To compare the efficacy of pneumatic compression therapy (PCT), lymphatic drainage exercises (LDE) and control group in patient with lower limb lymph edema

Abstract

Introduction: Lymphedema is a symptom of morphologically or functionally insufficient lymph transport. There are several etiological factors damaging the lymphatic pathways. Infections and trauma of limb skin and deep tissues evoke reaction of peripheral lymphatics and lymph nodes [1]. Aim and Objective: To compare the "efficacy of pneumatic compression therapy (PCT), lymphatic drainage exercises and control group in patient with lower limb lymph edema.

Full text

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International Journal of Surgery Science 2019; 3(1): 262-272
E-ISSN: 2616-3470
P-ISSN: 2616-3462
© Surgery Science
www.surgeryscience.com
2019; 3(1): 262-272
Received: 08-11-2018
Accepted: 12-12-2018
Niraj Kumar
Associate Professor, Shri Guru
Ram Rai Institute of Medical &
Health Sciences, Patel Nagar
Dehradun, Uttarakhand, India
Shama Parveen
Lecturer, Shri Guru Ram Rai
Institute of Medical & Health
Sciences, Patel Nagar Dehradun,
Uttarakhand, India
Tarang Srivastava
Associate Professor, Shri Guru
Ram Rai Institute of Medical &
Health Sciences, Patel Nagar
Dehradun, Uttarakhand, India
Anirban Patra
Assistant Professor, Shri Guru
Ram Rai Institute of Medical &
Health Sciences, Patel Nagar
Dehradun, Uttarakhand, India
Nishu Sharma
Assistant Professor, Shri Guru
Ram Rai Institute of Medical &
Health Sciences, Patel Nagar
Dehradun, Uttarakhand, India
Nilkamal Kumar
Professor, Surgery, Shri Guru Ram
Rai Institute of Medical & Health
Sciences, Patel Nagar Dehradun,
Uttarakhand, India
Correspondence
Niraj Kumar
Associate Professor, Shri Guru
Ram Rai Institute of Medical &
Health Sciences, Patel Nagar
Dehradun, Uttarakhand, India
To compare the efficacy of pneumatic compression
therapy (PCT), lymphatic drainage exercises (LDE) and
control group in patient with lower limb lymph edema
Niraj Kumar, Shama Parveen, Tarang Srivastava, Anirban Patra, Nishu
Sharma and Nilkamal Kumar
DOI: https://doi.org/10.33545/surgery.2019.v3.i1e.45
Abstract
Introduction: Lymphedema is a symptom of morphologically or functionally insufficient lymph transport.
There are several etiological factors damaging the lymphatic pathways. Infections and trauma of limb skin
and deep tissues evoke reaction of peripheral lymphatics and lymph nodes [1].
Aim and Objective: To compare the “efficacy of pneumatic compression therapy (PCT), lymphatic
drainage exercises and control group in patient with lower limb lymph edema.
Methodology: Subject randomly assigned into three groups viz group A, B and C. Group A patients given
Pneumatic Compression Therapy (PCT) and Manual Lymphatic Drainage (MLD). Group B given
Lymphatic Drainage Exercises (LDE) and Manual lymphatic drainage (MLD) and Group C given Manual
lymphatic drainage (MLD) for lower limb lymph edema. All three groups were treated for four weeks.
Results: The age, weight and height of subjects in groups A, B and C were compared by using analysis of
variance. There was no significant difference found in age, weight and height in all 3 groups (P>0.05). But
significant difference found at 3 to 4 weeks in all 3 groups. (P<0.05).
Conclusion: The present study concluded that group A (Pneumatic Compression Therapy and Lymphatic
Drainage Exercises) showed significant improvement as Group B (Manual lymphatic drainage (MLD) and
control group (lymphatic drainage exercises) for lower limb in lymphoedema.
Keywords: Pneumatic compression therapy (PCT) and manual lymphatic drainage (MLD), lymphatic
drainage exercises (LDE) and measure tape
Introduction
Lymphedema is a symptom of morphologically or functionally insufficient lymph transport.
There are several etiological factors damaging the lymphatic pathways. Infections and trauma of
limb skin and deep tissues evoke reaction of peripheral lymphatics and lymph nodes. Gradually,
lymphatic structures become destroyed, tissue fluid transport toward and along lymphatics slows
down, and edema of the dermis, subcutaneous tissue, as well as the muscular fascia and muscles
gradually develops. Besides inflammation and trauma, the iatrogenic damaging factors for
lymphatics are surgery and irradiation of lymph nodes in cancer therapy [1]. [Fig- 1]
Fig 1: Lymphedema

