Download pdf - INTERMITTENT PNEUMATIC COMPRESSION … review_intermittent...13 ABSTRACT Intermittent Pneumatic Compression (IPC) therapy is an effective modality to reduce the volume of the lymphedematous

13

ABSTRACT

Intermittent Pneumatic Compression(IPC) therapy is an effective modality toreduce the volume of the lymphedematouslimbs alone or in conjunction with othermodalities of therapy such as decongestivetherapy. However, there is no consensus onthe frequency or treatment parameters forIPC devices. We undertook a systematicreview of contemporary peer-reviewed litera-ture (2004-2011) to evaluate the evidence foruse of IPC in the treatment of lymphedema.In select patients, IPC use may provide anacceptable home-based treatment modality inaddition to wearing compression garments.

Keywords: intermittent pneumaticcompression, lymphedema, pneumaticcompression

Lymphedema is a condition resultingfrom lymphatic system disruption.Accordingly, protein-rich fluid accumulatesin soft tissues of the affected body parts, suchas arms, hands, trunk, head, or neck (1,2).There are two types of lymphedema, namely,primary and secondary lymphedema (3).Primary lymphedema can occur due to thedysplasia of the lymphatic system since birthor may occur later in life. Secondary lymphe-dema is more common in the U.S. and causedby the disruption of the lymphatic systemresulting from extrinsic cause such as cancer

Lymphology 45 (2012) 13-25

INTERMITTENT PNEUMATIC COMPRESSION THERAPY: A SYSTEMATIC REVIEW

J.L. Feldman, N.L. Stout, A. Wanchai, B.R. Stewart, J.N. Cormier, J.M. Armer

NorthShore University HealthSystem (JLF), Evanston, Illinois, Walter Reed Military Medical Center(NLS), Bethesda, Maryland, University of Missouri Sinclair School of Nursing (AW,BRS,JMA),Columbia, Missouri, and University of Texas MD Anderson Cancer Center (JNC), Houston, Texas

or its treatment (i.e., removal of axillarylymph nodes or radiation therapy) (1,4). It isestimated that one-third to two-fifths ofbreast cancer survivors are conservativelyestimated to develop lymphedema (5-7).Therefore, risk reduction and management oflymphedema is essential for these patients.

Pneumatic compression devices havebeen utilized in the medical management ofswelling since the early 1950’s (8,9). Theinitial IPC devices were pumps with a single-chamber pressure cuff that applied a uniformlevel of compression to the entirety of thelimb. Segmented compression devices weredeveloped in the 1970s and eventuallyevolved technologically to allow pressuregradients, with the pressure in the distalchambers being higher than in the proximalchambers and enabling a sequentialmechanism of distal to proximal applicationof pressure.

In recent years, advanced pneumaticcompression devices have evolved evenfurther in their sophistication and allow fordigital programming to mimic manuallymphatic drainage techniques and promotefluid clearance from the proximal trunk andextremity. The advanced IPC devices haveappliances that can treat the torso as well asthe limbs.

IPC devices can be broadly categorizedas outlined in Table 1 (10). As pumptechnology has progressed, it has beenaccompanied by a body of research

Permission granted for single print for individual use. Reproduction not permitted without permission of Journal LYMPHOLOGY.

14

supporting medical applications of thesedevices both alone and in conjunction withother compression treatment modalities foroptimal reduction and control of lymphe-dema. Research findings, however, aresomewhat lacking in terms of the reportedphysiological effects of pumps and supportfor the optimal application parameters forpump use. Further, reports vary regarding

volumetric improvements in swelling andsymptom relief associated with lymphedematreatment using IPC devices.

This manuscript presents the results of asystematic review investigating the evidencefor pneumatic compression use withlymphedema and provides recommendationsfor clinical applicability of these data.

TABLE 1Characteristics of IPC Devices


15

METHODS

A systematic review of the literature wasperformed to examine contemporary peer-reviewed literature (2004-2011) evaluating theuse of intermittent pneumatic compressiontherapy in the treatment of lymphedema. The current review is part of a larger projectof the American Lymphedema FrameworkProject (ALFP) in partnership with theInternational Lymphedema Framework (ILF)to provide evidence for the Second Edition ofthe Best Practices Document, a project whichprovides clinical practice guidelines on all aspects of lymphedema diagnosis andmanagement.

