Why Compression Pumps cause Complications with Lymphedema
There is always much discussion regarding the use of compression pumps
in the treatment of lymphedema. I thought it might be helpful to share
a couple article which shed much light on what exactly a pump does to
the lymphatics and what the complications can be from its usage.
Remember, the standard protocol for lymphedema treatment is manual
decongestive therapy and/or complex decongestive therapy.
Why Pumps cause Complications
from the Lymphoedema Assoc of Australia, written by Drs .R. Casley-Smith & Judith R. Casley-Smith
Almost all use compressed air to squeeze the swollen limb. There are a
variety available. Some patients (Grade 1 lymphoedema) are helped by
these; most (Grades 2 and 3) are not. Usually lymphoedemas which have
only been present a short time respond best; very fibrotic ones do not
respond at all. However the incidence of serious complications is the
same for both Grades.
What does a pump do? What does it not do? Why do we advise against
their use? They simply force fluid into the adjacent area. They do not
improve drainage from a limb in the long term. They can never clear an
area of the trunk into which the limb can drain.
There are two types of pumps available: 1. Segmental (sequential,
multi-chambered), i.e. a number of compartments which pump in sequence (the pressures in these may be graded); 2. non-segmental (single chambered), where the limb is simply enclosed by a continuous sleeve or stocking and is compressed all at once, then released. The former is more efficient; because of this it is also more dangerous and can cause much more damage. This is especially the case if the trunk (body) has not first been cleared manually.
Mercury is used in a few pumps, giving a very high but smoothly graded
compression. These seem not to give complications like the pneumatic
ones (when used with care) and are particularly useful for very
fibrotic regions; but they are rather expensive and complex, and few
therapists have them.
Why Pumps cause Complications
So much of the reduction by C.P.T./C.L.T. is obtained by simply making
a space into which the overloaded lymphoedematous part can drain. The
principles on which good conservative therapy depends for lymphoedema
treatment are therefore completely negated as far as the clearing of
the affected limb is concerned. Even if the trunk is cleared prior to
the pumping of the limb, this is usually inadequately done. At least 30
minutes would be needed to clear the trunk properly. This would need to
be continued during the pumping process to minimise damage. Even with
this, in some cases, the avoidance of damage is not possible.
The most superficial lymphatic vessels are very small and very fragile.
These are easily damaged and are certainly broken when a pressure of
more than 60 mm Hg is applied. (Pumps are often used at very much
greater pressures. ) Without these vessels, there is no
inter-connecting network over the body through which at least some of
the lymph can be transported. The slightly deeper vessels, very small
collecting lymphatics, may also be damaged. Some of these will
regenerate, given time, but meanwhile fibrotic (scar) tissue forms and
blocks the drainage in the adjacent tissue channels.
The deeper vessels may be encouraged to drain more by the pumping - but what happens when their drainage is either inadequate or is blocked
further along the lymphatic drainage system? Then the region just
proximal to (i.e. above) the 'sleeve' of the pump becomes overloaded.
The lymphatics in it often rupture and leak lymph to form a new area of
lymphoedema. This can lead to the formation of fibrous tissue like a
'cuff' around the upper part of the limb. This then contracts and
strangles the remaining lymphatics. Any nodes which remain and are
still filtering the lymph, but are already overloaded, as is the
superficial network in adjacent areas. Thus their ability to collect
from adjacent areas is reduced, e.g. from the chest wall for
lymphoedema of the arm. With lymphoedema of the arm, the opposite
chest, breast, and sometimes the opposite arm and the abdominal wall on
the same side, can also be made lymphoedematous.
In lymphoedema of the leg this is the abdominal wall and, even more
importantly, the genital area. In fact this overload can be so severe
that not only the genital area is made lymphoedematous, but the
previously 'normal' leg also swells. (In primary lymphoedema, the other
leg often has abnormal lymphatics even if it shows no evidence of
swelling in both primary and secondary lymphoedema.) In secondary
lymphoedema pelvic drainage may be affected. Thus the 'normal leg is a
leg 'at risk'.