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Lymphatic drainage exercises, often referred to as pumping
exercises, move fluids through lymphatic channels. Active,
repetitive ROM exercises are performed throughout each
session. The exercises follow a specific sequence to move away
from congested areas. It is similar to the sequence of massage
applied during manual lymph drainage [2].
Intermittent pneumatic compression (IPC) is a mechanical
Therapeutic modality that include an air pump that intermittently
inflates supportive sleeves, gloves or boots around an edematous
part to improve venous and lymphatic circulation [3].
IPC delivers the dual hematological benefits of suppressing pro-
coagulant activation and enhancing global fibrinolysis [4].
Manual lymphatic drainage (MLD) is a type of massage based
on preliminary evidence which is hypothesized to encourage the
natural drainage of the lymph, which carries waste products
away from the tissues back toward the heart [5, 6].
Aims and Objectives
To compare the “efficacy of pneumatic compression therapy
(PCT), lymphatic drainage exercises and control group in patient
with lower limb lymph edema.
Hypothesis
Null Hypothesis
There is no significant difference between pneumatic
compression therapy (PCT), lymphatic drainage exercises (LDE)
and control group in patient with lower limb lymph edema.
Experimental Hypothesis
There is a significant difference between pneumatic compression
therapy (PCT), lymphatic drainage exercises (LDE) and control
group in patient with lower limb lymph edema.
Operational Definitions
Lymphoedema
Lymphoedema has been defined as one of the most significant
survivorship issues after the surgical treatment of breast cancer,
and in this population has been documented to have significant
physical, functional, economic consequences, and impairment of
quality of life [7].
Pneumatic Compression Therapy (PCT)
Intermittent pneumatic compression is a therapeutic technique
used in medical devices that include an air pump and inflatable
auxiliary sleeves, gloves or boots in a system designed to
improve venous circulation in the limbs of patients who suffer
edema or the risk of deep vein thrombosis (DVT) or pulmonary
embolism (PE). When activated, the pump fills the air chambers
of the jacket in order to pressurize the tissues in the limb,
thereby forcing fluids, such as blood and lymph, out of the
pressurized area. A short time later, the pressure is reduced,
allowing increased blood flow back into the limb [7].
Manual lymphatic drainage (MLD)
Manual lymphatic drainage is not the same as massage; it
consists of intermittent, gentle pressure applied directly on the
skin to stretch the very small initial lymphatics, increasing
lymphatic vessel contraction, and lymph drainage of the affected
field. It has four essential hand strokes which must be circular or
spiral in character and with a slow frequency. The central fields
are treated first, and then the drainage continues peripherally [8].
Lymphatic Drainage Exercises
Lymphatic drainage exercises, often referred to as pumping
exercises, move fluids through lymphatic channels. Active,
repetitive ROM exercises are performed throughout each
session. The exercises follow a specific sequence to move away
from congested areas. It is similar to the sequence of massage
applied during manual lymph drainage [8].
Measure Tape
A flexible, non-stretch, woven fabric tape measure was used to
measure arm circumferences. It consists of a ribbon of cloth,
plastic, fiber glass, or metal strip with linear-measurement
marking. It is a common measuring tool. To assure consistent
tension over soft tissue, muscle, and bony prominences
registered nurses with previous training and extensive
experience in circumferential arm measurement techniques
completed the measurements the tape measure was calibrated in
meter and inch (150 meter/60 inches) [2].
Pitting Edema
Observable swelling of body tissues due to fluid accumulation
that may be demonstrated by applying pressure to the swollen
area (such as by depressing the skin with a finger). If the
pressing causes an indentation that persists for some time after
the release of the pressure, the edema is referred to as pitting
edema.
Degrees of Pitting Edema:-
 +1 pitting edema = trace = barely perceptible depression
 +2 pitting edema = mild = 0.6 cm depression with rebound
in less than 15 seconds
 +3 pitting edema = moderate = 0.6 to 1.3 cm depression
with rebound in 15 to 30 seconds
 +4 pitting edema = severe = 1.3 to 2.5 cm depression with
rebound of greater than 30 seconds [9].
Review of Literature
Anatomy of Lymphatic System
Lymphatic system is essentially a drainage system which is
accessory to the venous system. It is important to know that the
larger particles (proteins and particulate matter) can be removed
from the tissue fluid only by lymphatics. Therefore, the
lymphatic system may regarded as ‘drainage system of coarse
type’ and venous system as ‘drainage system of fine type’. The
tissue fluid flowing in the lymphatics is called lymph.
Components of Lymphatic System The lymphatic system
comprises: (1) lymph vessels; (2) central lymphoid tissues; (3)
peripheral lymphoid organs and circulating lymphocytes.[10]
(Fig. 2)

