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Efficacy and safety of far infrared radiation in lymphedema treatment: clinical evaluation and laboratory analysis

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Ke Li at Shanghai Jiao Tong University
Ke Li
Zheng Zhang
Zheng Zhang
Zheng Zhang
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Ning-Fei Liu at Shanghai Jiao Tong University
Ning-Fei Liu
Shao Qing Feng
Shao Qing Feng
Shao Qing Feng
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Abstract and Figures

Swelling is the most common symptom of extremities lymphedema. Clinical evaluation and laboratory analysis were conducted after far infrared radiation (FIR) treatment on the main four components of lymphedema: fluid, fat, protein, and hyaluronan. Far infrared radiation is a kind of hyperthermia therapy with several and additional benefits as well as promoting microcirculation flow and improving collateral lymph circumfluence. Although FIR therapy has been applied for several years on thousands of lymphedema patients, there are still few studies that have reported the biological effects of FIR on lymphatic tissue. In this research, we investigate the effects of far infrared rays on the major components of lymphatic tissue. Then, we explore the effectiveness and safety of FIR as a promising treatment modality of lymphedema. A total of 32 patients affected by lymphedema in stage II and III were treated between January 2015 and January 2016 at our department. After therapy, a significant decrease of limb circumference measurements was noted and improving of quality of life was registered. Laboratory examination showed the treatment can also decrease the deposition of fluid, fat, hyaluronan, and protein, improving the swelling condition. We believe FIR treatment could be considered as both an alternative monotherapy and a useful adjunctive to the conservative or surgical lymphedema procedures. Furthermore, the real and significant biological effects of FIR represent possible future applications in wide range of the medical field.
Calculation of upper/lower extremity volume using a summed truncated cone model. V (Volume) = ∑k = 1⁴hk(C k² + Ck Ck + 1+ C  k + 1²)/12π. A summation of four truncated cones’ volumes approximates upper/lower extremity volume (mL). C1-5 (cm) and h1-4 (cm) denote circumferences and heights of each truncated cone, respectively. In the left picture, C1 is the circumference at 20 cm above the superior border of patella, C2 is the circumference at 10 cm above the superior border of patella, C3 is the circumference at the superior border of patella, C4 is the circumference at 15 cm below the superior border of patella, and C5 denotes circumference at the ankle. In the right picture, C1 denotes circumference at 10 cm above the cubital crease, C2 is the circumference at the cubital crease, C3 is the circumference at 10 cm below the cubital crease, C4 is the circumference at the wrist, and C5 is the circumference at the dorsum of the hand
Calculation of upper/lower extremity volume using a summed truncated cone model. V (Volume) = ∑k = 1⁴hk(C k² + Ck Ck + 1+ C  k + 1²)/12π. A summation of four truncated cones’ volumes approximates upper/lower extremity volume (mL). C1-5 (cm) and h1-4 (cm) denote circumferences and heights of each truncated cone, respectively. In the left picture, C1 is the circumference at 20 cm above the superior border of patella, C2 is the circumference at 10 cm above the superior border of patella, C3 is the circumference at the superior border of patella, C4 is the circumference at 15 cm below the superior border of patella, and C5 denotes circumference at the ankle. In the right picture, C1 denotes circumference at 10 cm above the cubital crease, C2 is the circumference at the cubital crease, C3 is the circumference at 10 cm below the cubital crease, C4 is the circumference at the wrist, and C5 is the circumference at the dorsum of the hand
… 
CONSORT diagram of patient flow. There were 57 patients meeting the inclusion, 24 of whom were excluded and 1 dropped out. Finally, 32 patients were analyzed
CONSORT diagram of patient flow. There were 57 patients meeting the inclusion, 24 of whom were excluded and 1 dropped out. Finally, 32 patients were analyzed
… 
A photographic image shows the improvement of a patient pre- (a and b) and post-treatment (c and d)
A photographic image shows the improvement of a patient pre- (a and b) and post-treatment (c and d)
… 
