Why Compression Pumps Cause Damage

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Why Compression Pumps Cause Damage

Postby patoco » Sat Jun 10, 2006 1:13 pm

Why Compression Pumps Cause Damage

Our Home Page: Lymphedema People

http://www.lymphedemapeople.com

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Wanted to share this article written by those wonderful Australian lymphedema doctors which goes into detail exactly why pumps cause further damage to lymphatics.

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Why Pumps cause Complications

from the Lymphoedema Assoc of Australia, written by .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 lymphoedema.

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
parts.

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 swell.

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
therapist.

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 operators!

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 increased!

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
possible.

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 Legs:

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.

In Arms:

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 two studies:

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 < 0.001).

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.

Summary

Pumps should never be used alone. In particular, they should never be used:

after a bilateral mastectomy,
after pelvic operations when the tops of both legs have started to
swell,
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

The Lymphoedema Association of Australia

http://www.lymphoedema.org.au/

............

Responses to the Post

Barbara 07/27/2005

I feel compelled to speak to this. After arm surgery on both arms, I started LE massage therapy with a p/t in conjunction with a sequential pump. The pump in the office was sequential, but only involved the arm. I was ordered a special pump at the end of my therapy from a company called Flexitouch (cost over $11,000 to the insurance company). It is unique in that it has sequential coverage that wraps around the abdomen, the thigh, and the arm area as well as the arm itself. I was told to use it for 2 hours on each arm (I was being treated then for just the arms) every day. I used it for a few months, but I don't think it was worth the effort, even though it actually did cover the trunk. Maybe because of my size (I required extensions to the standard model that I am not sure I was using properly)I didn't think the sales person was very educated about the best placement of the wraps around the abdomen and leg. Sometimes I felt like the swelling lessened and sometimes, not. I think just laying down and resting with my legs elevated may have had the same result. Unfortunately, I have LE in all 4 limbs and my trunk. At the request of a new doctor, I was told to stop the pump. I have seen no change in the condition of my arms. At the same time, my trunk and abdomen have escalated and now I am swollen through the entire body and needing MLD and wrapping to address. The pumps described in the article don't mention the type that I had -- in that it did cover the arm juncture and the abdomen and thigh. I think that the company is moving in the right direction by addressing the need for this added coverage -- but their sales people need more education in how to instruct in proper use. I feel like my insurance paid a huge bill for something I will not use effectively. Now that I am facing MLD therapy for all 4 limbs and extended visits, I am sure they will question the investment as well.

Barbara
Springfield, PA
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Postby Noelle » Mon Oct 30, 2006 5:49 pm

I just read this post about compression pumps, and it's made me really nervous. I was prescribed a leg pump for my lymphedema as I'm going to have bunion surgery on my affected foot and won't be able to wear my compression garments while the foot heals. I've only been using the pump for three days, but I felt as though the fluid was being pushed into my abdomen. I didn't think much of it, but after reading your post, I'm now afraid that I might develop abdominal lymphedema. What can I do to prevent this from happening, and also to keep my unbandaged foot from swelling too much during the three weeks that the foot will need to heal?
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Postby lazyleftleg » Thu Apr 19, 2007 8:44 am

thanks for the info on this pat. i had a pump on my left leg while i was in the hospital having my daughter. my leg was so swollen i could not get my compression stocking on, so i asked if they had something to help and that is what they brought in. i wonder if this is part of the reason i am having so much trouble with my calf & ankle since the pump only went that far. i bet it did some damage to the vessels and now i'm paying long-term for temporary relief. uuuughhh! again, i'm glad i'll be getting back with a therapist soon.
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Postby jaddsy » Sat Jun 30, 2007 10:27 pm

I have been using the ****** for over a month and have been having good results. I have a full body suit that covers both of my legs and go to my waist. I feel so much better all over since using it. It might not work for everyone, but it is working for me. I need to work since it is only me, myself, and I in my home. This way I can have treatment everyday when I get home. It does feel good to have my legs massaged after a day at work. I was educated in what to watch for, such as infection, etc... and then I will stop the press until it's cleared. Using this machine has given me hope for the future, and working in a job I really love. Like I said, it might not work for everyone, but for me it's an answer to prayer. I am 51 and have lymphedema in both legs.

***editor's note: That pumps can move fluid is not without question. It is exactly for this reason (moving fluids without clearing the abdominal lymphatics) that they can cause genital lymphedema. ***
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Genital edema after external pump compression leg lymphedema

Postby patoco » Wed Jul 18, 2007 7:15 am

The risk of genital edema after external pump compression for lower limb lymphedema.

Boris M, Weindorf S, Lasinski BB.
Department of Pediatrics, North Shore University Hospital, Manhasset, Woodbury, New York, USA.

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.

PMID: 9561507 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/sites/entrez
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Postby Stacy » Thu Jul 19, 2007 3:14 pm

Pat-

I gave my LE therapist your article on compression pumps. She wasn't completely dismissive but said that she never had the pump set as high as was indicated in the article and that if MLD is done first, the risk of genital/abdominal LE is reduced.

I did use the pump during my treatments but declined a prescription for one to use at home. My previous experience with the pump made me very reluctant to use one at all. The first time I was precribed one was by a cardiovascular surgeon who told me I needed to "live with it"(LE), wrote a prescription and left. He gave me no instruction, the fellow who delivered it to my house had no idea how to even set the machine let alone use it. My calves after using the pump for about two months became increasingly fibrotic. All this because my insurance company at the time deemed MLD experimental treatment and I had to prove "conventional" therapy failed before they would pay for it. This was almost ten years ago and insurance companies are starting to wake up, thank God.

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