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Fig 2: Lymphatic System
Lymphatic Vessels
The lymphatic vessels of the lower limb can be divided into two
major groups; superficial vessels and deep vessels. Their
distribution is similar to the veins of the lower limb.
Superficial Lymphatic Vessels
The superficial vessels can be divided into two major subsets; (i)
medial vessels, which closely follow the course of the great
saphenous vein and; (ii) lateral vessels which are more closely
associated with the small saphenous vein.
Deep Lymphatic Vessels
These are far fewer in number than their superficial counterparts
and accompany the deep arteries of the lower leg. They are
found in 3 main groups: anterior tibial, posterior tibial and
peroneal following the corresponding artery respectively, and
entering the popliteal lymph nodes [11].
Inguinal Nodes
The inguinal nodes are found in the upper aspect of the femoral
triangle and are 1—20 in number. They are subdivided into 2
groupings determined by their position relative to a horizontal
line drawn at the level of termination of the great saphenous
vein. Those below this line are the sub-inguinal nodes
(consisting of a deep and superficial set) and those above are the
superficial inguinal nodes.
Superficial Inguinal Nodes
These form a line directly below the inguinal ligament and
receive lymph from the penis, scrotum, perineum, buttock and
abdominal wall.
Superficial Sub-Inguinal Nodes
These are located on each side of the proximal section of the
great saphenous vein. They receive afferent input primarily from
the superficial lymphatic vessels of the lower leg.
Deep Sub-Inguinal Nodes
These are often found in one to three in number and are most
commonly found on the medial aspect of the femoral vein. The
afferent supply to these nodes is from the deep lymphatic trunks
of the thigh which accompany the femoral vessels [11]. (Fig. 3):

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Fig 3: Lymph Nodes of Lower Limb
Popliteal Lymph Nodes
The popliteal lymph nodes are relatively small in size. They are
embedded in the popliteal fat. One lies just deep to the popliteal
fascia and drains the saphenous vein territory e.g. the superficial
regions of the lateral leg and the sole of the foot. A second node
lies near the popliteal artery. This receives lymphatic vessels
from the knee joint. The remaining nodes lie at the sides of the
popliteal vessels, and receive the lymph from the posterior and
anterior tibial vessels [12]. (Fig. 4):
Fig 4: Popliteal Lymph Nodes
Functions of lymph nodes
Lymph nodes serve as filters which filter bacteria and toxic
substances from the lymph.
Functions of the lymph nodes are:
1. When lymph passes through the lymph nodes, it is filtered
that is the water and electrolytes are removed. But the
proteins and lipids are retained in the lymph.
2. Bacteria and other toxic substances are destroyed by
macrophages of lymph nodes. Because of this, lymph nodes
are called defense barriers [13].
Author’s study description
Waldemar Lolszewski et al Foot, calf, and thigh skin and
subcutaneous tissue of stages IIIV lymphedematous lower limbs
contained similar calculated volumes of tissue fluid reaching on
average 50% of the total tissue volume.
Freire de Oliveira MM, et al. A study “Manual lymphatic
drainage and active exercise effects on lymphatic function do
not translate into morbidities in women who underwent breast
cancer surgery.” MLD and active exercise effects are equivalent
with regard to morbidity. Minor changes in lymphatic function
associated with either MLD or active exercises were not related
to patients' symptoms or signs.
Kirstin Lane, et al. A study on “Exercise and the lymphatic
system implications for breast-cancer survivors” Both resistance
and upper body exercises have not been shown to lead to
significant changes in arm volume; however further research is
needed using lymphoscintigraphy to better understand the effect
of short and long term exercises on lymphatic function.
Ana Carolina Pereira de Godoy One of the ways of treating
posttraumatic lymphedema is lymph drainage, and in recent
years, new techniques of manual and mechanical lymph
drainage have been developed Lymph Drainage of Posttraumatic
Edema of Lower Limbs 2018 [21].
Niraj kumar et al (2018) study we have discussed about
significant reduction of upper extremity lymph edema. The
group A (Pneumatic Compression Therapy and Lymphatic
Drainage Exercises) showed more improvement than group B
(Manual lymphatic drainage (MLD) and lymphatic drainage
exercises) [11].
Methodology
Sample
It is an experimental study design. A convenience sample of 45
subjects with lymphoedema was solicited from the OPD
physiotherapy department and surgery ward of Shri Guru Ram
Rai Institute of medical & Health Sciences / Shri Mahant
Indiresh Hospital Patel Nagar Dehradun. 15 subjects each in
three groups were selected according to inclusion and exclusion
criteria. Inclusion criteria Inclusion Criteria- Patient with lymph
edema, Age Group - 25-50 years. and Weight -50to 80 kg. post
traumatic complication, post-surgical complication, lower limb
lymph edema due to chemotherapy Exclusion Criteria- Subjects
with a history of severe acute traumas, Congenital disorder,
Patient with neurological deficit, Spondylolysthesis, Pott’s
spine, Rheumatoid Arthritis Disorder, Ankylosing Spondylosis.

