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| Lymphovenous Canada: How effective are pneumatic extremity pumps in treating lymphedema? Although extremity pumps have been used since the late 1960's, there has been some debate on their effectiveness. Recent studies suggest that pumps can play a useful role in treating lymphedema and that claims pumps are harmful are highly exaggerated. Below is selected research which has been recently conducted in this area. Cautions do exist on using pumps. They are not recommended during episodes of inflammatory phlebitis or pulmonary embolism (blood clots). Some researchers (Boris, 1998)1. have suggested that lower limb users may be at risk of developing genital lymphedema while others (Brennan, 1998)2. have warned against using a pump during an infection, metastatic disease and ongoing radiation. As with any treatment, patients should consult with their doctor and/or licensed and reputable health care professionals before embarking on any treatment regime. Some clinicians in the area have suggested that multi-chamber (segmented) pumps with calibrated pressure gradients are more effective than single chamber pumps without gradient pressure, although an American evaluation undertaken in 1998 by the Blue Cross Blue Shield Technology Evaluation Center (TEC) comparing the efficacy of different types of pneumatic extremity pumps found there was "insufficient evidence to permit conclusions regarding whether the efficacy of lymphedema pumps varies across pump type."3. Most researchers recommend the use of compression garments to maintain the reduction of edema after pump use. Many suggest conservative treatments such as elevation, exercise, massage and the use of compression garments prior to using extremity pumps. More objective scientific research is clearly called for to determine under what conditions extremity pumps work most effectively on persons who have lymphatic conditions. 1. Boris M, Weindorf S, Lasinski BB. The risk of genital edema after external pump compression for lower limb lymphedema. Lymphology 1998 Mar;31(1):15-20 2. Brennan MJ. Lymphedema Following the Surgical Treatment of Breast Cancer:A Review of Pathophysiology and Treatment, Journal of Pain and Symptom Management 1992;7:110-116. 3. Lefevre, F. Special Report: Comparative efficacy of different types of pneumatic compression pumps for the treatment of lymphedema, Blue Cross Blue Shield Association, 1998. A Retrospective Study of the Effects of the Lymphapress Pump on Lymphedema in a Pediatric Population Lymphology 34(2001) 156-165 by A. Hassall, C. Graveline and P. Hilliard, Dept. of Rehabilitation Services, the Hospital for Sick Children, Toronto, Ont. This study reports positive results from the use of the Lymphapress pump (LP, Global Medical Imports, Digby, N.S., Canada) studied retrospectively on 16 children with primary or secondary lymphedema of the upper or lower extremities by measuring the volume and circumference of the limbs before and after treatment. The study notes that clinicians at the Hospital for Sick Children have used the Lymphapress Pump (LP) with no noticeable side effects. They state in the study that although advocates of manual lymph drainage maintain that use of the LP leads to the development of fibrous bands which further impede lymph drainage or produce lymphedema in unaffected limbs, the effectiveness of physiotherapy in the management of lymphedema has not be documented. "No randomized controlled trials in adults or children have been reported. No study of these two therapies has produced statistically significant findings in favour of one over the other." The study reported that 88% of their subjects experienced no complications directly arising from pump use. The more serious complications of lymphedema, genital and truncal edemas did not appear to be caused by the pump nor did it cause lymphedema in the unaffected limb. "The boy with bilaterial LE lymphedema and edema of the groin and scrotum was reluctant to discontinue pumping despite these regional swellings, because he had a decrease in infectious episodes while on treatment. It remains unclear whether pumping when these comorbid conditions are present is harmful." They conclude by suggesting that more research is needed: at a microcirculatory level on the effects of compression on lymphatic structure in both children and adults; the validity and reliability of the thigh-to-foot ratio measures used to evaluate bilateral lymphedema; whether the Lymphapress pump, complex physical therapy, or a combination of the two is the best non-operative method to control childhood lymphedema. Some flaws with the study are noted in the editorial "Pumps and Lymphedema" (pgs. 150-151) - such as: the small sample, the variation of protocol from 2-7 days per week, and the use of exercise and compression garments with the pump Editor Charles Witte writes, "overwhelming benefits and advantages of complex physical therapy have been claimed, and an aura of fear and apprehension has evolved surrounding these dogmatic warnings to avoid compression devices." Witte adds that despite the high cost of the devices and their dubious benefit, "it is also apparent that these devices have been used for a long time, that serious documented complications of their appropriate use are infrequent, and even these are largely related to transient edema accumulation in the genital region after application to the lower extremities." He concludes, saying, "Careful analysis of this paper suggests that pneumatic compression has limited, if any, value in the treatment of lymphedema. On the other hand, one suspects that the complications and dangers often attributed to usage of 'pumps' are exaggerated and overblown." The authors can be contacted for more information through: Ms. Alison Hassall, BSc. PT Dept. of Rehabilitation Services The Hospital for Sick Children 555 University Ave. Toronto, Ont. Tel: (416) 813-6755 Fax: (416) 813-8557 A copy of the study can be obtained from the Lymphology journal