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Manual lymphatic drainage in chronic venous disease: A forgotten weapon in our armory

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Abstract

Objectives: The objective of this study is to evaluate the effect of manual lymphatic drainage (MLD) on venous flow and its effect on wound healing in patients with advanced chronic venous insufficiency (CVI). Design: This was a prospective nonrandomized cross-sectional study. Setting: Participants were assessed from a group of patients presenting to a vascular clinic at a tertiary care center, in South India. Participants: Thirty-eight patients with the venous ulcers were enrolled in this study. Intervention: MLD was applied by a certified physical therapist to the lower limb following a standard protocol. The patient and the caregiver were also educated on methods of MLD so as to carry on the treatment in a home-based setting. Main Outcome Measurements: Subjective analysis of symptom relief and ulcer healing were analyzed at 1 week and at 6 months. Results: There was a significant improvement in patient symptoms with respect to ulcer healing and reduction of edema. Conclusions: MLD is an important adjunct in the treatment of advanced CVI.
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266
Abstract
Original Article
inTRODUcTiOn
Venous ulcers are the most advanced stage of chronic venous
insufciency (CVI), as identied by the clinical, etiologic,
anatomic, and pathophysiologic (CEAP) C6 classication.[1]
They are often recurrent, may persist for years, and result
in repeated infections and cellulitis. In addition, venous
ulcers have signicant socioeconomic and psychological
consequences reducing the quality of life.[2]
The mechanism of ulcer formation involves a series of
pathophysiologic steps that include (1) obstruction and/or
reux, (2) persistent venous hypertension, and (3) increased
capillary ltration and interstitial uid load. Typically, excess
interstitial uid is removed by the lymphatics, but if the uid
load overwhelms the lymphatic capacity or if the lymphatics are
defective, the accumulation of interstitial uid, macromolecules,
and cytokines lead to edema (CEAP C3), breakdown of
subcutaneous tissue (C4A, B), and formation of ulcers (C6).[3]
Once formed, an ulcer will not heal unless venous hypertension
and excess capillary fluid filtration are ameliorated. The
processes to treat venous hypertension include endoablation/
open surgery of the supercial veins, phlebectomy, and venous
stenting. These procedures have been proven to be useful in
patients with normal lymphatic function. However, multiple
studies have proven that patients with venous ulcers have
abnormal lymphatic drainage.[3-6] Although the lymphatic
contribution to venous ulcer formation, recurrence and healing
have long been recognized, authoritative reviews on CVI
management does not recommend treating the lymphatics as
an adjunct to surgical treatment.[7]
The objective of this study was to establish the role of manual
lymphatic drainage (MLD) as an adjunct in the treatment of venous
ulcers by documenting clinical and subjective improvement in
patients with this form of advanced venous disease.
MeTHODS
This study was conducted after obtaining the approval of the
Local Institutional Review Board and in accordance with the
Helsinki Declaration.
Objectives: The objective of this study is to evaluate the effect of manual lymphatic drainage (MLD) on venous ow and its effect on
wound healing in patients with advanced chronic venous insufciency (CVI). Design: This was a prospective nonrandomized cross-sectional
study. Setting: Participants were assessed from a group of patients presenting to a vascular clinic at a tertiary care center, in South India.
Participants: Thirty-eight patients with the venous ulcers were enrolled in this study. Intervention: MLD was applied by a certied physical
therapist to the lower limb following a standard protocol. The patient and the caregiver were also educated on methods of MLD so as to carry
on the treatment in a home-based setting. Main Outcome Measurements: Subjective analysis of symptom relief and ulcer healing were
analyzed at 1 week and at 6 months. Results: There was a signicant improvement in patient symptoms with respect to ulcer healing and
reduction of edema. Conclusions: MLD is an important adjunct in the treatment of advanced CVI.
Keywords: Clinical, etiologic, anatomic, and pathophysiologic, chronic venous disease, manual lymphatic drainage
Address for correspondence: Dr. Prabhu Premkumar,
E-mail: prabhupremkumar@gmail.com
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DOI:
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How to cite this article: Samuel V, Premkumar P, Selvaraj D, Kota AA,
John JM, Stephen E. Manual lymphatic drainage in chronic venous disease: A
forgotten weapon in our armory. Indian J Vasc Endovasc Surg 2018;5:266-9.