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Vertebro-Basilar Insufficiency, Cardiac Problem. Instrumentation
for Data Collection -Measure tape and Pitting Edema:
Procedure
The 45 subjects were randomly taken and assigned into group A,
B and C. Prior to participation all subjects were informed about
the study and an informed consent was taken. Group A patients
given Pneumatic Compression Therapy (PCT) and Manual
Lymphatic Drainage (MLD). Group B given Lymphatic
Drainage Exercises (LDE) and Manual lymphatic drainage
(MLD) and Group C given Manual lymphatic drainage (MLD)
for lower limb lymph edema. All three groups were treated for
four weeks.
Intermittent Pneumatic Compression Therapy (IPCT)
Treatment Protocol
Intermittent pneumatic compression is a therapeutic technique
used in lower limb that include an air pump and inflatable
auxiliary sleeves, gloves or boots in a system designed to
improve venous circulation patients with lower limb
Lymphoedema. When activated, the pump fills the air chambers
of the jacket in order to pressurize the tissues in the limb,
thereby forcing fluids, such as blood and lymph, out of the
pressurized area.
Multichamber sleeve is used to provide sequential compression,
the distal segment inflates frist to the maximum pressure and
then, as it deflates, the more proximal segments inflates
sequentially, generally to slightly lower lavels of pressure. For
lower limb Lymphoedema inflation pressure is between 40 and
80 mm Hg. Total treatment time recommended vary 2-3 hours
per treatment, with treatment frequency should be 6 times per
week is recommended. The frequency and duration of treatment
should be the minimum necessary to maintain good
Lymphoedema control or satisfactory progress towards the goals
of treatment. (48) [Fig-5].
Recommended parameters for the application of
Intermittent Pneumatic Compression Therapy (IPCT)
Fig 5: Lower Limb Lymphoedema Treated with Pneumatic Compression Therapy
Problem
Inflation/Deflat in time in seconds (ratio)
Inflation pressure (mm Hg)
Treatment time (Hour)
Lymph Edema
80-100/25-35 (3:1)
40-80 lower Limb
2-3 Hours
Residual limb Reduction
40-60/10-15 (4:1)
40-80 lower Limb
2-3 Hours
Lymphatic drainage exercises for lower extremities
Total body relaxation
Have the patient assume a comfortable supine position and begin
deep breathing. Then, isometrically contract and relax the
muscles of the lower trunk (abdominals and erector spinae)
followed by the hips, lower legs, feet, and toes.
Lower Extremity Exercises
We have started following exercise before lower limb lymphatic
drainage exercises. All these exercise given 15 repetitions for
two sets.
 Alternate knee to chest exercises
 Bilateral knees to chest
 Gluteal setting and posterior pelvic tilts.
 Single knee to chest with the involved lower extremity.
 External rotation of the hips while lying supine with both
legs elevated and resting on a wedge or wall.
 Active knee flexion of the involved lower extremity while
lying supine.
 Active plantarflexion and dorsiflexion and circumduction of
the ankles while lying supine with lower extremities
elevated.
 Active hip and knee flexion with legs externally rotated and
elevated against a wall.
 Active cycling and scissoring movements with legs
elevated.
 Bilateral knee to chest exercises, followed by partial curl-
ups
 Rest with lower extremities elevated.
Lymphatic Drainage Exercises for Lower Extremities
The selection and sequences of exercises described in this
section are designed to assist in the drainage of lower limb
lymphedema. Many of the individual exercises suggested in
Lymphoedema protocols, such as ROM of the ankle joint and
some of the hip joint or lower extremity exercises are not
exclusively used for lymph drainage. They also are used to
improve mobility and strength [30].
1. Posterior pelvic tilt: Perform these exercises with hips and
knees flexed, in the supine position. Start by lying on your back
on a matted surface, your feet flat on the floor with your hips
and knees bent to approximately 45 degrees.
 Fold arms in front of the chest, and relax the back.
 Exhale as you pull your belly button back toward your
spine, lifting your buttocks and pressing your lower back
firmly against the floor.
 Hold this position for 3 seconds.
 Inhale as you return to the start position. [31] [Fig. 6]