Change value of extracellular fluid, extremity fluid, extremity circumferences, and quality of life after treated by far infrared radiation. ***p < 0.001
Change value of extracellular fluid, extremity fluid, extremity circumferences, and quality of life after treated by far infrared radiation. ***p < 0.001
… 
The performance of ultrasound. The thickness of skin and subcutaneous tissue reduced after being treated by far infrared radiation. At the same time, the scope of dark space reduced and the echogenic line became clearer. Small arrow, the layer of skin; large arrow, the layer of subcutaneous tissue. a The extremity with lymphedema before far infrared radiation treatment. b The extremity with lymphedema after far infrared radiation treatment. c The healthy extremity. d The change value of thickness of skin and subcutaneous tissue in extremity with lymphedema. ***p <0.001
+1
The performance of ultrasound. The thickness of skin and subcutaneous tissue reduced after being treated by far infrared radiation. At the same time, the scope of dark space reduced and the echogenic line became clearer. Small arrow, the layer of skin; large arrow, the layer of subcutaneous tissue. a The extremity with lymphedema before far infrared radiation treatment. b The extremity with lymphedema after far infrared radiation treatment. c The healthy extremity. d The change value of thickness of skin and subcutaneous tissue in extremity with lymphedema. ***p <0.001
… 
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ORIGINAL ARTICLE
Efficacy and safety of far infrared radiation in lymphedema
treatment: clinical evaluation and laboratory analysis
Ke Li
1
&Zheng Zhang
1
&Ning Fei Liu
1
&Shao Qing Feng
1
&Yun Tong
2
&
Ju Fang Zhang
3
&Joannis Constantinides
4
&Davide Lazzeri
5,6
&Luca Grassetti
6
&
Fabio Nicoli
4,5,7
&Yi Xin Zhang
1
Received: 25 August 2016 /Accepted: 21 December 2016 /Published online: 26 January 2017
#Springer-Verlag London 2017
Abstract Swelling is the most common symptom of extrem-
ities lymphedema. Clinical evaluation and laboratory analysis
were conducted after far infrared radiation (FIR) treatment on
the main four components of lymphedema: fluid, fat, protein,
and hyaluronan. Far infrared radiation is a kind of hyperther-
mia therapy with several and additional benefits as well as
promoting microcirculation flow and improving collateral
lymph circumfluence. Although FIR therapy has been applied
for several years on thousands of lymphedema patients, there
are still few studies that have reported the biological effects of
FIR on lymphatic tissue. In this research, we investigate the
effects of far infrared rays on the major components of
lymphatic tissue. Then, we explore the effectiveness and safe-
ty of FIR as a promising treatment modality of lymphedema.
A total of 32 patients affected by lymphedema in stage II and
III were treated between January 2015 and January 2016 at
our department. After therapy, a significant decrease of limb
circumference measurements was noted and improving of
quality of life was registered. Laboratory examination showed
the treatment can also decrease the deposition of fluid, fat,
hyaluronan, and protein, improving the swelling condition.
We believe FIR treatment could be considered as both an
alternative monotherapy and a useful adjunctive to the conser-
vative or surgical lymphedema procedures. Furthermore, the
real and significant biological effects of FIR represent possible
future applications in wide range of the medical field.
Keywords Far infrared radiation .Infrared ray .
Lym phe dem a .Lymp hat ic tissu e .Fat .Hyaluronan
Introduction
The lymphatic system is the second largest circulation system
in our bodies. Lymphatic obstruction may lead to an increase
of the protein content in the extravascular tissue, with conse-
quent retention of water and swelling of soft tissues. The ab-
normal buildup of fluid stimulates proliferation of fibroblasts
as well as nonpitting edema and the development of swelling,
most often in the arms or legs, causing lymphedema. There are
two types of lymphedema: primary and secondary, and the
prevalence all over the world has reached from 1.3/1000 to
1.5/1000 [1–3]. Primary lymphedema is rare and is caused by
congenital dysplasia of lymphatic system, lack of lymph
nodes or lymphatic vessels, and incompetence of lymph nodes
or lymphatic vessels, whose prevalence is nearly 1.15/
100,000. Secondary lymphedema occurs as a result of a
Ke Li, Zheng Zhang, Luca Grassetti and Fabio Nicoli contributed equally
to this work.