A systematic review of the literature wasperformed in two phases (Fig. 1).The initialphase was performed by a reference researchlibrarian who searched 11 medical indices(PubMed, Medline, CINAHL, CochraneLibrary databases (Systematic Reviews andControlled Trials Register), PapersFirst,Proceedings First, Worldcat, PEDro,National Guidelines Clearing House, ACPJournal Club, and Dare) for articles usingterms to capture all literature related tolymphedema (lymphedema, lymphoedema,elephantiasis, swelling, edema, and oedema).Article archives of the authors and referencelists from related articles were also examinedthrough 2010. Further, additional literaturein 2011 was considered for inclusion. A totalof 5,927 articles were retrieved by thereference librarian search. Of 5,927 articles,4,624 articles were excluded because theywere not related to lymphedema (screen 1).This left 1,303 articles to be reviewed by threeeditors for inclusion criteria (research study,lymphedema- related, 10 cases) andexclusion (gray literature) criteria. A total of644 articles were excluded, thus leaving 659articles for consideration for the topicreviews, including IPC (screen 2). The searchresults were then imported into Endnote(Build 3210) to remove duplicates. In thisphase, key words for IPC were applied[pneumatic compression device, intermittent

compression therapy (ICT)], IPC,compression pressure). A total of 13 articleswere selected and reviewed by the authorteam (screen 3). Inclusion criteria for thefinal review included valid study design orliterature review (randomized controlled trial,controlled trial, and literature review);primary or secondary study outcome waslymphedema; and IPC was the intervention.A total of 13 studies met inclusion criteria(screen 4). The studies are outlined in Table 2.

Of the articles reviewed, two weresystematic reviews, one was a literature

Fig. 1. Literature review process for IPC andlymphedema systematic review


16

review, two were randomized control trials,six were controlled trials, and two were casestudies. Each article was summarized by one author and reviewed by another author to ensure appropriate and accuraterepresentation of the material. Informationwas abstracted on study design, sample,measures, intervention, pump features,pressure, frequency, outcomes, adverseevents, strengths, and weakness. TheBandolier Strength of Evidence Guidelinesfrom The Oxford Medical Journal was usedto rank the reviewed articles (11). Table 3outlines the Bandolier model.

FINDINGS

Two level I systematic reviews werepublished regarding IPC therapy bothfocused on IPC outcomes associated withbreast cancer-related lymphedema. Rinehart-Ayres et al (12) published a 2010 systematicreview on the use of IPC for treating breastcancer-related lymphedema (BCRL). Of 26full-text articles, only eight studies weredesigned as research studies and adhered toSackett’s levels of evidence. The conclusionwas that there was no evidence to suggestthat the use of IPC in the treatment of upperextremity lymphedema provides greaterreduction in lymphedema than educationabout arm care and hygiene, and there wasno evidence to support one type of IPC deviceover another. There was no consensus offeredon the number of treatments, treatmentregimen, or pump pressure settings. Moseleyet al (13) published a 2007 systematic reviewon the use of conservative therapies to treatbreast cancer-related lymphedema. Theyidentified IPC devices as one of the modali-ties most likely to provide greater volumetricreductions in the treatment of BCRL.

The remaining articles reported a broadrepresentation of outcomes, and the studiesreported here all investigated uniqueoutcomes variables. The general themes inoutcome reporting center around:physiological changes associated with IPC

device use, parameters for optimal pressurelevels, and volumetric changes with IPC use.

Physiological Changes

Olszewski et al (14) studied tissue fluidpressure and flow under the skin in thesubcutaneous tissue of the lower extremitywith obstructive stage II to IV lymphedema.The limbs were studied both at rest andduring distal-to-proximal manual compressionand pneumatic compression under variouspressures and sleeve inflation timing.Pneumatic compression generated tissue fluidpressures on the average 20% lower than thepressure in the inflated sleeve chambers. Thevariance in pressure gradient between theskin and subcutis may be attributed to skinrigidity (fibrosis), low hydraulic conductivityof the subcutis, and dissipation of the appliedforce in the subcutis to the proximal non-compressed regions. Pneumatic sequentialcompression produced unidirectional flowtoward the groin without backflow.

Adams et al (15) employed an investiga-tional near-infrared fluorescence technique toevaluate the physiological response to IPCtherapy in three control subjects and sixsubjects with unilateral breast cancer-relatedlymphedema. Lymphatic propulsion rate,apparent lymph velocity, and lymphaticvessel recruitment were measured before,during, and after 2.5 hours of advanced IPCtherapy. Lymphatic function improved in allcontrol subjects and all asymptomatic arms in BCRL subjects. Lymphatic functionimproved in only 4 of 6 BCRL affected armssuggesting that pneumatic compression alonemay not be sufficient to improve lymphuptake when system dysfunction is present.