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Fig 6: Posterior pelvic tilt
2. Partial curl-ups: Perform these exercises with hips and knees
flexed, in the supine position. To start, lie on your back with
your knees bent and feet flat on the floor. Don’t press your neck
or lower back to the floor. Breathe deeply. You should feel
comfortable and relaxed in this position:
 Cross your arms loosely.
 Tighten your abdomen and curl halfway up, keeping your
head in line with your shoulders.
 Hold for 5 seconds. Uncurl to lie down [31]. (Fig:- 7)
Fig 7: Partial curl- ups
3. Unilateral knee-to-chest movements
In the supine position, repeat this exercise for another 15
repetitions. If lymphedema is present in only one lower
extremity, perform repeated knee to chest movements with the
uninvolved leg first and then the involved leg.
4. Bilateral knees to chest
In the supine position, flex both hips and knees, grasp both
thighs, and gently pull them to the abdomen and chest. Repeat
10 to 15 times.
5. Gluteal setting
 In supine lying and leg extended.
 Instruct the patient to contract the muscles of buttocks.
 Encouraged the patient to hold the contraction for 5 to 10
sec.
 Let the patient relax.
6. External rotation of the hips
Lie in the supine position with the legs elevated and resting
against a wall or on a wedge. Externally rotate the hips, pressing
the buttocks together, and holding the outwardly rotated
position. Repeat several times. (Fig-8).
Fig 8: External rotation of hips
7. Knee flexion to clear the popliteal area
While lying in the supine position and keeping the uninvolved
lower extremity extended, flex the involved hip and knee
enough to clear the foot from the mat table. Actively flex the
knee as far as possible by quickly moving the heel to the
buttocks. Repeat approximately 15 times.
8. Active ankle movements
With both legs elevated and propped against a wall, or just the
involved leg propped against a door frame and the uninvolved
leg resting on the floor, actively plantarflex the ankle and curl
the toes; then dorsiflex the ankle and extend the toes as far as
possible for multiple repetitions. Finally, actively circumduct the
foot clockwise and counter clockwise for several repetitions.
9. Wall slides in external rotation
With the feet propped up against the wall, legs externally
rotated, and heels touching, slide both feet down the wall as far
as possible and then back up the wall for several repetitions.
[Fig-9]

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Fig 9: wall slides in external rotation
10. Leg movements in the air
With both hips flexed and the back flat on the floor and both feet pointed to the ceiling, alternately move the legs, simulating
cycling, walking, and scissoring motions. [Fig- 10].
Fig 10: Leg movements in the air
11. Hip adduction across the mid line
Lie in the supine position with the uninvolved leg extended. Flex
the hip and knee of the involved leg. Grasp the lateral aspect of
the knee with the contralateral hand; pull the involved knee
repeatedly across the midline in a rocking motion. [Fig-11]
(NOTE: If lymphedema is bilateral, repeat this exercise with the
other lower extremity.)
Fig 11: Hip adduction across the mid line