*Ju Fang Zhang
zhjuf@vip.ina.com.cn
*Yi Xin Zhang
zhangyixin6688@hotmail.com
1
Department of Plastic and Reconstructive Surgery, Shanghai Ninth
People’s Hospital, Shanghai JiaoTong University School of
Medicine, Shanghai, China
2
Department of Medical Cosmetology Surgery, Jinhua People’s
Hospital, Jinhua, China
3
Department of Medical Cosmetology Surgery, Hangzhou First
People’s Hospital, Hangzhou, China
4
Department of Plastic and Reconstructive Surgery, Guy’s and Saint
Thomas’NHS Foundation Trust, London, UK
5
Plastic Reconstructive and Aesthetic Surgery, Villa Salaria Clinic,
Rome, Italy
6
Department of Plastic and Reconstructive Surgery, Marche
Polytechnic University, Ancona, Italy
7
Department of Plastic and Reconstructive Surgery, University of
Rome “Tor Vergata”, Rome, Italy
Lasers Med Sci (2017) 32:485–494
DOI 10.1007/s10103-016-2135-0
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... Showalter et al. [65] 64 reports significance was only noted between patients who had used the sauna, and having a cut in the arm. Li et al. [84] conducted an experimental study looking at the efficacy and safety of far infrared radiation in patients with lymphoedema. The study was conducted on 32 patients, 11 of whom had lymphoedema. ...
... The initial studies that covered the usage of heat exposure to lymphedematous limbs actually found a therapeutic effect rather than a negative one. These studies were done by Chinese researchers who looked at the usage of microwave therapy or heat therapy for patients with filarial limbs [84]. These studies showed positive results in almost 2/3 rd of the large sample size spanning over 1000 patients. ...
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... 18) FIR can induce beneficial effects, including improving endothelial function, promoting wound healing, and keeping unassisted patency of arteriovenous fistulae in both in vitro and in vivo studies. 13,19,20) These physiological characteristics and basic functions of FIR have been also described in detail in a previous study. 14) Recently, the interest in using FIR for improving clinical outcomes has been increasing in many medical fields related to these physiological functions. ...
... 14) Recently, the interest in using FIR for improving clinical outcomes has been increasing in many medical fields related to these physiological functions. Li et al. 19) have reported significant reductions of limb circumference measurements and improvement of quality of life after FIR therapy in patients with lymphedema. Furthermore, laboratory examinations showed that FIR therapy could decrease deposition of protein, fat, and concentrations of tumor growth factor-β1 and interleukin-18 and improve the swelling condition. ...
Far-Infrared Radiation to Improve Clinical Outcomes after Arthroscopic Rotator Cuff Repair: A Prospective Randomized Comparative Clinical Study
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... 그러나 이러한 대체요법은 알레르기 반응 등 안전성의 위험이 있으며, 재배 조건에 따라 치료 효과가 일 관되지 않을 수 있다는 문제가 있다 (Mainardi et al., 2009 (Qin et al., 2024). 이러한 세포 자극은 혈액 순환 촉진 및 혈 류량을 증가시키고, 상처 치유 속도를 높이고 통증과 염증을 완화하 는 등 생리 활성을 통해 건강을 개선하는 임상적인 효과가 보고되어 있다 (Hong & Jeoung, 2020;Li et al., 2017 (Dolgorsuren et al., 2014;Liang et al., 2008;Lin et al., 2007;Shin & Han, 2000;Yamashita, 2012) (Dolgorsuren et al., 2014;Liang et al., 2008;Lin et al., 2007;Shin & Han, 2000;Yamashita, 2012) Tnf-α, tumor necrosis factor alpha; Il-1β, interleukin 1 beta; Il-6, Intereukin-6; Cox-2, cyclooxygenase-2; Gapdh, glyceraldehyde-3-phosphate dehydrogenase; TNF-α , tumor necrosis factor alpha; IL-1β , interleukin 1 beta; IL-6 , Intereukin-6; COX-2 , cyclooxygenase-2; GAPDH , glyceraldehyde-3-phosphate dehydrogenase. The primers of Tnf-α, Il-1β, Il-6, Cox-2, Gapdh were designed to target gene sequences in the species Mus musculus (house mouse). ...
