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Review
Isabel Teo, Anna Coulborn, DA Munnoch
Use of the HIVAMAT® 200 with manual
lymphatic drainage in the management of
lower-limb lymphoedema and lipoedema
Lower limb oedema is aributed to
increased uid in the extracellular
space, which may be due to local
or systemic causes. Local causes include
lymphoedema, lipoedema, deep vein
thrombosis and venous disease. Systemic
causes include cardiac failure, renal failure,
hypoalbuminaemia and medications such
as calcium-channel blockers, steroids and
anti-inammatory drugs (Gorman et al,
2000). e principles of oedema treatment
are to rst manage the precipitating cause
if possible. If there is persistent uid in
the limbs, however, methods to encourage
uid to move back into the venous or
lymphatic circulation are advocated
(Gorman et al, 2000).
Lymphatic drainage
Manual lymphatic drainage (MLD)
facilitates the drainage of accumulated
extracellular uids via the collecting
lymphatic pathways. MLD is a standard
lymphoedema treatment modality (Ezzo
et al, 2015). Performed by an appropriately
HIVAMAT® 200
HIVAMAT® 200 (which stands
for HIstological VAriable MAnual
Technique), which is made by Physiomed
Elektromedizen AG, is also known as Deep
Oscillation® therapy. A special design makes
it possible, using electrostatic araction and
friction, to produce mechanical vibrations
in the body, not only at the skin surface but
also in deeper tissues (Brenke and Siems,
1996; Boisnic and Branchet, 2013). e
frequency can be varied within the 5–250 Hz
range. e therapist applies an electrode to
his or her own arm while the patient holds
a small titanium bar, which connects both
individuals to the equipment (voltage
source). ere is a vinyl lm between the
applicator and/or vinyl gloves are used.
e patient functions as a dielectric. is
results in a weakly conducting capacitive
layer between the contact surfaces. In
action, pulsed electrostatic aractions draw
and pull the tissue towards the applicator/
gloved hand and release it at the rhythm of
the chosen frequency. e therapist sets the
Abstract
Background: Manual lymphatic drainage (MLD) is a well-recognised and traditional treatment
modality for oedema. HIVAMAT® 200 is a novel device that uses an intermient electrostatic eld
to stimulate blood and lymphatic ow, thereby reducing oedema. is study aims to compare the
eects of MLD alone to HIVAMAT® 200 plus MLD. Method: ree females with lipoedema and
two males with lymphoedema were recruited. e larger leg was treated with HIVAMAT® 200 plus
MLD and the contralateral limb with MLD only over the course of 3 weeks. Ecacy of treatment
was determined with measurements of leg volumes and high-denition ultrasound to analyse
oedema. Results: e mean reduction in volume for the HIVAMAT® 200 plus MLD-treated
legs was 902 ml (SD 793 ml) and the mean reduction in MLD-only legs was 707 ml (SD 630 ml).
While there was greater improvement in the HIVAMAT® 200-treated limb, this was not statistically
signicant (p=0.06). Using high-denition ultrasound to analyse oedema, the limbs treated with
HIVAMAT ® 200 plus MLD showed signicantly greater reduction in levels of oedema than the
limbs treated with MLD alone (p=0.017). Conclusion: HIVAMAT® 200 reduces lower-limb
oedema and is at least as ecacious as MLD in achieving volume reduction. Prospective studies
with larger numbers of participants are required to further evaluate this.
Key words
HIVAMAT ®200, manual lymphatic drainage;
lipoedema; lymphoedema; oedema
Isabel Teo is specialist registrar in plastic surgery,
Ninewells Hospital, Dundee, Scotland; Anna Coulborn
is tissue viability nurse and lymphoedema nurse specialist,
Eastbourne Wound Healing Centre, Eastbourne, UK;
DA Munnoch is consultant plastic surgeon, Ninewells
Hospital, Dundee, Scotland
Declaration of interest: None.
qualied practitioner, the aected area is
manually massaged in a distal to proximal
direction to encourage excess uid to
return to the circulation system (Ezzo et
al, 2015). e frequency and duration of
treatment is tailored to individual patients.