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Rest
With feet elevated and legs propped up against the wall, rest in
this position for several minutes after completing exercises.
Then rest the legs partially elevated on a wedge, and remain in
this position for another 30 minutes [24].
Guidelines to the patient
Guidelines for Lymphatic Drainage Exercises
The patient should follow these guidelines when performing a
sequence of lymphatic drainage exercises. These guidelines
apply to management of lower extremity lymphedema and
reflect the combined opinions of several authors and experts in
the field.
Preparation for Lymphatic Drainage exercises
 Set aside approximately 20 to 30 minutes for each exercise
session.
 Perform exercises twice daily every day.
 Have needed equipment at foot, such as a foam roll, wedge,
or exercise wand.
During Lymphatic Drainage Exercises
 Wear compression bandages or a customized compression
garment.
 Precede lymphatic drainage exercises with total body
relaxation activities. Follow a specified order of exercises.
 Perform active, repetitive movements slowly, about 1 to 2
seconds per repetition.
 Elevate the involved limb above the heart during distal
pumping exercises.
 Combine deep breathing exercises with active movements
of the head, neck, trunk, and limbs. Initially, perform a low
number of repetitions.
 Increase repetitions gradually to avoid excessive fatigue.
 Do not exercise to the point where the edematous limb
aches.
 Incorporate self-massage into the exercise sequence to
further enhance lymph drainage.
 Maintain good posture during exercises.
When strengthening exercises are added to the lymph drainage
sequence, use light resistance and avoid excessive muscle
fatigue.
After Lymphatic Drainage Exercises
 If possible, rest with the involved extremity elevated for 30
minutes.
 Set aside time several times per week for low-intensity
aerobic exercise activities, such as walking or bicycling for
30 minutes
 Carefully check for signs of redness or increased swelling in
the edematous limb, either of which could indicate that the
level of exercise was excessive [28].
Data Analysis
IMB SPSS software 25.0 version used for data analysis.
Variable i.e. age weight and height of group A, B and C were
analyzed by using one way ANOVA. One way ANOVA was
used to analyze the variable i.e measure tape at 0,1,2,3 and 4
week. Post hoc analysis using Tukey HSD was used for pair
wise compression of measure tape at 0,1,2,3 and 4 weeks. The
significant level of this study was 0.05.
Results
The age, weight and height of subjects in groups A, B and C
were compared by using analysis of variance. There was no
significant difference found in age, weight and height in all 3
groups (P>0.05) (Table 1).
Comparison of measure tape between groups was done by using
ANOVA. No significant difference was found from 0 to 1 week
(P>0.05). But significant difference found at 2 to 4 weeks in all
3 groups. (P<0.05) (Table 2)
Comparison of pitting edema between groups was done by using
ANOVA. There was no significant difference found at 0 and 1
weeks (P<0.05). But significant difference was found at 2 to 4
weeks in all 3 groups. (P<0.05) (Table 2)
Comparison of measure tape between the 3 groups i. e. groups
A,B and C was done by Post Hoc test using Tukey HSD at 0 to
1st week. There was insignificant difference between the groups.
Also there was no significant difference was found at 2 and 4
weeks between A & B and B & C (P>0.05) but significant
difference was found between A & C at 2 to 4 weeks (P<0.05)
(Table 3).
Comparison of pitting edema between the 3 groups i.e groups A,
B and C was done by using Post Hoc test (Tukey HSD) at 0 to 1
week. No significant difference was found between the groups
(P>0.05). Also no significant difference was found at 2 to 4
week between A & B and B & C.(P>0.05) But significant
difference was found between A & c at 2 to 4 weeks.(P<0.05)
(Table 4).
Table 1: Demographic data
Variable
f- value
p-value
Age
1.776
0.491
Weight
1.165
0.322
Height
2.687
0.080
Table 2: Comparison of Measure Tape and Pitting Edema between groups 0 to 4 weeks.
Variable
Week
f- value
p-value
Measure Tape
0
0.024
0.976
1
0.160
0.853
2
5.615
0.007
3
10.635
0.000
4
12.860
0.000
Pitting Edema
0
0.209
0.812
1
0.929
0.403
2
9.086
0.001
3
13.899
0.000
4
12.293
0.000