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... In far-infrared therapy, far-infrared rays (FIRs) penetrate the epidermis to increase the body's core temperature, improve blood flow, and activate various metabolic functions [1]. FIRs can reach 4-5 cm into the epidermis and are absorbed by tissues, increasing the vibrational motion of water molecules and generating heat [2]. ...
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... FIR (λ = 4-1000 µm, 12.4 meV-1.7 eV) is a subdivision of the electromagnetic spectrum that has been investigated for its biological effects [8]. FIR can transfer heat to deep areas of the human body by radiation because it has a higher energy efficiency than surface thermal conduction [9]. It can penetrate up to 4-5 cm from the epidermis, where it is absorbed into tissues and generates a thermal effect by increasing the vibrational motion of water molecules [8]. ...
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... Aging is also associated with a decline in skin elasticity and tissue tone. This loss of elasticity can impede the ability of tissues to accommodate fluid accumulation, leading to increased swelling and severity of lymphedema symptoms [31]. Lastly, older individuals generally have a slower healing process and may take longer to recover from surgery. ...
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Full-text available
  • Sep 2014
Lymphedema is a chronic disorder characterized by lymph stasis in the subcutaneous tissue. Lymphatic fluid contains several components including hyaluronic acid and has many important properties. Over the past few years, significant research has been performed to identify an ideal tissue to implant as a filler. Because of its unique composition, fat harvested from the lymphedema tissue is an interesting topic for investigation and has significant potential for application as a filler, particularly in facial rejuvenation. Over a 36-month period, we treated and assessed 8 patients with lymphedematous limbs who concurrently underwent facial rejuvenation with lymphedema fat (LF). We conducted a pre- and post-operative satisfaction questionnaire survey and a histological assessment of the harvested LF fat. The overall mean general appearance score at an average of 6 months after the procedure was 7.2±0.5, demonstrating great improvement. Patients reported significant improvement in their skin texture with a reading of 8.5±0.7 and an improvement in their self-esteem. This study demonstrates that LF as an ideal autologous injectable filler is clinically applicable and easily available in patients with lymphedema. We recommend the further study and clinical use of this tissue as it exhibits important properties and qualities for future applications and research.
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Heating and Compression Bandage Treatment Is Effective for Chronic Lymphedema with Dermatolymphangioadenitis—A Case-Controlled Study
Article
  • Jun 2016
Background: To investigate the therapeutic effect of far infrared rays and compression bandaging in the treatment of chronic lymphedema with dermatolymphangioadenitis (DLA). Methods: Between 2005 and 2013, 106 patients with chronic lymphedema with DLA treated at the Shanghai Ninth People's Hospital were retrospectively reviewed. These patients were divided into an infrared and a bandaging group (80 patients, group 1) and bandaging only group (26 patients, group 2). Outcome measures include DLA frequency, patients' subjective feedback with regards to their symptoms, and the relationship between continuous elastic compression bandaging and relapse of DLA. Results: The frequency of DLA in group 1 and group 2 were significantly reduced after treatment (p = 0.000 and 0.004, respectively). Seventy five percent (60) of patients in group 1 and 19% (5) of patients in group 2 suffered no further episodes of DLA during the follow-up period. In group 1, over 90% of patients reported a subjective improvement in their symptoms and the relapse rate was shown to be lower using elastic compression bandaging when higher pressures were applied. Conclusion: Heating with compression bandaging can be an effective treatment strategy to reduce DLA and improve the quality of life for those patients with chronic lymphedema associated with DLA.