Compression, in the form of bandages or
garments, is applied in between sessions and
thereaer to minimise the re-accumulation
of uid.
MLD is hypothesised to stimulate
lymphatic contractile function by tissue
manipulation, and hence promote
the clearance of lymph uid from the
aected areas. Tan et al (2011) injected
indocyanine green intradermally into
subjects and compared the pre-MLD
lymphatic contractile function against
post-MLD lymphatic function in healthy
and lymphoedematous limbs. ey
found that the average lymph velocity
increased in both lymphoedematous and
asymptomatic limbs, which supports the
hypothesis that MLD stimulates lymphatic
contractile function.
Journal of Lymphoedema, 2016, Vol 11, No 1 49
Review
pressure gradient, speed and direction of
the movements. e patient can treat him-
or herself with applicators if appropriate.
e treatment procedure is characterised
by minimal external mechanical eect,
which allows it to be used in cases of
acute pain, so tissue trauma and in the
treatment of wounds. Numerous pilot
studies have demonstrated pain reduction,
minimisation of oedema, antibrotic
and anti-inammatory eects, as well as
improved wound healing (Gasbarro et
al, 2006; Fisteo et al, 2011; Hernández
Tápanes, 2012; Boisnic and Branchet,
2013). HIVAMAT is commonly used
for the treatment of lymphoedema (Jahr
et al, 2008). Deep Oscillation® has been
shown by echographic image recording to
penetrate to a depth of 8 cm (Hernández
Tápanes et al, 2010).
Aim
e aim of this study was to evaluate
whether HIVAMAT® 200, combined with
MLD, is useful as an adjunctive treatment
modality in lower limb swelling compared
to the ecacy of MLD alone.
Methods
Patients who were referred for therapist-
led treatment of lower limb swelling were
considered for this study. e inclusion
criteria included:
• Age >18 years
• Lower-limb swelling (unilateral or
bilateral)
• e request for the treatment of excess
uid volume
• Informed consent to participate for the
full 3 weeks of the study.
Exclusion criteria included previous
treatment of any form on the participants’
limbs. is study was approved by the local
ethics commiee.
e rst ve consecutive patients fullling
the criteria were three females (lipoedema)
and two males (lymphoedema). In each
case, one leg was treated with HIVAMAT®
200 plus MLD, and the other with MLD over
the course of 3 weeks. Ecacy of treatment
was determined by measurements of leg
volumes and high-denition ultrasound
(HDU) scanning to analyse oedema.
Limb volume measurements and HDU
scans to measure oedema were taken
before, during and at the end of treatment
(designated time 0, end of week 1 and end
of week 3, respectively). Objective leg
volumes were determined by measuring
the circumference of each limb at 4 cm
intervals, beginning from the malleolus
and advancing proximally to the groin.
Truncated-cone measurements were
utilised and the volume of the leg between
two adjacent measurements (a segment)
was calculated using the following formula
to give a volume in millilitres:
V= 4/12 π (C11+ C11 + C22)
where V is the volume of a segment, and
C1 and C2 are the measured adjacent
circumferences.
e entire limb volume is calculated by
adding up the volumes of all the segments.
is is a validated method of limb volume
measurement commonly used in clinical
practice (Ridner et al, 2007; Schaverien et
al, 2012; Teo and Munnoch, 2015).
