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Complete decongestive physiotherapy (CDP) has gained popularity as an effective treatment for lymphedema and aggressive implementation has become the mainstay of all therapy for lymphedema. Complete decongestive physiotherapy consists of the following four individual components:

• Manual Lymph Drainage
• Multi-layer compression bandaging
• Exercise therapy
• Meticulous skin/nail care

The objective of CDP is to:

• Encourage lymph movement
• Reduce fibrotic tissue
• Improve the shape of the limb for a better fit for compression sleeve or stocking
• Reverse skin condition

Complete decongestive physiotherapy has been shown to be very effective in reducing limb volume in several studies. Data indicates that it can lead to a 55-60% reduction in volume in upper extremities and up to 65% reduction in the lower extremities for up to 9 months after initiation of therapy.

CDP in contraindicated in the presence or development of:

• Cellulitis
• Acute bronchitis
• Deep vein thrombosis
• Infection

If the lymphedema is located in an area where therapy needs to be administered in the abdominal area, such as following surgery in the pelvic or groin region, therapy is discontinued in the presence of:

• Pregnancy
• Aortic aneurysm
• Inflammatory bowel disease
• Abdominal pain

Manual Lymph Drainage

Manual lymph drainage (MLD) is a gentle manual treatment technique that is designed to:

• Encourage the development of collateral lymph vessels
• Redirect lymph flow to unobstructed cutaneous lymphatic vessels
• Stimulate the flow of lymph from the congested area where it has accumulated into more centrally located lymphatic vessels that eventually return the lymph back into the venous circulation
• Enhance lymphatic contractility

MLD was developed in 1932 by Dr. E. Vodder, a Danish physician, and his wife. It differs from massage therapy in both technique as well as purpose. Whereas the purpose of massage therapy is to work the "kinks" and "knots" out of tight, tense muscle groups, the focus of MLD is strictly the lymphatic system and seeks to re-route the lymph flow around the blocked areas and direct it towards the lymphatic system. This technique of gentle massage is the only form of therapy that affects the contractility of the lymph vessels. Massage that is too aggressive or too deep can lead to spasm of the lymphatic vessels which can exacerbate the edema.

Massage begins at the neck and proceeds towards the side of the trunk adjacent to the swollen limb. This progression prepares the collateral lymph routes for accommodating the increased lymph which will drain away from the limb. The light, rhythmic massage movements move the skin and stimulate the underlying vessels in a specific direction.

The treatment entails gentle, rhythmic, moving and stretching the skin to promote absorption of fluid from interstitial spaces into any functioning lymphatic vessels. If lymph nodes are compromised (not just the vessels) it is important to establish alternative routes for the lymph to flow by rhythmically massaging the area around the damaged nodes. Otherwise, the lymph that flows into the vessels following MLD will have nowhere to drain. Initially, MLD is done once a day and then is slowly reduced as the patient responds. It is administered by professionals, such as physical or occupational therapists, who have undergone proper training in this technique as established by the National Lymphedema Network.