Received: July, 2018. Accepted: August, 2018.
Manual Lymphatic Drainage in Chronic Venous disease:
A Forgotten Weapon in our Armory
Vimalin Samuel, Prabhu Premkumar, Dheepak Selvaraj, Albert Abhinay Kota, Joel Mathew John, Edwin Stephen
Department of Vascular Surgery, Christian Medical College, Vellore, Tamil Nadu, India
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Samuel, et al.: Manual lymphatic drainage in venous disease: A forgotten weapon in our armory
Indian Journal of Vascular and Endovascular Surgery ¦ Volume 5 ¦ Issue 4 ¦ October-December 2018 267
Clinical criteria
Following informed consent, 38 patients with chronic venous
ulcers were enrolled into the study between April 2015 and
March 2016. Patients were recruited prospectively as they
presented in the clinic and the data collected was analyzed.
Inclusion criteria included a minimum age of 18 years and the
presence of a venous ulcer (C6) in either leg. Exclusion criteria
included inability to tolerate the compression; or clinically
significant arterial disease, defined by an ankle-brachial
index <0.7, toe pressures <30 mmHg, or transcutaneous
oximetry <30 mmHg. Patients with diabetic foot ulcers,
exposed bone or tendons, autoimmune disease, or vasculitis
were excluded from the study. Patients who opted to use
four-layer bandaging for compression therapy were also
excluded from the study.
Venous duplex scanning (7-mm linear array transducer scanned
at 6–12 MHz) was undertaken with participants in a standing
position to conrm the diagnosis of CVI and to determine
the exact anatomical location of venous reux (supercial,
perforating and/or deep vein system). Clinical history,
symptoms, and severity of disease, according to CEAP clinical
class were obtained following established guidelines.
Once identied, the patients underwent a multidisciplinary
approach to treatment as is our protocol for all patient with
advanced venous disease [Figure 1].
Once diagnosed to have venous ulcers, the patients were
initiated on compression therapy using short stretch
bandaging, MLD, and dressings. The supercial venous
system was evaluated using duplex ultrasound. Any
supercial incompetence found was treated with endoablation/
Trendelenburg’s operation/phlebectomy, iliac vein stenting,
or foam sclerotherapy as appropriate. They were encouraged
to continue compression and MLD at home after discharge
from the hospital.
Technique of manual lymphatic drainage
The MLD included the CVD limb affected, and it was
performed by a trained physiotherapist according to the
technique of Vodder [Figure 2].[8] Each person in the study
group underwent a series of ve MLD sessions. Each procedure
was performed 5 times a week for 20 min each time. The
patient and the primary caregiver were encouraged to learn
the technique of MLD and continue the same, even at home.
The patients were reviewed after 1 week and a subjective
assessment was done. A review assessment was also done at
the end of 6 months.
ReSUlTS
A total of 196 patients were referred for MLD during the
study. These included patients with CVI (n = 118) and
lymphedema (n = 76). Of the patients that were referred for
CVI, n = 22 were for C3 disease, n = 25 were for C4 disease,
n = 33 were for C5 disease, and n = 38 were for C6 disease.
The latter formed the study group [Figure 3].
The study group was from all over the country, some of them
traveling 2000 km from home for treatment. The population
demographics were as portrayed in Table 1.
There were 17 patients with duration of symptoms more than
12 months. The predominant pathological incompetence
Figure 1: Multidisciplinary approach to the treatment of chronic venous
insufficiency
Figure 2: Technique of manual lymphatic drainage
Figure 3: Patient recruitment data
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Samuel, et al.: Manual lymphatic drainage in venous disease: A forgotten weapon in our armory
Indian Journal of Vascular and Endovascular Surgery ¦ Volume 5 ¦ Issue 4 ¦ October-December 2018
268
was at the sapheno-femoral, and sapheno-popliteal junction
(n = 44) and the most common intervention performed was
foam sclerotherapy [Table 2].