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Clinical practice guidelines for the care and treatment of breast cancer: 11. Lymphedema
Article
  • Jan 2001
Objective: To provide information and recommendations for women and their physicians when making decisions about the management of lymphedema related to breast cancer. Options: Compression garments, pneumatic compression pumps, massage and physical therapies, other physical therapy modalities, pharmaceutical treatments. Outcomes: Symptom control, quality of life, cosmetic results. Evidence: Systematic review of English-language literature retrieved primarily from MEDLINE (1966 to April 2000) and CANCERLIT (1985 to April 2000). Nonsystematic review of breast cancer literature published to October 2000. Recommendations: Pre- and postoperative measurements of both arms are useful in the assessment and diagnosis of lymphedema. Circumferential measurements should be taken at 4 points: the metacarpal-phalangeal joints, the wrists, 10 cm distal to the lateral epicondyles and 15 cm proximal to the lateral epicondyles. Clinicians should elicit symptoms of heaviness, tightness or swelling in the affected arm. A difference of more than 2.0 cm at any of the 4 measurement points may warrant treatment of the lymphedema, provided that tumour involvement of the axilla or brachial plexus, infection and axillary vein thrombosis have been ruled out. Practitioners may want to encourage long-term and consistent use of compression garments by women with lymphedema. One randomized trial has demonstrated a trend in favour of pneumatic compression pumps compared with no treatment. Further randomized trials are required to determine whether pneumatic compression provides additional benefit over compression garments alone. Complex physical therapy, also called complex decongestive physiotherapy, requires further evaluation in randomized trials. In one randomized trial no difference in outcomes was detected between compression garments plus manual lymph drainage versus compression garments alone. Clinical experience supports encouraging patients to consider some practical advice regarding skin care, exercise and body weight. [A patient version of these guidelines appears in Appendix 2.] Validation: An initial draft of this document was developed by a task force sponsored by the BC Cancer Agency. It was updated and revised substantially by a writing committee and then submitted for further review, revision and approval by the Steering Committee for Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Sponsor: The steering committee was convened by Health Canada. COMPLETION DATE: October 2000.
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Long-Term Catheterization of the Intestinal Lymph Trunk and Collection of Lymph in Neonatal Pigs
Article
  • Mar 2016
  • JoVE
Catheterization of the intestinal lymph trunk in neonatal pigs is a technique allowing for the long-term collection of large quantities of intestinal (central) efferent lymph. Importantly, the collection of central lymph from the intestine enables researchers to study both the mechanisms and lipid constitutes associated with lipid metabolism, intestinal inflammation and cancer metastasis, as well as cells involved in immune function and immunosurveillance. A ventral mid-line surgical approach permits excellent surgical exposure to the cranial abdomen and relatively easy access to the intestinal lymph trunk vessel that lies near the pancreas and the right ventral segment of the portal vein underneath the visceral aspect of the right liver lobe. The vessel is meticulously dissected and released from the surrounding fascia and then dilated with sutures allowing for insertion and subsequent securing of the catheter into the vessel. The catheter is exteriorized and approximately 1 L/24 hr of lymph is collected over a 7 day period. While this technique enables the collection of large quantities of central lymph over an extended period of time, the success depends on careful surgical dissection, tissue handling and close attention to proper surgical technique. This is particularly important with surgeries in young animals as the lymph vessels can easily tear, potentially leading to surgical and experimental failure. The video demonstrates an excellent surgical technique for the collection of intestinal lymph.