Fistulae (i.e. holes through the skin from which lymph leaks) can be
produced proximal to the sleeve of the pump, and also in the genital
area (of both men and women). These are sites where bacteria can easily
enter and so cause infection and inflammation. These worsen the
lymphoedema and can even be life-threatening.
Pumps can also transmit infection from one patient to another, or make
one more likely by abrading the skin. They can cause damage to the
small blood vessels and hence bruising. Again, this tends to worsen a
Pumps cannot remodel the limb in the way that CPT (CLT) can because
they work on the limb as a whole and cannot concentrate on individual
The results of using pumps have very seldom been published - and never
the long-term results. Those that have been are poor compared with CPT
(CLT). Even when the trunk and adjacent areas have been cleared prior
to pumping a limb, the results are poor compared with those of other
treatments (e.g. CPT plus benzo-pyrones) and the complications still
occurred in some cases.
The complications caused by pumps are several:
genital lymphoedema (including fistulae by which lymph leaks to the
skin, and bacteria may enter), lymphoedema of the trunk (and breast) adjacent to the affected limb, lymphoedema in the (previously apparently normal) opposite limb, transferring the lymphoedema to that part of the limb not covered by the cuff of the pump (ultimately causing a fibrous band which blocks any remaining lymphatics), and bruising and aching.
We know of many cases where the genital areas of men or women
(previously normal) were made lymphoedematous by pumps.
Sometimes the other limb, which was clinically normal, but is always a
'limb at risk', was overloaded by the pump and has also started to
They can cause lymphoedema in an arm, breast and one side of the chest
which was 'at risk' but still normal before the pump (e.g. especially
after a bilateral mastectomy). Lymphoedema of the abdomen may be
caused, or made much worse.
Pumps can also cause fistulae to form (leaking channels through the
skin) and blisters of lymph, via which bacteria readily gain access to
the lymphoedematous tissue with disastrous results.
Any formation of an oedematous cuff at the proximal end of the pump's
sleeve must be avoided. This is a collection of high-protein fluid
which will cause chronic inflammation and a fibrotic band, which will
contract and hinder the little lymph drainage which is still present.
If pumps have to be used, this tragedy can be avoided by measuring the
limb just above the cuff of the pump. Stop the pump at once if this
region starts to increase in size. The more efficient,
multi-compartment pumps are the most dangerous!
When legs are being pumped, the genitalia (in both men and women) MUST be examined frequently, otherwise genital lymphoedema may be produced.
This is much harder to treat, and causes far more difficulties for the
patient than simple lymphoedema of the leg.
If a limb becomes red, bruised or painful, stop the pump and tell the
Pumps are always very dangerous if most of the lymph nodes draining a
limb have been destroyed by surgery and/or radiation, and should not be
used in primary lymphoedema. If pumps are used, it is VITAL that the
pressures are no higher than 40 mm Hg; using greater pressures risks
even more damage.
At the International Congress of Lymphology (Washington, 1993) there
was a general agreement that, if pumps are used at all, the 'body
reservoirs' (i.e. the quadrant of the trunk adjacent to the affected
limb, and the two quadrants adjacent to this) should be cleared first
by massage. Some considered that pumps were valuable for some patients, but they had to be fully supervised and used carefully. They should never be used indiscriminately at home, but only by well-trained
Pumps are not cheap. Costs of using them often equal or exceed
C.P.T./C.L.T., which would give much better results with far fewer
risks. Some therapists and doctors even sell them to patients (at great
personal profits) to take home with them for unsupervised use. Both the
wisdom and the ethics of this are highly dubious.
Some therapists (often encouraged by health insurance companies) are
trying to save costs by mixing pumps, massage, exercises and
compression bandaging and garments. Patients should be aware that (from the so far published results) this does not give as good reductions as properly applied Complex Physical (Lymphedema) Therapy (C.P.T./ C.L.T), the pumps can still cause the complications mentioned above, and it appears that the costs are not reduced - indeed in some cases they are
All this is not to say that pumps should never be used. Properly
trained C.P.T./C.L.T. therapists are unfortunately not available
everywhere. Some hospitals can only offer pumps. However it is
important that their dangers be appreciated and avoided as far as
When must pumps NOT be used?