Pressure Level

According to Mayrovitz (16), thecompression pressure settings routinely usedare well in excess of pressures measuredwithin the normal skin lymphatic vessels,which are in the range of ± 4 mmHg to 8


17

TA

BL

E2

Art

icle

s A

bstr

acte

d an

d R

evie

wed


18


19


20


21

mmHg depending on measurement methodand site. The pressure used must be sufficientto overcome the resistive forces within thetissue being treated, and in lymphaticobstruction, the subcutaneous tissue pressurecan be significantly elevated with pressures in edematous lymphatics and tissues rangingfrom 15 to 18 mmHg (17). A peak inflationpressure of 25 to 50 mmHg might besufficient for most patients in the absence of significant fibrosis.

Partsch et al (18) published a consensusof the literature on the indications forcompression therapy in venous and lymphaticdiseases. The levels of compression shown to be effective in different experiments arebroad, and range between 5-10 mmHg and>120 mmHg. There also is a need to differen-tiate between sustained and intermittentpressure. Data from studies of skin micro-circulation show that ischemic skin damagemay occur from high levels of compressionapplied for long periods. A sustained pressureof 60-70 mmHg may be considered as themaximum upper limit. Strong levels ofevidence support the use of IPC forthrombosis prevention after surgery, in the

treatment of post-thrombotic syndrome, andin lymphedema.

Szolnoky et al (19) stated that pumpsmust be used at relatively low pressure toavoid collapse of the superficial lymphaticsand as part of a comprehensive CDTprogram. In this study, MLD alone or inconjunction with IPC at 50 mmHg as part of a CDT protocol resulted in notablereductions in arm lymphedema andsubjective complaints.

Treatment Times and Frequency

Ridner et al (20) analyzed self-reporteddata generated as part of a manufacturer’smarket survey on home-based IPC treatmentwith a programmable device. Patients wereinstructed to use the pump one hour twice aday for the first month, followed by one hourper day thereafter as a maintenancetreatment. Among participants with non-cancer related lymphedema, approximately56% reported following the prescribedmaintenance protocol, with 7% reporting usemore than once a day and 37% less than onceper day. Of those patients with cancer-related

TABLE 3Bandolier Ranking System


22

lymphedema, 32% followed the prescribedprotocol, 21% reported they used the devicemore than twice per day, and a total of 47%of these participants reported they used thepump less than the prescribed protocol. Inthe non-cancer group, 7% did not use thepump at all. In the cancer group, 4% reportedno use. No statistically significant associationwas found between reported use pattern andage, gender, lymphedema severity, or timesince diagnosis. Those who used the pump asprescribed reported higher satisfaction.

Subjective Reported Changes

Ridner et al (20) studied home-basedlymphedema treatment retrospectively andreported on changes in clinical utilizationbehaviors. Ninety-five percent of participantsreported a self-perceived positive limb volumeoutcome. Forty-two percent reported self-perceived limb volume decreases as much as20%, and an additional 20% reporteddecreases of less than 20%. They found astatistically significant drop in the use ofclinician-administered MLD, from a rate of60% MLD-usage before using a program-mable IPC device to a 13% MLD-usage rateat follow-up. There was also a decrease in theapplication of compression bandages and inthe teaching of self-MLD.

In a non-randomized, quasi-experimental,pre-test/post-test designed study of 12 breastcancer patients with truncal lymphedematreated with a programmable IPC device,Ridner et al (21) found there was statisticallysignificant improvement in the symptoms ofheaviness and tightness in the swollen truncalareas after five treatments. There was nosignificant reduction in truncal girth.

Hammond (22) described a single casestudy of a woman with breast cancer-relatedlymphedema who experienced no furtherepisodes of cellulitis and hospitalizations overa 3-year time period after the initiation ofIPC. Additionally, she reported less intensiveand less frequent medical follow up.Hammond (23) also reported a five patient

case study on the use of a programmable IPC device to treat truncal and arm breastcancer-related lymphedema. After receiving 2 months of in-clinic decongestive therapy,including in-home self-treatment with theIPC device, the patients showed reductions in trunk and arm swelling, fibrotic tissuesoftening, pain reduction, and improvedrange of motion and flexibility. The patientsreported enhanced in-home compliance withtheir self-treatment program.

