments available for those with head and neck
oedema, highlighting how outcomes may be improved and quality of life enhanced, when LLLT is
oered as part of a holistic treatment plan. A case study using LLLT is also presented.
Key words
LLLT, low level laser therapy, low level light
therapy, lymphoedema, oedema
Natalie Lee is Clinical Advisor, Haddenham Healthcare
and Lymphoedema Specialist, LymphCare UK. Jane Wigg
is Clinical Innovations Manager, Haddenham Healthcare
and Clinical A dvisor for LymphCare UK and Director,
Leduc UK . James D Carroll is Founder / CEO and
Technical Advisor on LLLT, THOR Photomedicine Ltd.
Declaration of interest: is article was supported by
Haddenham Healthcare, UK.
(International Lymphoedema Framework
[ILF], 2006). Swelling occurs as a result of
lymphatic system insuciency or failure,
resulting in an inadequate clearance of
lymph uid and abnormal accumulation
of interstitial uid in the tissues (Lee et al,
2011). e lymphatic system acts as a one-
way drainage system made up of vessels,
nodes, and valves that transport uid from
the interstitial spaces through the lymphatic
system back into the circulation at the heart,
bypassing the venous system due to larger
molecules, mainly proteins and fats, being
too large to be transported by the venous
microcirculation (Stanton, 2000).
Incidence and prevalence of
lymphoedema following head
and neck cancer
In their systematic review, Deng et al
(2011) note that no reports are available
on the incidence and prevalence of
lymphoedema related to head and neck
treatments in the USA, however four
European studies that identied incidence
rates were found. ese studies used

Practice development
36 Journal of Lymphoedema, 2013, Vol 8, No 1
experience functional diculties with
speech, oral hygiene, swallowing, reduced
food intake, oen leaving patients feeling
that they have been le with a constant
reminder of their cancer diagnosis (Keeley,
2000). Current initiatives in clinical practice
indicate that regional lymphoedema clinics
utilise psychosocial assessment tools ,such
as LymQoL, to measure the eectiveness
of treatments and have adapted them more
specically to include questions related
to midline and head and neck oedema
(Keeley et al, 2010). Deng et al (2011)
state that the incidence and severity of head
and neck lymphoedema and related brosis
are unknown, however the functional loss
and physical symptom burden could be
seen as a direct result of the alterations in
tissues caused by lymphoedema and related
brosis, arguing that more research specic
to this area needs to be carried out.
Assessment of head and neck oedema
Deng et al (2011) state that it is challenging
to obtain measurements for head and
neck oedema and argue that, although
tape measures have traditionally been
used to assess lymphoedema, there is
diculty in establishing anatomical
reference points to ensure reproducible
measurements. e research examined
highlighted inconsistencies in reference
points, and sample sizes that were too
small to demonstrate a clear evidence for
the accuracy of this type of measurement.
However, Deng et al (2011) state that these
have limitations for assessment as they do
not assess skin changes that commonly
manifest in later stages of lymphoedema.
Weissleder and Schuchhardt (2008) state
the use of inspection and palpation are
most benecial during the assessment of
oedema, especially midline oedema. e
use of photography, facial movements
and mobility, and skin changes (e.g. peau
d’orange) also need to be assessed.
Laryngeal cancer commonly involves
the central compartment of the neck, which
is rich in lymphatics, with lymph nodes
that are most commonly removed during
surgery for cancers of the head and neck.
Mascagni (1787; cited in Browse
et al [2003]) was able to show in detail the
normal lymphatics of the head, neck, and
axilla, which highlighted that the lymphatics
of the face drain into the groups of lymph
nodes in the occipital, mastoid, and parotid
regions. e supercial lymphatics of the
use allowing for data to be obtained from
any area and at various depths at that site
of the body, using a single measurement
(Mayrovitz et al, 2009; Figure 1).
e use of the MMDC on six patients
with head and neck oedema has shown
reductions of facial oedema ranging from
45–85% water and reducing following LLLT
to 37–54% showing a vast improvement in
all patients. is suggests that the MMDC
has the potential to provide objective
measurement for facial oedema and other
regions of oedema.
LLLT
What is LLLT?