e HDU scanner (Episcan Longport
Inc; with a frequency of 20 MHz, which
gives an axial resolution at 65 μm) is an
assessment tool that provides quantitative
information on the uid content of the
epidermis, dermis and subcutis. Each
HDU scan is analysed using a form of
pixel distribution analysis whereby pixels
below certain intensities are classed as
low echogenic pixels (LEPs). e ratio
of LEPs to total pixel (TP) count reects
the dermal water content. is provides
a quantitative assessment of the level of
oedema in the tissue (Gniadecka, 1996;
Gniadecka and Quistor 1996). e scan
is taken consistently at the mid thigh and
mid calf, for values of the proximal and
distal legs, and the distal and proximal
readings averaged to represent the average
LEP:TP ratio for the entire limb.
e larger leg in all patients was assigned
Study leg
volume (cc)
Control leg
volume (cc)
Subject Age Gender Diagnosis Time 0 Final Time 0 Final
1
57 M
Right leg lymphoedema secondary to
complications following right inguinal
hernia and orchidectomy 12,402 12,190 12,351 10,911
2 56 F Lipoedema 15,339 14,831 13,581 13,568
3 52 M Primary lymphoedema of the right leg 16,940 15,217 13,068 12,241
4 47 F Lipoedema 14,477 13,557 12,851 12,746
5 43 F Lipoedema 16,354 14,781 15,593 14,443
Table 1. Effect of HIVAMAT® 200 plus manual lymphatic drainage on the study leg
versus manual lymphatic drainage alone in the control leg in the 5 study subjects.
Figure 1. Mean volume of limbs treated with HIVAMAT® 200 plus manual lymphatic
drainage versus manual lymphatic drainage only (control) before (Time 0), during and at
the end of the assessment period.
50 Journal of Lymphoedema, 2016, Vol 11, No 1
Review
200 plus MLD limbs (Figure 1), this
did not reach statistical significance
(p=0.06).
e HDU scans showed that the mean
LEP:TP ratios improved for the proximal
and distal legs, indicating a reduction
in oedema in the HIVAMAT® 200 plus
MLD legs. Interestingly there was an
increase in LEP:TP for the legs treated
with MLD only (Figure 2) in the proximal
leg. Figure 3 shows the LEP:TP ratios
for the distal (HIVAMAT® 200-treated)
leg, demonstrating greater reduction in
oedema in the treatment this leg compared
MLD only.
e overall LEP:TP ratio for each limb
(taking the mean of the distal and proximal
reading) and change from time 0 to week
3 was compared in the HIVAMAT® 200
plus MLD group versus the MLD-only
group using t-test analysis. is showed a
statistically signicant improvement in the
reduction of oedema in the HIVAMAT®
200 group (p=0.017).
Discussion
Lymphoedema and lipoedema
Lower-limb swelling can occur for a
multitude of reasons, and can generally be
aributed to increased deposition of uid
and/or fat. Lymphoedema is a common
cause of lower limb swelling, in which an
abnormality of lymphatic ow results in
pooling of protein-rich lymph uid in the
interstitial tissues (Gorman et al, 2000). A
study across a west London community in
2003, for example, reported a lymphoedema
prevalence rate of 1.33/1,000 across
all age groups (Moa et al, 2003).
Lymphoedema may occur following trauma
or infection or be secondary to malignancy
or oncological treatment, such as nodal
surgery or radiotherapy. Lymphoedema
may also occur without any identiable
precipitating causes, when it is known as
primary lymphoedema.
e standard treatment for
lymphoedema is complete decongestive
therapy (Huang et al, 2013), also known
as decongestive lymphatic therapy,
which should be provided by a qualied
specialist practitioner (International
Society of Lymphology, 2013).
Decongestive lymphatic therapy consists
of an initial reductive phase and subsequent
maintenance phase. e initial phase
consists of MLD, multilayer compression
bandaging, therapeutic exercises, skin care
lipoedema, one male had primary
lymphoedema and one had secondary
lymphoedema following complications
after a right hernia repair and right
orchidectomy. The volumes of each study
leg versus the control (MLD-only) leg
over the 3 weeks of treatment are given
in Table 1.