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Table 3: Post Hoc Tests for measure tape between groups A, B and C from 0 to 4 weeks.
Variable
Group (i)
Group (j)
Mean Difference (i-j)
Std. Error
Signification (p-value)
Measure Tape 0 Week
1
2
0.06667
0.34975
0.980
1
3
0.06667
0.34975
0.980
2
3
-0.06667
0.34975
0.980
Measure Tape 1 Week
1
2
0.06667
0.36048
0.981
1
3
-0.13333
0.36048
0.927
2
3
-0.06667
0.36048
0.981
Measure Tape 2 Week
1
2
-0.73333
0.34303
0.094
1
3
-01.13333
0.34303
0.005
2
3
0.73333
0.34303
0.094
Measure Tape 3 Week
1
2
-0.73333
0.34733
0.100
1
3
-1.60000
0.34733
0.000
2
3
0.73333
0.34733
0.100
Measure Tape 4 Week
1
2
-0.73333
0.38490
0.150
1
3
-1.93333
0.38490
0.000
2
3
0.73333
0.38490
0.15
Table 4: Post Hoc Tests for Pitting Edema between groups A, B and C from 0 to 4 weeks.
Variable
Group (i)
Group (j)
Mean Difference (i-j)
Std. Error
Signification (p-value)
Pitting Edema 0 week
1
2
-1.73333
2.80461
0.811
1
3
-1.33333
2.80461
0.883
2
3
1.73333
2.80461
0.811
Pitting Edema 1 week
1
2
-0.86667
2.59197
0.940
1
3
-3.40000
2.59197
0.379
2
3
0.86667
2.59197
0.940
Pitting Edema 2 week
1
2
-4.66667
3.14052
0.308
1
3
-13.20000
3.14052
0.000
2
3
4.66667
3.14052
0.308
Pitting Edema 3 week
1
2
-5.66667
2.94104
0.144
1
3
-15.33333
2.94104
0.000
2
3
5.66667
2.94104
0.144
Pitting Edema 4 week
1
2
-4.73333
3.12254
0.294
1
3
-15.13333
3.12254
0.000
2
3
4.73333
3.12254
0.294
Fig 12: Mean and standard deviation of Measure Tape between groups A, B and C

International Journal of Surgery Science
~ 271 ~
Fig 13: Mean and standard deviation of Pitting Edema between groups A, B and C
Discussion
Havas et al. (2000) finding those 2 hour of steady exercise
increase lymph clearance rate five folds in the first 15 minutes
while the rest of time it was increases 2-3 folds.
Lane et al. (2005) which demonstrated increase lymphatic
clearance in the hand of healthy women who performed arm
crank erogometry for five minutes [15].
Morris, R. J. Woodcock, J. P. (2004). Studies indicated that
CDT program is effective in reducing Lymphoedema volume
and pain in women with moderate post breast surgery
lymphoedema [11].
Neeraj et al. (2016) The McKenzie treatment is effective on both
low back pain and neck pain. Several studies have been done to
prove the individual effect of McKenzie, Hot Pack and
Strengthening exercise in both low back pain and neck pain. But
none of study has been done to prove which one is more
effective so the need arises to see the comparative effect of
McKenzie, Strengthening Exercise and Hot Pack [38].
Nishu Sharma et al (2018) The study concluded that hand
functions improved by Intermittent Pneumatic Compression and
Mirror Therapy in subacute stroke subjects and interventions
should be emphasize to restore motor and sensory function [40].
In present study we have discussed about anatomy and
physiology of lymphatic system, therapeutic effects of exercises
and their indication, contraindication, principles, guidelines to
the patient and specific sequences of exercise protocol for lower
limb.
In present study we have discussed about significant reduction
of lower limb lymph edema (P>0.05). The group A (Pneumatic
Compression Therapy and Lymphatic Drainage Exercises)
showed more improvement than group B (Manual lymphatic
drainage (MLD) and lymphatic drainage exercises).
Conclusion
The present study concluded that group A (Pneumatic
Compression Therapy and Lymphatic Drainage Exercises)
showed significant improvement as Group B (Manual lymphatic
drainage (MLD) and control group (lymphatic drainage
exercises) for lower limb in lymphoedema.
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