LLLT is the application of light (usually
a low-power laser or light emiing diode
[LED]) to promote tissue repair, reduce
inammation, reduce oedema, and
induce analgesia. LLLT has been the
subject of several systematic reviews for
a range of musculoskeletal pathologies
with favourable conclusions reported by
Chow et al (2009), Bisset et al (2011),
International Association for the Study of
Pain (2009), and Haldeman et al (2009).
e laser or LED device typically
emits light in the red and near-infrared
light spectrum (600 nm–1 000 nm), the
power output is usually in the range of
1 mW–500 mW and the irradiance is
generally the range of 5 mW/cm2–5 W/
cm2. Treatment time per point is typically
the range of 30–60 seconds per point and
most pathologies require the treatment
of multiple points (Huang et al, 2009).
Treatments can be weekly, though more
frequent treatments may be more eective.
For acute and postoperative pathologies
as lile as one treatment may be all that is
necessary, but for chronic pain, degenerative
conditions, and lymphoedema ten or more
sessions may be necessary.
neck consist of lymph vessels that drain to
the submental, submandibular, and cervical
areas, then drain into the deep cervical
glands lying near the internal jugular vein.
Lack of specic information on referral
oen presents therapists with confusion
as where to direct lymphatic ow when
performing MLD, as in many cases the
nature of any surgery or subsequent
radiotherapy will have damaged lymph
nodes resulting in lymphoedema.
Clinicians usually have limited information
regarding the level of damage caused
during surgery or radiotherapy, or on which
lymph nodes and drainage pathways are
still viable. Weissleder and Schuchhardt
(2008) explain that ultrasound, computed
tomography, and magnetic resonance
imaging are not sucient to safely assess
the lymph nodes of the neck, although they
do prove useful in the diagnosis of recurrent
disease and for the assessment of interstitial
uid or existing oedema.
Lymphoscintigraphy involves injection
of a radio-labelled colloid protein that is
tracked along the lymphatics with a gamma
camera. is helps to identify lymphatic
insuciency (Todd, 2010), but is not
usually performed in the lymphoedema
clinic and requires referral to a specialist
centre, which may delay treatment for
lymphoedema and is seen as an invasive
technique for patients.
Evidence is emerging to support the use
of bio-impedance, which is more sensitive
than circumferential measurements
in the assessment and prevention of
lymphoedema (Vicini et al, 2013). It is
commonly used for limb oedema, but is
being used in experimental seings for
assessing midline oedema. Bio-impedance
involves aaching electrodes to specic
points on the body, then passing an electrical
current that transmits through the water
component of the tissues to measure the
resistance, providing a reading to indicate
extracellular uid volume (ILF, 2006). is
process is a less time-consuming method of
assessing lymphoedema and, if developed
further for midline assessment, will
provide a more objective measurement for
clinicians. By contrast, the use of dielectric
constant analysis, using the MoistureMeter
DC (MMDC; Deln Technologies), which
assesses local tissue water by placing a small
probe onto the aected area, could prove
invaluable in the monitoring of head and
neck oedema. e MMDC is simple to
Figure 1. The MoistureMeter DC
(Delfin Technologies).

Practice development
38 Journal of Lymphoedema, 2013, Vol 8, No 1
How LLLT works
Most of the eects of LLLT can be explained
by light absorption in mitochondria (Eells
et al, 2004; Karu, 2008; 2010). Every cell in
the body contains hundreds or thousands
of mitochondria. Mitochondria make
cellular energy (ATP) from oxygen and
pyruvate. In stressed or ischemic tissues,
mitochondria make their own nitric oxide
(mtNO; Cleeter et al, 1994; Antunes et al,
2004; Palacios-Callender et al, 2004) that
competes with oxygen. mtNO binds to
cytochrome c oxidase (CcO; the terminal
enzyme in the electron transport chain)
and displaces oxygen (Galkin et al, 2007).
is displacement of oxygen has two
negative eects:
• Reduced ATP synthesis.
• Increased oxidative stress (leading to
inammation via the inammatory
“master switch”, NF-kB; Bolanos
et al, 1994; Cleeter et al, 1994; Antunes
et al, 2004; Palacios-Callender et al,
2004; Lane, 2006; Chen, 2011).
e eect of LLLT on hypoxic / stressed
tissues can be described in four stages:
1. Primary eect: Absorption by CcO
CcO absorbs red and near infrared light,
the transfer of light energy by this enzyme
triggers a series of downstream eects
(Yu et al, 1997; Karu and Kolyakov,
2005; Karu, 2008).