At the first follow-up at 1 week, 25 patients reported a
subjective improvement in symptoms of heaviness of legs,
edema, and pain.
The second follow-up was done at 6 months, with clinical visits
and telephonic interviews. 20 patients were able to continue
self-administered MLD and two patients were not able to
continue [Table 3]. The patients for whom follow-up was
available (n = 22) were assessed for improvement in edema and
ulcers that had healed. 19 patients reported an improvement in
edema, ulcer decreased in size in 12 patients, and ulcer healing
was reported in 8 patients [Table 4].
DiScUSSiOn
In our center, MLD is commonly prescribed as a treatment
for patients with CVI, especially when the lymphatic system
is affected and edema is present. Even before undergoing
surgery for venous insufciency, MLD also appears to play an
important role in improving the reux volume index, disease
severity, quality of life, and venous edema.[9]
Compared to compression therapy and ankle exercises, which
predominantly enhance venous blood ow in the deep veins,
MLD is able to increase blood ow in both supercial and
deep veins.[10]
In conservative treatment of CVI, methods such as elimination
of risk factors, pharmacotherapy, compression therapy or
physical exercise have a well-proven track record, whereas
MLD has not yet achieved the status it deserves. There are not
many publications or ongoing research concerning the role of
MLD in the treatment of CVI.
In this study, our demographics showed that we have a male
preponderance male:female (8.4:1) for advanced venous
disease as shown in previous studies of similar nature
conducted in India.[2] A large proportion (n = 27) of our patients
were in the 18–60 year age group, i.e.: The most economical
productive period of patient life. The socioeconomic impact of
venous ulcer disease has been demonstrated previously and the
trend continues in this study also.[1] Hence, every intervention
in this group designed to heal the venous ulcer will have a
positive overall economic impact. This study shows that there
is an almost immediate effect on starting MLD in patients
with advanced CVI (C6) with 25 patients (65%) reporting
improvement in symptoms. Compromised lymphatic drainage
has been shown to be a copathological factor in patients with
venous disease contributing to the development of edema,
lipodermatosclerosis, and even venous ulcers.[11] Hence, any
improvement in lymphatic drainage will show immediate
results as depicted by our study.
The number of endovenous ablations in the study group does
not correspond to the number of patients with junctional
incompetence [Table 2]. Many of the patients were not
willing to wait for interventions and chose to return at a later
date. As our study population was spread across a distance
of more than 2000 km, the attrition rate was also high, with
16/38 patients (42%) lost to follow up.
There was a signicant improvement in ulcer healing in
patients that continued to practice MLD as shown in Table 4.
These patients continued MLD as an adjunct to compression
therapy to achieve improvement in the size of the ulcer and in
some cases (n = 8), complete ulcer healing.
Foldi has already reported the ineffectiveness of MLD without
compression therapy in their studies.[12] Ochałek and Grądalski
claim that it is essential to simultaneously perform compression
therapy to prolong the anti-edema effects of MLD.[13] In our
practice, we ask our patients to continue both compression
with MLD to get the best results.
The results obtained in this study on the use of MLD in the
treatment of patients with CVD are comparable with the results
obtained by Crisóstomo et al. and Molski et al.[9,10]
The main problem with continuing MLD is the reduced
availability of trained professionals to implement the MLD
over a long duration. Furthermore, the economics of treatment
Table 1: Population demographics
Table 2: Duration of symptoms, pattern of disease and
intervention
Table 3: Follow‑up at 6 months
Table 4: Subjective assessment of improvement
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Samuel, et al.: Manual lymphatic drainage in venous disease: A forgotten weapon in our armory
Indian Journal of Vascular and Endovascular Surgery ¦ Volume 5 ¦ Issue 4 ¦ October-December 2018 269
for CVI dictate that constant use of the physiotherapists may
not be nancially viable to the healthcare provider. The median
cost of venous ulcer care per year, in the U.S, is US$3036.[12]
The use of self-administered MLD after an initial period of
supervised learning provides an alternative to the patient to
continue MLD at home. With the use of self-administered
MLD, we were able to keep venous ulcer care costs to
around US$1000 inclusive of total outpatient costs (facility
and physician), hospitalizations (if any), dressing supplies,
medications (topical and oral), and home healthcare Despite the
demographic variability of our study population, 20/38 patients
were able to continue MLD at home.