Based on our findings and those from many colleagues in Australia and
in many countries, we believe that pumps should not be used alone. In
particular, they should never be used:
In any case with even a suspicion of genital lymphoedema.
In primary lymphoedema of the leg (in case it precipitates lymphoedema
of the other leg or the genital area) .
Secondary lymphoedema of the leg when the inguinal nodes (in the groin)
or the deep pelvic ones have been removed or irradiated.
When there is any evidence of arterial disease (e.g. in diabetes).
When more than one area of the body is lymphoedematous.
When a bilateral mastectomy (or irradiation) has been performed. (It is
imperative not to overload the contralateral side through the
collateral drainage normally present.)
Where another area of the body is already involved (e.g. the adjacent
chest wall or, in primary lymphoedema, other parts of the body).
Studies on the Effects of Pumps
At the Congress of the International Society for Lymphology (Sep 95) we
and our colleagues (Dr. M. Boris and Mrs. Bonnie Lasinski) presented
a). Responses to questionnaires sent to 1,517 Australian lymphoedema
sufferers (1,036 replied).
b). Genital involvement was studied in the first 128 consecutive leg
lymphoedemas at a USA lymphoedema treatment centre. Of these, 53 had
been exposed to pumps, the rest had not.
The former (a) estimated pump usage, results and complications for many
patients, but relied on their own assessments. The latter (b) studied
fewer cases, but each was assessed by trained observers.
Of the 1,036 patients (a), pumps had been used in 462. Of these, 199
noted some improvement, but complications increased from 13% (arms) and 30% (legs) to 32% and 55%
(p < 0.001). These included: lymphoedema produced in previously normal genitalia, trunks or contralateral limbs, proximal fibrous bands, bruising and aching. Grade 1 improved more (59%), than Grades 2 and 3 (37%, p = 0.001); but the incidences of complications were identical (19%).
Sequential pumps gave more improvements than single chambered (34%
became 47%, p = 0.01), but also more complications (9% became 23%, p <
Of the 128 consecutive patients (b) at a single USA treatment centre,
genital lymphoedema was present in only 2 of the 75 unexposed to pumps;
it had been caused by pumps in 23 of the 53 exposed to them (p <
0.001). Its incidence was not affected by not allowed, age, duration, Grade,
causation, or uni-/ bilateral lymphoedema.
Thus, pumps gave somewhat better results in Grade 1 than Grade 2
lymphedema, but still caused just as many complications. These were
both frequent and very serious.
Pumps should never be used alone. In particular, they should never be
after a bilateral mastectomy,
after pelvic operations when the tops of both legs have started to
in primary lymphoedema (it is risky even with only one limb involved;
the other may start to swell),
if a patient has more than one area of the body involved (either primary or secondary lymphoedema). The pump may quite simply be responsible for 'blowing up' the next area, which up to that time was
apparently 'normal' and may well have remained so!
if there is already genital lymphoedema,in Grade 2 lymphoedema, when there is much fibrosis
------------ Article Two -------------
The Risk of Genital Edema After External Pump Compression for Lower
Marvin Boris, M.D., Stanley Weindorf, M.D., Bonnie B. Lasinski, B.S.
P.T., M.A. Lymphedema Therapy, Woodbury, New York
In a single lymphedema treatment facility, 128 consecutive patients
with lower limb lymphedema were retrospectively analyzed for the
development of genital edema. The patients were separated for analysis
on the basis of who used or did not use compressive pump therapy. Of
the 128 patients with lower limb lymphedema, 75 received no pump
therapy, and 53 used pumps. Of the 75 who did not use pump compression,
only 2 had genital edema. Of the 53 patients who used pump compression,
23 patients developed genital edema after pump therapy (p<.0001).
The incidence of genital edema was unaffected by age, not allowed, grade or
duration of lymphedema, whether lymphedema was primary or secondary,
whether a single or sequential pump was used, the pressure level
applied, or duration or hours per day of pump therapy.
Compressive pump therapy for lower limb lymphedema produces an
unacceptably high incidence of genital edema.