2. Secondary eect: Modulation of ATP, nitric
oxide, and reactive oxygen species
Changes in ATP, reactive oxygen species,
and nitric oxide follow light absorption
by CcO. ese eects are redox state and
dose dependent. In hypoxic or otherwise
stressed cells it has been shown that,
following LLLT, nitric oxide is released,
ATP is increased, and oxidative stress
is reduced (Zhang et al, 2009; Serveo
et al, 2010; Sharma et al, 2011; de Lima
et al, 2012; Lim et al, 2012).
3. Tertiary eect: Downstream intracellular
responses (gene transcription, and cellular
signalling
e downstream eects of LLLT
released nitric oxide, increased ATP, and
reduced oxidative stress are many. ey
are context and cell type specic. Either
directly or indirectly these biochemical
intermediates aect components
in the cytosol, cell membrane, and
nucleus that control gene transcription
and subsequently cell proliferation,
migration, necrosis, and inammation
(Zhang et al, 2009; Serveo et al, 2010;
In turn, this improvement has a positive
eect on patients’ QoL in all groups as
reduced movement and function are well
documented as a side eect of surgery
and lymphoedema (Piller and elander,
1998).
e rationale for treating other
symptoms with this modality is based on
the theory that LLLT boosts healing by
promoting tissue regeneration, reducing
inammation, and relieving pain (Hung
et al, 2009). Practitioners are reporting the
positive eects LLLT has on lymphoedema
(Carati et al, 2003). Tilley (2009) reports
that there are over 2500 titles in scientic
literature that relate to the therapeutic
use of LLLT, with over 300 of these being
double-blind studies. However, much of the
LLLT research for lymphoedema reports
only on BCRL and there is limited evidence
to support its use in head and neck oedema
(Tilley, 2009). Patients treated with LLLT
in Wigg (2009) reported a reduction in the
thickness of tissues, with 83% reporting
improved range of movement.
Irradiation parameters and dose
e eects of LLLT are dependent on
irradiation parameters, treatment location,
and treatment time. Too lile irradiance
(beam intensity) or too lile treatment
time may have no signicant eect on
the cells in the tissues treated; too much
irradiance or too much treatment time may
inhibit cellular function (Table 1).
ere is no agreement on how to report
dose. It is sometimes reported as joules
(J) per point, but also as J/cm2 (uence).
It has been argued that wavelength and
irradiation are the “medicine”, and time
applied is applied is the “dose” (Haung et al,
2011; Table 2).
LLLT and cancer: Does
treatment contribute to
recurrence?
Clinicians are oen reluctant to implement
LLLT as part of treatment where there
is active cancer, or where the patient has
not had conrmation of remission. is is
oen due to the knowledge that LLLT has a
direct eect on cell function and clinicians
are concerned that it could cause disease
recurrence or progression. However, the
European Society of Oncology have revised
guidelines that now state that LLLT may
be considered for reducing the incidence
Sharma et al, 2011; de Lima et al, 2012;
Lim et al, 2012).
4. Quaternary eect: Extracellular, indirect,
distant eects
Tissues that have not absorbed photons
can also be aected indirectly via
secretions from cells that have absorbed
light. Cells in blood and lymph can be
activated and they travel signicant
distances from the treatment area to have
distant (i.e. systemic) eects (Hopkins
et al, 2004). ese can be autocrine,
paracrine, and endocrine eects
(sometimes known as a “bystander”
eects).
Oedema / lymphatic ow
LLLT has been used for the treatment of
BCRL and is the subject of two systematic
reviews: Omar et al (2011) found ve
trials suitable for review and concluded
that there was moderate to strong evidence
for the eectiveness of LLLT in the
management of BCRL. Lima et al (2012)
found four trials suitable for inclusion and
concluded that LLLT showed favourable
results in reducing limb volume. However,
studies comparing LLLT with the standard
approach were not reported. A laboratory
trial on Carrageenan-induced oedema in
the mouse paw found that treating lymph
nodes alone was enough to reduce oedema
(Meneguzzo et al, 2013). e mechanism
of action is unknown.