The small study group makes it difficult to prove any
statistically signicant outcomes and is one of the limitations of
this study. The high attrition rate may be explained by the vast
distances which patients traveled to be treated, which makes
following up these patients, logistically difcult.
Quality of life (QoL) assessment in patients with CVI seems
to be a useful objective method, which contributes to the
evaluation of disease severity, as well as to the evaluation
of treatment effects. It also provides an objective measure of
degree of improvement in patients that have initiated MLD.
QoL questionnaires, such as CIVIQ, VCSS, SF-36, and HAD,
are considered as very useful and credible in the evaluation of
disease severity and in the evaluation of conservative treatment
as well as surgical treatment. However, we were not able to
implement the above in our study group.
cOnclUSiOnS
Self-administered MLD decreases the degree of disease severity
in patients with chronic venous disease, as well as offering
an important adjunct to compression in the treatment of CVI.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conicts of interest.
ReFeRenceS
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2. Selvaraj D, Kota A, Premkumar P, Stephen E, Agarwal S. Socio-demography
and clinical prole of venous ulcer. Wound Med 2017;19:1-4.
3. Rasmussen JC, Aldrich MB, Tan IC, Darne C, Zhu B, O’Donnell TF Jr.,
et al. Lymphatic transport in patients with chronic venous insufciency
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4. Rasmussen JC, Tan IC, Marshall MV, Fife CE, Sevick-Muraca EM.
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5. Tan IC, Maus EA, Rasmussen JC, Marshall MV, Adams KE, Fife CE,
et al. Assessment of lymphatic contractile function after manual
lymphatic drainage using near-infrared uorescence imaging. Arch
Phys Med Rehabil 2011;92:756-640.
6. Rasmussen JC, Tan IC, Marshall MV, Adams KE, Kwon S, Fife CE,
et al. Human lymphatic architecture and dynamic transport imaged
using near-infrared uorescence. Transl Oncol 2010;3:362-72.
7. Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL,
Gloviczki ML, et al. The care of patients with varicose veins and
associated chronic venous diseases: Clinical practice guidelines of the
Society for Vascular Surgery and the American venous forum. J Vasc
Surg 2011;53:2S-48S.
8. Földi M, Strößenreuther R. Treatment of the leg. Foundations of Manual
Lymph Drainage. 3rd ed. Elsevier Mosby; 2005.
9. Molski P, Ossowski R, Hagner W, Molski S. Patients with venous
disease benet from manual lymphatic drainage. Int Angiol
2009;28:151-5.
10. Crisóstomo RS, Candeias MS, Armada-da-Silva PA. Venous ow during
manual lymphatic drainage applied to different regions of the lower
extremity in people with and without chronic venous insufciency:
A cross-sectional study. Physiotherapy 2017;103:81-9.
11. Mortimer PS. Implications of the lymphatic system in CVI-associated
edema. Angiology 2000;51:3-7.
12. Földi E. The treatment of lymphedema. Cancer 1998;83:2833-4.
13. Ochałek K, Grądalski T. Manual lymph drainage usage invascular
diseases. Acta Angiologica 2011;3:1-10.
[Downloaded free from http://www.indjvascsurg.org on Wednesday, January 2, 2019, IP: 181.214.24.34]
... [10] This was ratified in a study of thirty-eight patients with VLU from Vellore, India [ Figure 4]. [11] This modality requires the patient and caregiver to undergo training for about 30 minutes a day for 3-5 days, depending on how quickly they learn the technique. It is low cost, reproducible yet effective. ...
... [1] There are also articles on the real-world experience of decongestive therapy in an Indian setting [2] and of the application of the technique of manual lymphatic drainage in venous disease. [3] There is exciting new developments in the fields of imaging and also of surgical interventions in lymphatic disease and it will fall upon those managing vascular disease to take this forward. There is a huge burden of secondary lymphedema within the borders of our country and large parts of the developing world and a solution to this would be a godsend for many. ...
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