The mean reduction in volume for
the HIVAMAT® 200 plus MLD legs was
902ml (standard deviation 793 ml) and
MLD-only legs was 707ml (standard
deviation 630 ml). While there was
greater improvement in the HIVAMAT®
to receive HIVAMAT® 200 plus MLD and
the smaller contralateral leg MLD only.
Treatments were administered twice-
weekly for the 3 weeks. HIVAMAT® 200
was applied at each session for 25 minutes
at 200 Hz. igh-length compression
garments (Class 2 or 3) were given to
patients, to be worn continuously on both
legs in the interim. All data were analysed
using SPSS V20.
Results
Mean patient age was 51 years (range
43– 57 years). All three females had
Figure 2. Analysis of the low echogenic pixels to total pixels (LEP:TP) ratio reecting tissue
oedema in the proximal legs. e LEP:TP ratio for HIVAMAT® 200 plus manual lymphatic
drainage (blue line) showed a reduction in oedema, while manual lymphatic drainage only
(red line) showed a slight increase in oedema.
Figure 3. Low echogenic pixels to total pixels (LEP:TP) ratios of the distal leg demonstrating
greater reduction of oedema in the distal limbs treated with HIVAMAT® 200 plus manual
lymphatic drainage (blue line) compared to manual lymphatic drainage only (red line).
Journal of Lymphoedema, 2016, Vol 11, No 1 51
Review
and education in self-management. The
maintenance phase consists of lifelong
self-delivered drainage, skin care and the
use of compression garments (Huang et
al, 2013).
Lipoedema is a bilateral and
symmetrical limb condition that
typically results in enlarged, painful
lower limbs, although the upper limbs
may be affected as well. It almost
exclusively affects women and causes
gross enlargement of the entire lower
limb, with characteristic sparing of
the ankles and feet (Langendoen et al,
2009). The aetiology is unknown but
is postulated to be related to circulating
oestrogens, as the onset is often
associated with hormonal changes,
such as puberty or pregnancy. There is
increased deposition of fatty tissue with
excess fluid (Langendoen et al, 2009).
Földi and Földi (2006) performed an
epidemiological study and estimated that
11% of the female population is affected.
The diagnosis of lipoedema is made
on clinical grounds as described by Wold
et al (1951):
• Almost exclusive occurrence in
females
• Bilateral and symmetrical enlargement
with minimal involvement of the feet
• Minimal pitting oedema
• Tenderness on pressure
• Easy bruising
• Persistent enlargement after elevation
of the extremities or weight loss.
Assessing volume reduction treatment
There are numerous methods to assess
response to volume reduction treatment
and these include patient-reported
outcome measures, such as reduction in
heaviness and pain scores, episodes of
cellulitis or quality of life questionnaires
(Lopez Penha et al, 2014; van de Pas
et al, 2015). More objective methods
of assessing the success of treatment
include volume measurement and
ultrasound scans (Boyages et al, 2015).
Many techniques for volume
measurement have been described.
Magnetic resonance imaging, laser
plethysmography (Stephan et al,
2000), computer-aided design and
hand scanners are some of the current
methods for limb volume measurement.
The water displacement method is based
on Archimedes’ principle and involves
immersing the entire limb in water and
calculating the volume of displaced fluid.
This is considered the gold standard
against which other volume techniques
are compared (Sander et al, 2002;
Karges et al, 2003; Ng and Munnoch,
2010) but has practical limitations with
regards to equipment and patient factors.
Girth measurement with a measuring
tape is simple, quick, cost-effective
and acceptable to patients. Karges et al
(2003) compared water displacement
and girth measurement and found both
methods to be consistent and accurate.
The authors use girth measurements in
their clinical practice, find it clinically
reliable, and hence suitable for the
intentions of this study.
HDU scanning is a method of
analysing the water content in tissues.