Volumetric Changes

Pilch et al (24) compared the use ofsingle and three-compartment sleeves, andfound that IPC reduced the extent of edema,with no significant differences between thetype of IPC device applied. They hypothesizethat, unlike MLD where lymphatic pressureis applied centripetally from proximal todistal parts of the extremity, the IPC wave in sequential compression is directedcentripetally, but starts in the distal parts ofthe extremity. If any mechanical blockhampers lymph outflow, the pressure waveshift to the proximal extremity parts mayeven hamper lymph drainage, if it is notpreceded by emptying of the proximallymphatic vessels. Pilch et al (24) state thatanother reason for the significant reduction in lymphedema, independent of the compres-sion sequence, might involve the physiologicalmechanism of IPC. IPC acts as a “musclepump” which facilitates the flow of lymph inlymphedema. During compression, the lymphvessels collapse and their content is shiftedtoward proximal parts of the extremity whilethe release of compression during adecompression interval allows refilling oflymph vessels with lymph.

DISCUSSION

Overall, the use of IPC devices forlymphedema treatment is well-founded in the literature. This review presents Level IIand III evidence to support physiological


23

changes associated with IPC use in patientswith lymphedema. These studies, indivi-dually, targeted two primary outcomes: 1)inter-vessel fluid pressure changes and theassociation with applied IPC pressures; and2) the uptake of radiotracer dye into thelymphatic system. Each of these endpointsspeaks to the effectiveness of the IPC devicein changing the physiological milieu of thelymphatic system through compressionapplication, a mechanism necessary topromote fluid uptake and alleviate limbswelling. These studies are consistent withpast findings of improved tissue fluidtranslocation (25,26). However, there isevidence to suggest tissue fluid transport isnot associated with transport of macro-molecules (i.e., protein) from the interstitialtissue (27). This may raise questions as to theeffectiveness of IPC as a stand-alonemodality that promotes sustainable limbvolume congestion (26,27). The results heresupport the necessity of a multi-modalityapproach when fluid uptake is desired in analtered state of lymphatic function (15).

Level I - III evidence supportscompression pressures in the range between30 and 60 mmHg. There is agreement thatIPC pressure is dissipated when applied totissue. Forces such as tissue resistance andblood pressures should be considered whenapplying IPC and suggest that a directrelationship exists between the level ofpressure needed to impact fluid uptake andthe level of resistance the tissue affords.Advanced stages of lymphedema arecharacterized by interstitial fibrosis whichresults in greater tissue resistance thereforecompression levels should be set withconsideration for the relatively delicatenature of the superficial lymphatics in aneffort to not cause ischemic damage.

There is no standard consensus for thefrequency of IPC treatments. This reviewportrays the results of one study that offersLevel III evidence as to IPC frequency andduration. While an optimal strategy for IPCuse likely varies based on the tissue and blood

flow characteristics, the study presented heredemonstrates that patient preference plays asignificant role in determining the frequencyof IPC use. While specific IPC parametersshould be outlined for patients (28),considerable variance in reported IPC use isexpected. Attention to patient adherence,identification of barriers to IPC treatmentand willingness to tailor treatment prescrip-tion should be investigated as mechanisms toensure optimal IPC use. IPC use undoubtedlycontributes to volumetric reduction oflymphedema. However, the sustainability ofvolume reduction when using IPC alone iscalled into question through this review.

Adverse Events

None of the abstracted lymphedemastudies reported significant adverse eventsduring or after the IPC treatments. In theVanscheidt et al (29) study of compressiontherapy for chronic venous edema, twopatients reported discomfort at 60 mmHgwhen being treated with intermittentpneumatic compression but not at 40 or 50mmHg. One patient treated with sustainedpneumatic compression had skin irritationand three subjects reported discomfort atleast once. It can be concluded that underthese controlled circumstances, IPC deviceshave little detrimental effect on patient safety.

Cost Considerations

IPC devices range in price from severalhundred to several thousand dollars. Thisreview highlights evidence that suggestspotential for time-saving in the clinical settingwith IPC device use. This may indirectlydecrease overall resource utilization andcosts; however, no economic comparison hasbeen conducted to evaluate the direct andindirect costs associated with IPC use. Onesingle case study suggested significant costsavings with decreased incidence of infectionand reduced hospitalizations when an IPCdevice was used to control lymphedema.


24

However, further investigation is warrantedto explore the cost benefit of IPC use.

