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Progression of lymphostatic and venous edemas in the extremities leads to the early beginning of a combined physical compression therapy. The initial lymphatic drainage is followed by compression therapy using medical stockings. The use of compression stockings is the basis for long-term therapy. According to the edema, individual leg or arm stockings are used.

Introduction:

The progressive course of lymphostatic edema and its resultant connective tissue proliferation, fibrosis and sclerosis as well as impairment of the local metabolism requires the early start of conservative long-time therapy in the form of combined decongestive therapy.

This consists of out-patient or in-patient manual lymph drainage followed by bandaging and the use of compression stockings or hose, decongestive exercises and skin care to prevent infections.

Treatment with compression bandaging or garments increases the interstitial tissue pressure. This results in an increased reabsorption in the venous capillary loop and a better filling of the initial lymph vessels to de-edematisation: Parallel to this we see compression atrophy of the collagen connective tissue with corresponding volume reduction.

The practical procedure to be used with the physical treatment is determined by the severity of the lymphedema as well as the type and extent of possible secondary tissue changes caused by therapeutic interventions. [operation, radiation]

Compression stockings:

At the conclusion of the 4 - 6 week long de-edematising phase, measurements are taken for a compression stocking. Correct control of the lymphostatic extremity edema with a compression garment is required for effective longtime therapy. The choice of appropriate compression garment material and the execution of maintenance therapy or a combination: [e.g. wearing two stockings on top of each other] requires an experienced practitioner and referring doctor.

Primary lymphedema is the swelling of soft tissue as a result of protein rich fluid in the interstitial spaces. As a result, lymph transport is impeded because of predisposed dysplasia of the lymph vessel system.

In the first stage of the lymph edema, the affected extremity can be treated by a class n stocking, either the tubular knitted type or, better, a coarse knitted seamed garment. [e.g. Jobst]

In the second stage, class III compression stocking is used, either with a tubular knitted or, better, a coarse knitted seamed garment.

In the third stage [lymphostatic elephantitis] with coarse skin flap formations and, sometimes, massive skin texture changes, high compression pressure is warranted. This means wearing class IV or even a double stocking to achieve the necessary compression. If the edema is very large distally, an additional knee stocking must be worn to achieve the necessary pressure. Usually a toecap is added for edema in the toes.

The compression pressure used and the appropriate type of garment depend on the severity and the site of the lymphedema, and also on the age of the patient. Secondary illnesses, such as radiation scars or rheumatoid arthritis, should be taken into consideration. The use of a double stocking does not mean the compression pressure is doubled. The combination of a class III compression stocking and class III compression hose results not in the pressure of a class VI stocking but rather in the pressure of a class IV stocking.

Optimally, a massive lymphedema will be treated with a flat knitted seamed garment. There is no chafing or constriction, and air circulation is good. The garment can be correctly sized by the manufacturer whereas with the seamless tubular knitted garments one must often compromise.

Secondary Lymph Edema:

The most frequent form of lymphedema is lymphedema following mastectomy or lumpectomy. Postoperative radiation of the regional lymph nodes, which is usually prescribed, increases the chance of edema.

Therapeutic maintenance with compression stockings is the same as that required for primary lymphedema. It must take into account both the patient's needs and the different combinations of garments that are possible: [e.g., compression arm stocking with or without gauntlet and with or without fingers]. As rule, measurements are taken when the maximal de-edematised condition has been achieved. With a few exceptions, such as damage of the arm nerves through radiation or restricted range of movement because of secondary illness, class II compression is used. [Jobst]

Lipedema Syndrome:

Lipedema is a chronic illness characterized by symmetrical disorder of the fatty tissue distribution, predominantly from the iliac crest to the lower leg, coupled with an orthostatic inclination to edema.

A lipo-Iymphedema is the disorder of fatty tissue distribution, together with secondary damage to the lymph vessel system.

A pure lipedema in the first grade [e.g. missing edema and lymphostasis sign] does not usually call for manual therapy. Compression treatment with class II medical compression hose is sufficient. In these patients, a decrease in volume can be achieved provided the compression hose is worn regularly. To reduce pain, a compression bandage is recommended after manual lymph drainage. Without manual lymph drainage, compression pressure is often not tolerated.

The rare Mandelung's disease can be treated with a compression jacket.

In advanced cases, class II or III compression stockings made of strong seam wear should be worn, but only after several weeks of intensive in-patient decongestive therapy. Compression treatment should continue until freedom from pain is achieved.

When lipo-Iymphedema is present, physical decongestive therapy is indicated and is usually successful. The length of treatment depends on the severity of the illness. To ensure the success of the therapy, strong class II compression hose is prescribed. With distally localized lymphedemas, an additional compression knee stocking [class II or III] can be used.

With older monstrous lipo-Iymphedema, a volume reduction is not usually possible. Compression hose are nonetheless recommended. Chafing will be avoided. Consequently the client can walk better, and a therapeutic effect on the peripheral lymphedema is achieved.

Phlebedema:

There is close relationship between the venous and lymphatic systems. A venous decompensation, for instance, because of the increase of the lymph obligatory water and protein, leads to an excess load on the lymphatic system. This can be alleviated through emptying the functional reserves. To avoid damage to the lymph vessel system, the first treatment goal is to remove the disturbed venous circulation.

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The first step in out-patient care depends on the initial condition. Treatment involves compression bandages or physical decongestive therapy followed, by the fitting of a compression stocking. The compression, however, does not remove the reason for the venous drainage impairment. Surgery is advisable to help the insuffident venous system.

Phlebo-Lympbedema:

Extremity edema occurs on the grounds of chronic venous insufficiency [CVI], because of post thrombotic syndrome [PTS], extensive primary varicose veins, or valvular agnesia.

Damage to the lymph vessels results from venous decompensation together with an increase in the lymph obligatory water and protein load. After draining the functional reserves of the lymph vessel system, lymphostatic edema results. Inflammatory venous processes result in lymphangitis and lymph-adenitis because of the decreased transport capacity.

After invasive therapy to correct the venous changes, a consequent decongestive follow-up treatment of the remaining lymphostasis is usually necessary for the rest of the patient's life. In addition to therapy, the patient requires compression stockings [usually class II.]

Using Compression Stockings:

1) In cases of lymphedema, the compression stocking should be made to measure, since individual proportions fluctuate widely. The use of a form makes the procedure easier. There are no guidelines for measurement. Because of individual differences, a proper fit depends on the experience of the person measuring.

2) 2) Venous edemas of the extremities need a made-to-measure stocking only when additional lymphogenous damage exists [phlebo-Iymphedema].

3) The extremity must always be measured in the maximal de-edematised state of the limb.

4) Toe edemas are fitted with compression toecaps, class I or II, according to the severity of the edema.

5) With secondary leg and genital edema following cancer of the prostate, a compression stocking with a half-pant is used together with a stocking with hip fasteners. The leg-ring on the stockingless leg should never be tight. Otherwise, an artificial edema is created. Suspenders with shoulder padding are recommended to prevent the straps from sliding down. A stocking with a hip closure is not recommended as a rule. It slips and creates creases behind the knee resulting in more edema.

6) For patients with a secondary illness, e.g. arthrosis of the hip, putting on compression hose is very difficult or even impossible. It is much easier to put on two different pieces: the pants first followed by the stocking part which can be fastened to the pants.

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