Impact of treatment on QoL
A study by Wigg (2010) demonstrated
that the use of LLLT improved outcome
measures in the patients studied.
Improvements were seen in QoL and other
reported eects, such as improvement in
scars, and tissues feeling less tight. Wigg
(2010) also reported a 33% improvement
in movement in the group; mobility was
one of the seven main themes from the
analysis of the 12-month study. is led to
sta from the clinic where the study took
place using LLLT in combination with so
tissue massage and myofascial release to
further improve mobility.
Scar tightness and pain following surgery
are particularly prevalent in those patients
who have oedema and reduced movement
following treatments for head and neck
cancer. When analysing data of head and
neck patients only, Wigg (2010) found that
62% of patients reported increased range of
movement following treatment with LLLT.

Practice development
Journal of Lymphoedema, 2013, Vol 8, No 1 39
and severity of oral mucositis in cancer
patients (Peterson et al, 2011). In 2012, the
Multinational Association for Support in
Cancer Care also revised their guidelines to
recommend LLLT (Migliorati et al, 2013).
Myakishev-Rempal et al (2011)
conducted a nonmelanoma UV-induced
skin cancer study of the eects of LLLT on
tumor growth and found that aer 60 LED
treatments (twice a day for 30 days) there
was no measurable eect on tumor growth.
de Vries et al (2011) found that, aer
assessing records for 1298 patients treated
for breast cancer between 2000 and 2008
– of whom 52 had laser and MLD for
lymphoedema and were extracted, as well
as those with records of cancer recurrence
between 2000 and 2010 – there was no
statistically signicant dierences between
those receiving MLD / laser combination
versus those receiving none.
Several studies have been conducted
into the eect of LLLT on cancer cells.
Myakishev-Rempal et al (2011) showed
that there was no measurable eect on
330 squamous cell tumours in mice.
Satana-Blank et al (2002) evaluated the
relationship between toxicity levels and
LLLT in patients who had advanced
neoplasms and clinical evidence of
progressive disease reporting improvement
in QoL index and Karnofsky performance
wear appropriate glasses to avoid observing
the ashing light (THOR, 2012).
Availability of LLLT
Data from the British Lymphology Society
(BLS, 2012) directory reveal that LLLT is
not widely oered in UK. Of 252 clinics
data observed only seven oered LLLT as a
treatment; two of these clinics were private,
the remaining ve oered treatment
through the NHS. However, these data are
reliant on clinicians updating the directory,
and gures obtained from a company that
distributes two types of LLLT devices
shows that 24 clinics in the UK have
purchased units, suggesting more clinics
are using LLLT than have reported that
use to the BLS, or LLLT devices have been
purchased but not used.
Clinics may not have access to LLLT
equipment, or having equipment that is
not being used, due to a lack of acceptance
of the therapy from governing bodies, the
extensive testing and writing of protocols
needed due to concerns regarding safety
of the equipment, in addition to issues for
funding to purchase expensive equipment.
Treating with LLLT: A case study
Mr Graham [pseudonym] underwent a
total laryngectomy, excluding lymph node
dissection, for advanced carcinoma of the
status in all patients at the rst two intervals.
is further highlights that LLLT may be
useful in the treatment of certain multidrug
resistant tumours (Lanzafame, 2011).
Evidence suggests that caution should
be exercised when using higher irradiance
laser sources, as stimulation directly over
melanomas can increase tumour growth
in mice. However there is no evidence
to suggest that LLLT used at low levels,
such as those used for lymphoedema and
other therapies, will produce the same
stimulation of cells (Frigo et al, 2009).
Safety considerations
ere are few safety considerations for
clinician or patient from the 104 Diode
Cluster Probe (THOR) as it is an LED
probe, and not a laser. However, the
LTU-904 (RianCorp) is a class one laser.
Lasers are classied in order of hazard
to the eye; a class 1 laser is a low output
laser in the visible to infrared wavelengths
(670 nm–950 nm) and no additional safety
procedures are required as there is no risk
of eye damage as dened by the standards
set by the International Electrotechnical
Commission (www.iec.ch).