Clinical Relevance and Impact on Best Practice

Previous studies report that CDT is anaccepted and effective combination oftechniques which decongests the soft tissueswelling associated with lymphedema (1,3,30-32). While the use of IPC devices has notbeen traditionally espoused as an acceptedcomponent of the gold standard of CDT, thisreview suggests there is a viable place for IPCdevices to be utilized as an adjunct in effectivemanagement of lymphedema. Further, severalclinical studies have used IPC in the contextof their trials and have demonstrated goodutility and outcomes with IPC devices (30,31).

The results of this systematic reviewindicated that IPC devices are well-toleratedin low to moderate pressure ranges, and thedevice enables compression application in thepatient’s home. IPC is also a safe andeffective intervention for many suffering withchronic lymphedema who have little to noaccess to medical care in the health caresystem of proximity. Considering the agingpopulation of the United States, it is wise torecognize interventions that have goodclinical utility and are easily and safelyapplied by patients or their immediate care-givers in an independent, home-structuredenvironment. This application calls forfurther studies among the aged and disabledin a culturally-sensitive environment.

This review demonstrates variability inIPC-related clinical outcomes based onindividual patient presentation. No clearsingle Best-Practice guideline for IPCemerges as preferential. It is clear, however,that an individualized, multi-modal approachis optimal to treat lymphedema and evidenceshows that IPC devices may play a formativerole in this approach. Clinical recommenda-tions for pneumatic pressures can be guidedby the literature offered here, but nouniversal consensus is noted, pending furtherrigorous studies. These points of non-

consensus have lead to international scientificbodies taking initiative to explore the currentstate of the science through convenedsymposia and conferences. The InternationalCompression Club (ICC) has publishedconsensus documents highlighting the obviousdearth in the current literature surroundingthe use of compression therapy to treatlymphedema (15). The ICC documents offersuggestions for Best Practice based on asynthesis of the current literature and suggestclinical trials that are needed to alleviate gaps in the current literature. Theserecommendations are supported by this 2004-2011 review.

A limitation of this systematic review isthat it was limited to the English languageliterature or available translated non-Englishliterature published from 2004 to 2011 inpeer-reviewed sources. Despite our bestefforts, it is possible that potentially eligiblestudies might have been missed.

REFERENCES

1. Földi, M, E Földi, S Kubik: Textbook ofLymphology: For Physicians and LymphedemaTherapists. Urban and Fisher, San Francisco,CA, 2006.

2. Cormier, JN, RL Askew, KS Mungovan, et al:Lymphedema beyond breast cancer: Asystemic review of cancer-related secondarylymphedema. Cancer 116 (2010), 5138-5149.

3. International Society of Lymphology: Thediagnosis and treatment of peripherallymphedema: 2009 consensus document of the International Society of Lymphology.Lymphology 42 (2009), 51-60.

4. National Lymphedema Network: Positionstatement of the National LymphedemaNetwork: The diagnosis and treatment of lym-phedema. Accessed April 10, 2012, at http://www.lymphnet.org/pdfDocs/nlntreatment.pdf.

5. Deo, SVS, S Ray, GK Rath, et al: Prevalenceand risk factors for development oflymphedema following breast cancertreatment. Indian J. Cancer 41 (2004), 8-12.

6. Armer, JM, BR Stewart: Post-breast cancerlymphedema: Incidence increases from 12 to30 to 60 months. Lymphology 43 (2010), 118-127.

7. Ronka, RH, MS Pamilo, KAJ von Smitten, etal: Breast lymphedema after breast conservingtreatment. Acta Oncol. 43 (2004), 551-557.

8. Brush, BE, TJ Heldt: A device for relief oflymphedema. JAMA 158 (1955), 34-35.


25

9. Brush, BE, JH Wylie, J Beninson: Thetreatment of postmastectomy lymphedema.Arch. Surg. 77 (1958), 561-567.

10. Medical coverage policies: Lymphedemapumps. Accessed April 10, 2012, athttps://www.bcbsri.com/BCBSRIWeb/pdf/medical_policies/Lymp hedemaPumps.pdf.

11. Bandolier: Type & strength of evidence.Accessed April 10, 2012, at http://www.medicine.ox.ac.uk/bandolier/band6/b6-5.html.

12. Rinehart-Ayres, M, K Fish, K Lapp, et al: Useof compression pumps for treatment of upperextremity lymphedema following treatmentfor breast cancer: A systematic review. Rehab.Oncol. 28 (2010), 10-18.

13. Moseley, AL, CJ Carati, NB Piller: Asystematic review of common conservativetherapies for arm lymphoedema secondary tobreast cancer treatment. Ann. Oncol. 18(2007), 639-646.