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＂In Vitro＂ and ＂In Vivo＂ Studies of the Biological Effects of Bioceramic (a Material of Emitting High Performance Far-Infrared Ray) Irradiation
Article
  • Jun 2015
Bioceramic is a material that emits high performance far-infrared ray, and possess physical, chemical and biological characteristics on irradiation of water, particularly to in reducing the size of water clusters, weakening of the hydrogen bonds of water molecules and other effects on physical and chemical properties of water. In this review paper, we summarized the in vivo and in vitro biological effects of Biocermaic, and included previous published data on nitric oxide (NO), calmodulin induction on cells, effects of bioceramic on intracellular heat shock protein (HSP-70) and intracellular nitric oxide (iNO) contents of melanoma cells, antioxidant effects of Bioceramic on cells and plants under H₂O₂-mediated oxidative stress, effects on anti-oxidative stress of myoblast cells and on preventing fatigue of amphibian skeletal muscle during exercise, anti-inflammatory and pain relief mechanism, effects on the chondrosarcoma cell line with prostaglandin E2 (PGE2) production, effects on the rabbit with inflammatory arthritis by injection of lipopolysaccharides (LPS) under monitoring by positron emission tomography (PET) scan, effects on psychological stress-conditioned elevated heart rate, blood pressure and oxidative stress-suppressed cardiac contractility, and protective effects of non-ionized radiation against oxidative stress on human breast epithelial cell. We anticipate that the present work will benefit medical applications.
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Treating Chronic Post-Mastectomy Lymphoedema With Low Level Laser Therapy: A Cost Effective Strategy To Reduce Severity and Improve the Quality of Survival
Article
  • Jan 1995
While there are some controversies and uncertainties about the effectiveness of LLLT in acute tissue disease and damage situations and some uncertainty about penetration, scatter and reflection effects of laser light, most do not apply to the progressive condition of chronic lymphoedema. In this study patients with moderate to severe chronic lymphoedema associated with axillary clearance and radiotherapy received 16 LLLT treatment sessions each of 2 ∼4 J/cm2 over a period of 10 weeks. Each patient was their own control with the contralateral arm being used as a base reference point. The progression of LLLT was monitored fortnightly by circumference measurement, plethysmography, tonometry and bio-impedance as well as by subjective questioning of the patients. At the end of the 10 week period, oedema volumes decreased by an average of 19%, the lymphoedematous tissues progressively softened, the ECF volume significantly decreased and patients reported significant progressive improvements in aches and pains, tightness, heaviness, cramps, pins and needles, mobility and perception of circumference. The results show that when we are dealing with evaluation of treatment efficacy, we must not only present and interpret quantitative results but also the qualitative ones relating to the patient's quality of life. With declining health budgets, the cost of treatment is also a crucial issue. The cost of LLLT treatment in a public hospital was estimated at AU 16perpercentagepointreductioncomparedwithapproximatelyAU16 per percentage point reduction compared with approximately AU 60 per percentage point reduction with the multifaceted complex physical therapy programs. LLLT is thus a cost effective strategy for the treatment of chronic lymphoedema.
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Arm Volumetry Versus Upper Extremity Lymphedema Index: Validity of Upper Extremity Lymphedema Index for Body-Type Corrected Arm Volume Evaluation
Article
  • Jul 2014
Background: Volumetry, measurement of extremity volume, is a commonly used method for upper extremity lymphedema (UEL) evaluation. However, comparison between different patients with different physiques is difficult with volumetry, because body-type difference greatly affects arm volume. Methods: Seventy arms of 35 participants who had no history of arm edema or breast cancer were evaluated. Arm volume was calculated using a summed truncated cone model, and UEL index was calculated using circumferences and body mass index (BMI). Examinees' BMI was classified into 3 groups, namely, low BMI (BMI, <20 kg/m), middle BMI (BMI, 20-25 kg/m), and high BMI (BMI, >25 kg/m). Arm volume and UEL index were compared with corresponding BMI groups. Results: Mean (SD) arm volume was 1090.9 (205.5) mL, and UEL index 96.9 (5.6). There were significant differences in arm volume between BMI groups [low BMI vs middle BMI vs high BMI, 945.2 (107.4) vs 1045.2 (87.5) vs 1443.1 (244.4) mL, P < 0.001]. There was no significant difference in UEL index between BMI groups [low BMI vs middle BMI vs high BMI, 97.2 (4.2) vs 96.6 (4.6) vs 96.7 (9.9), P > 0.5]. Conclusions: Arm volume significantly increased with increase of BMI, whereas UEL index stayed constant regardless of BMI. Upper extremity lymphedema index would allow better body-type corrected arm volume evaluation compared with arm volumetry.
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