Of course the laser should not be directly
emied to the eye. In the case of the LED
probe, which ashes at a frequency of 2.5 Hz,
patients with photosensitive epilepsy should
close and shield their eyes with a towel or
Parameter Unit Explanation Notes
Wavelength Nanometer (nm) Colour of the light LLLT has been successful in the range 600–1000 nm but wavelengths outside these ranges have been
effective. The peak penetrating wavelengths are in the range 700–900 nm. Wavelengths used
in published lymphoedema research include lasers and LEDs at 632.8, 660, 808, 890, 904 and 905 nm.
Power Watt (W) LLLT devices typically in the range 5–500 mW though power outside this range have been successful.
Powers used in published lymphoedema research include lasers and LEDs 5–30 mW. Because these are
low power lasers and LEDs the power is usually expressed in milliwatts (mW, Watts–3).
Beam area Centimetre The surface area of the The two devices referenced in this paper (104 Diode Cluster Probe [THOR]; LTU-904 [RianCorp])
squared (cm2) beam on the skin both have emitters that when used in contact use produce a beam area of approximately 0.2 cm2. The
RianCorp device has one beam and the THOR device has 104 beams.
Irradiance Watts per Power div ided by the area For superficial pathologies (e.g. Achilles tendinopathies or later epicondylitis) LLLT only been
centimetre of the beam. Sometimes successful in the range 5–100 mW/cm2. Unfortunately none of the lymphoedema studies
(W/cm2) referred to as “power density” reported the irradiance despite its critical relevance as shown in other pathologies. However, some
trials provide enough data for irradiance to be calculated:
LTU-904 delivers 25 mW/cm2
104 Diode Cluster Probe delivers 49 mW/cm2
Irradiance can be calculated by dividing fluence by treatment time.
Table 1. Low level laser therapy (LLLT) irradiation parameters
Parameter Unit Explanation Notes
Time Second (s) For the two devices* reference in this paper the treatment times are 60 s per point.
Fluence Joules per centimeter Power × time For the two devices* reference in this article:
squared ( J/cm2) divided by beam area LTU-904 delivers 1.5 J/cm2
04 Diode Cluster Probe delivers 3.0 J/cm2
Energy Joules Power × time For the two devices* reference in this article:
LTU-904 device delivers 0.03 J per point
04 Diode Cluster Probe delivers 1.2 J per point
*The RianCorp device covers one point, the THOR device covers 104 points at once.
Table 2. Low level laser therapy (LLLT) dose

Practice development
40 Journal of Lymphoedema, 2013, Vol 8, No 1
larynx. He subsequently had a tracheostomy
and was to have a speaking valve ed, but
his is postoperative recovery was marred by
a serious myocardial infarction.
Following recovery from myocardial
infarction, Mr Graham underwent 35 fractions
of radiotherapy over 5 weeks that resulted in
a permanent lymphoedema throughout his
submandibular region. Mr Graham felt that
the oedema would intermiently block his
tracheostomy. His rehabilitation was further
delayed due to not being able to have his
speaking valve ed.
Mr Graham was referred to the
lymphoedema clinic. Referral documents
did not provide details of how many lymph
nodes had been removed at surgery and,
although palpation and inspection clearly
conrmed a lymphoedema present, more
information involving lymph nodes removal
or metastasis would have assisted in the
planning of treatment.
Current practice for the
treatment of lymphoedema
According to the BLS (1999), following
a holistic assessment and diagnosis,
treatment of lymphoedema should
involve a combination of interventions
including skin care, exercise, support with
compression bandaging or hosiery, simple
or manual lymphatic drainage to promote
maintenance of oedema and prevent
complications such as infection.
In cases of head and neck oedema
resulting from radiotherapy, skin care is
important as further damage to lymphatics
and trauma to skin increases the risk of
infection due to a build-up of protein and
other molecules in the interstitial space
(ILF, 2006). Mr Graham was advised to
perform daily skin care and used an electric
razor to minimise the risk of cuts from wet
shaving.
Quere and Sneddon (2012), state that low-
compression, made-to-measure garments
can prove useful in the management of
head and neck oedema, but care needs to be
taken as oedema can increase in areas where
there are openings, such as the eye sockets
(Weissleder and Schuchhardt, 2008). Mr
Graham was issued with a chin strap that was
helped maintain his submandibular oedema.