14. Olszewski, WL, P Jain, G Ambujam: Tissuefluid pressure and flow in the subcutaneioustissue in lymphedema-hints for manual andpneumatic compression therapy.Phlebolymphology 17 (2010), 144-150.

15. Adams, KE, JC Rasmussen, C Darne, et al:Direct evidence of lymphatic functionimprovement after advanced pneumaticcompression device treatment of lymphedema.Biomed. Opt. Express 1 (2010), 114-125.

16. Mayrovitz, HN: Interface pressures producedby two different types of lymphedema therapydevices. Phys. Ther. 87 (2007), 1379-1388.

17. Christenson, JT, L Wulff: Compartmentpressure following leg injury: The effect ofdiuretic treatment. Injury 16 (1985), 591-594.

18. Partsch, H, M Flour, PC Smith: Indicationsfor compression therapy in venous andlymphatic disease consensus based onexperimental data and scientific evidence.Under the auspices of the IUP. Int. Angiol. 27(2008), 193-219.

19. Szolnoky, G, B Lakatos, T Keskeny, et al:Intermittent pneumatic compression actssynergistically with manual lymphaticdrainage in complex decongestive physio-therapy for breast cancer treatment-relatedlymphedema. Lymphology 42 (2009), 188-194.

20. Ridner, SH, E McMahon, MS Dietrich, et al:Home-based lymphedema treatment inpatients with cancer-related lymphedema ornoncancer- related lymphedema. Oncol. Nurs.Forum 35 (2008), 671-680.

21. Ridner, SH, B Murphy, J Deng, et al:Advanced pneumatic therapy in self-care ofchronic lymphedema of the trunk. Lymphat.Res. Biol. 8 (2010), 209-215.

22. Hammond, T: Reductions of complicationsand associated costs with flexitouch therapyfor lymphedema. Open Rehab. J 2 (2009), 54-57.

23. Hammond, T, HN Mayrovitz: Programmableintermittent pneumatic compression of therapyfor breast cancer treatment-related truncaland arm lymphedema. Home Health CareManagement & Practice 22 (2010), 397-402.

24. Pilch, U, M Wozniewski, A Szuba: Influenceof compression cycle time and number ofsleeve chambers on upper extremity lymphe-dema volume reduction during intermittentpneumatic compression. Lymphology 42(2009), 26-35.

25. Baulieu, F, JL Baulieu, L Vaillant, et al:Factorial analysis in radionuclidelymphography: assessment of the effects ofsequential pneumatic compression.Lymphology 22 (1989), 178-185.

26. Mridha, M, S Odman: Fluid translocationmeasurement. A method to study pneumaticcompression treatment of postmastectomylymphoedema. Scand. J. Rehabil. Med. 21(1989), 63-69.

27. Miranda, FJ, MC Perez, ML Castiglioni, et al:Effect of sequential intermittent pneumaticcompression on both leg lymphedema volumeand on lymph transport as semi-quantitativelyevaluated by lymphoscintigraphy. Lymphology34 (2001), 135-141.

28. Wilburn, O, P Wilburn, SG Rockson: A pilot,prospective evaluation of a novel alternativefor maintenance therapy of breast cancer-associated lymphedema BMC Cancer (2006)Accessed April 10, 2012, athttp://www.biomedcentral.com/content/pdf/1471-2407-6-84.pd f.

29. Vanscheidt, W, A Ukat, H Partsch: Dose-response of compression therapy for chronicvenous edema-higher pressures are associatedwith greater volume reduction: Tworandomized clinical studies. J. Vasc. Surg. 49(2009), 395-402.

30. Szuba, A, JP Cooke, S Yousuf, et al:Decongestive lymphatic therapy for patientswith cancer-related or primary lymphedema.Am. J. Med. 109 (2000), 296-300.

31. Szuba, A, R Achalu, SG Rockson:Decongestive therapy for patients with breastcarcinoma-related lymphedema: Arandomized prospective study of a role foradjunctive intermittent pneumaticcompression. Cancer 95 (2002), 2260-2267.

32. Koul, R, T Dufan, C Russell, et al: Efficacy of complete decongestive therapy and manuallymphatic drainage on treatment-relatedlymphedema in breast cancer. Int. J. Radiat.Oncol. Biol. Phys. 67 (2007), 841-846.

Joseph L. Feldman, MD, CLT-LANA2650 Ridge Avenue, Suite 2217 Evanston IL 6020Tel: 847-570-2066E-mail: [email protected]