It is simple, pain-free and provides a
quantitative assessment of the level of
oedema. The scan typically shows red
pixels, which indicate tissue oedema
(Figure 4), and blue pixels (Figure
5), which indicate healthy tissue. As
mentioned in the methods section, each
tissue scan is automatically analysed
using a form of pixel distribution
analysis, whereby pixels below a certain
intensity are classed as LEP. The ratio of
LEP:TP ratio has been shown to reflect
dermal water content.
HIVAMAT 200’s therapeutic
Deep Oscillation® effects create cyclic
movement through the entire depth of
soft tissue from the skin, subcutaneous
fat and muscles through to blood vessels
and lymphatics (Fistetto et al 2011).
This stimulates the mechanical pumping
and redistribution of fluids. Deep
Oscillation® is designed as an adjunct
to surgical or other wound healing,
sports medicine and respiratory diseases
(Corneaux, 2011). Reinhold et al
(2014) performed a study on 40 patients
following osteosynthesis procedures
on the extremities and spinal column.
Patients were randomised to either Deep
Oscillation® therapy or control. The
found a significant pain-alleviating effect
with Deep Oscillation®. Boisnic and
Branchet (2013) conducted a clinical
study of 20 subjects with periorbital
bags or dark circles. They concluded that
Deep Oscillation therapy was effective in
reducing both dark circles and bags by an
average of 40%. This was determined by
photography and dermatological scores,
as well as ultrasound analysis. Jahr et al
(2008) randomised 21 patients who had
secondary lymphoedema of the breast
following cancer treatment to either MLD
supplemented with Deep Oscillation, or
to MLD alone. They found that Deep
Oscillation plus MLD was significantly
better for relieving pain and swelling
than MLD alone. Gasbarro et al (2006)
analysed the effects of HIVAMAT 200
on the limbs of 20 patients and achieved
a remarkably significant reduction in the
circumference of the limbs and in the
subcutis thickness. Other studies have
found HIVAMAT 200 to be useful in the
treatment of sports injuries, burns and
epicondylitis (Brenke and Siems, 1996;
Hernández Tápanes et al, 2010; Aliyev et
al, 2012).
Limitations
There are several drawbacks to this study.
The patient numbers are small and the
assignment of the larger leg to HIVA MAT
200 plus MLD and smaller leg to MLD
only incorporates a level of bias. While
Figure 4. High-denition ultrasound scan
showing a relative excess of red pixels
compared to blue pixels, indicating oedema.
Figure 5. High-denition ultrasound
scan showing reduction in red pixels and
increase in blue pixels compared to Figure
4, indicating a reduction in oedema.
52 Journal of Lymphoedema, 2016, Vol 11, No 1
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both lipoedema and lymphoedema cause
excess leg volume and oedema, the former
is a bilateral condition and the latter
often unilateral, making comparisons of
the treatment and control leg distinct in
these two diseases. The true efficacy of
any treatment is highly reliant on patient
compliance and the use of garments in the
long term, which cannot be evaluated in
a 3-week time period. Nonetheless, this
pilot study provides valuable information
on deep oscillation therapy.
Conclusion
This is the first prospective study
comparing HIVAMAT 200 plus MLD
versus MLD only in the lower limbs.
Although our results suggest greater
efficacy with Deep Oscillation therapy
for volume reduction, this did not reach
statistical significance. The data do,
however, show that HIVAMAT 200
was more effective in reducing oedema
than standard MLD alone. The results
of this pilot study are encouraging, and
HIVAMAT 200 could be a useful addition
to practitioners’ armamentarium when
treating oedematous limbs.
Acknowledgements
AC designed the initial study and undertook
treatments. IT and DAM reviewed all data,
analysed the results and wrote the paper.
The authors would like to thank Dr S Young
who undertook the ultrasound analysis.
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survival condition. Eur J Dermatol 23(1): 59–63
Boyages J, Kastanias K, Koelmeyer LA et al (2015)
Liposuction for advanced lymphedema: a
multidisciplinary approach for complete reduction
Journal of Lymphoedema, 2016, Vol 11, No 1 53