Compression garments may not always be
appropriate due to the eect they have on
the patients’ psychosocial wellbeing, being
a visible reminder of the patients’ cancer
diagnosis.
reducing his self-massage sessions as the
oedema had reduced, which may have led
to the slight rell. Mr Graham reported
that he had an improvement in movement
and that he could li his chin to see beer
in the mirror for shaving. e speech and
language therapist involved in Mr Graham’s
care stated that she would like to perform
investigations to evaluate internal structures
in a patient with head and neck oedema
who had undergone LLLT.
Mr Graham continued to wear his chin strap
during the evenings to maintain the results.
Following the improvement in his oedema he
was successfully ed with a speaking valve
and is enjoying an improved QoL.
Mr Graham’s neck post-treatment is
shown in Figure 4; his pretreatment photos
were deleted due to a computer error and
therefore the before and aer evaluation of
photos could not be undertaken. However,
discussion with clinicians involved in his
care conrmed how much his oedema had
reduced.
MLD is the mainstay of treatment in
head and neck oedema forming part of
the treatment regime during the intensive
phase of decongestive therapy, before
ing hosiery and as part of maintenance
treatment (Leduc, 2012). According to
Williams (2010), there are various MLD
techniques used to stimulate lymphatic
ow and contraction of the lymphangions.
Various techniques and specic hand
movements are used to encourage protein
and uid uptake into the initial lymphatics,
without increasing capillary ltration
(Williams, 2005). e Leduc method was
undertaken twice daily for Mr Graham.
LLLT for lymphoedema
LLLT can be particularly benecial when
tissues are brosed as a result of radiotherapy
or surgical scaring (Carati et al, 2003; Piller,
2006). e ideal treatment programme for
patients with lymphoedema is to treat daily.
e 104 Diode Cluster Probe
(Figure 2) is set to deliver treatment over the
area targeted in 60 seconds at a frequency
of 2.5 Hz. As this is a large probe, covering
44.2 cm2, it is suggested that clinicians treat
over lymphatic pathways before treating
localised regions of brosis.
A smaller probe, such as the 904-LTU
(Figure 3), on a “high” seing will deliver
treatment to an area and depth of 2 cm2 and
should be used at positions 4 cm apart for
60 seconds at each position. As this covers
a smaller area, time constraints may dictate
that a region of brosis is treated rather
than lymphatic pathways. To document
treatment, protocols have been developed
that ensure the dose is recorded accurately
and registers the device used. e use of
an evaluation tool allows for the clear and
concise recording of the application of
LLLT and outcomes.
In combination with MLD, compression
garments, and self-care activities (skin care,
facial exercises), Mr Graham commenced
daily LLLT for 3 weeks, with reducing sessions
over 3 months. His progress was recorded
using an evaluation chart of the type shown
in Appendix I.
Following his rst week of treatment,
Mr Graham experienced a signicant
reduction in oedema and an improvement
in swallowing. At his nal review
(3 months), Mr Graham reported that,
although there had been a slight rell in
his oedema, it was still a vast improvement
compared with pretreatment. He reported
Figure 2. The 104 Diode Cluster Probe
(THOR).
Figure 3. The LTU-904 (RianCorp).
Figure 4. Mr Graham post-treatment.

Practice development
Journal of Lymphoedema, 2013, Vol 8, No 1 41
Conclusion
Although there is limited research to
support the use of LLLT in those patients
with head and neck oedema, studies
conducted in BCRL suggest it may be a
useful modality in treating all types of
lymphoedema. e small studies evaluated
here, along with a number of consensus
statements by oncology groups, support
the use of LLLT in the prevention of oral
mucositis in head and neck cancer; it is
clear that when LLLT at the correct dose
does not cause reoccurrence or mutations
in cancer cells.
New objective assessment tools will
allow for beer monitoring of outcomes
and provided evidence to aid increased
acceptance of LLLT. It is clear from clinical
practice and the literature that LLLT is a
cost-eective modality for lymphoedema,
due to the lasting eects that the therapy has
on the cells, and on ensuring maintenance
of oedema. e initial cost for equipment
should be outweighed by improved
outcomes and patient QoL and reduced
treatment times.
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Appendix I. Evaluation form.