by writing: Charles L. Witte, M.D., Arizona Health Sciences Center, Dept. of Surgery (GS&T), P.O. Box 245063, Tucson, AZ 85724-5063 USA Tel: (520) 626-6118 Fax:(520) 625-0822 e-mail: lymph@u.arizona.edu Clinical practice guidelines: pneumatic compression pumps From: Clinical practice guidelines for the care and treatment of breast cancer: 11. Lymphedema Susan R. Harris, Maria R. Hugi, Ivo A. Olivotto, Mark Levine, for the Steering Committee for Clinical Practice Guidelines for the Care and Treatment of Breast Cancer CMAJ 2001;164(2):191-9 One randomized trial has demonstrated a trend in favour of pneumatic compression pumps compared with no treatment. Further randomized trials are required to determine whether pneumatic compression provides additional benefit over compression garments alone. There has been only one randomized trial that has evaluated pneumatic compression pumps for the treatment of lymphedema. Dini and colleagues35. assigned 80 women with postmastectomy lymphedema to either intermittent pneumatic compression or no treatment. Women in the treatment group underwent a 2-week cycle of 5 pump sessions per week, each session lasting 2 hours, followed by a 5-week break, and then another 2-week treatment cycle. Although the mean decrease in arm circumference in the treatment group was nearly 4 times that in the control group (1.9 cm v. 0.5 cm), the post-test differences between the 2 groups failed to reach statistical significance (p = 0.084), possibly because of the small sample and the large variability in both the initial arm measurements and the circumferential changes within each group (level II evidence). The experience with lymphedema pumps has also been reported in a number of level V studies.36,37,38,39,40,41,42 The results have been mixed. These studies were limited by their small samples, mixed populations (arm and leg edema), lack of control groups and lack of outcome measures that assessed symptoms such as pain and heaviness. In one study pneumatic compression produced a reduction in lymphedema volume that was 18% greater than the reduction produced by elastic compression;41. in another study no difference was detected between elastic compression and pneumatic compression.36. No comparative studies have been published to determine the most effective pumping time, pressure levels or kind of pump. There is a suggestion,44. but not unanimous agreement,43. that sequential, multichambered pumps are more effective than monochambered pumps. The former produce a linear pressure wave from distal to proximal portions of the limb that reduces the tendency of fluid to collect in the hand. There are several commercially available pumps, ranging in complexity and cost. Most pumps used by therapists, clinics and consumers are complex and cost several thousand dollars. Pump therapy is contraindicated in the presence of active infection or deep vein thrombosis in the limb. 35. Dini D, Del Mastro L, Gozz A, Lionetto R, Garrone O, Forno G, et al. The role of pneumatic compression in the treatment of postmastectomy lymphedema. A randomized phase III study. Ann Oncol 1998;9:187-91. 36. Bertelli G, Venturini M, Forno G, Macchiavello F, Dini D. An analysis of prognostic factors in response to conservative treatment of postmastectomy lymphedema. Surg Gynecol Obstet 1992;175:455-60. 37. Kim-Sing C, Basco VE. Postmastectomy lymphedema treated with the Wright linear pump. Can J Surg 1987;30:368-70. 38. Pappas CJ, O'Donnell TF. Long-term results of compression treatment for lymphedema. J Vasc Surg 1992;16:555-62. 39. Klein MJ, Alexander MA, Wright JM, Redmond CK, LeGasse AA. Treatment of adult lower extremity lymphedema with the Wright linear pump: statistical analysis of a clinical trial. Arch Phys Med Rehabil 1988;69:202-6. 40. Raines JK, O'Donnell TF, Kalisher L, Darling RC. Selection of patients with lymphedema for compression therapy. Am J Surg 1977;133:430-7. 41. Swedborg I. Effects of treatment with an elastic sleeve and intermittent pneumatic compression in post-mastectomy patients with lymphedema of the arm. Scand J Rehabil Med 1984;16:35-41. 42. Richmand DM, O'Donnell TF Jr, Zelikovski A. Sequential pneumatic compression for lymphedema. Arch Surg 1985;120:1116-9. |
| Medical supply stores can order pumps for you. Two places I have heard of that works with insurance plans is: http://advancedrehabtechnologies.net/ http://www.absolutemedical.net/ |
| Absolute Medical, Inc. is a durable medical equipment company that is committed to providing the best in home compression pump therapy for people with chronic edemas including primary and secondary lymphedema, chronic venous insufficiency, long-standing (venous return) ulcers, and other vascular disorders. We also offer... Insurance coverage verification for all varieties of insurance including Medicare. Direct insurance billing for qualifying patients. At-home equipment installation and set-up. Comprehensive instruction by qualified personnel. And 24-hour customer service. |
| LYMPHLAND |
| With all the different insurance plans out
there, getting reimbursed is
complicated. Many standard Medical Equipment companies may not have the
knowledge to get the multi-chambered, gradient pumps covered. And they
are expensive.
Medicare does require that conservative methods be tried for at least thirty days before the best equipment. And there are different requirements for different types of Lymphedema. Cancer patients have different standards than do patients w/ venous ulcer problems. At my company, Advanced Rehab Technologies, Inc. we often put a standard, non gradient pump on a patient for a month trial, so as to meet Medicare expectations. If the patient fails, or has problems with this pump, then we can move forward with the more advanced pump. Sounds backwards , but that is the insurance issue today. As always, pumps are not the total solution. Follow your medical professionals advice and follow a multi-faceted approach to dealing with it. Sincerely, Dan Dulnikowski of Advanced Rehab Technology **Dan is a valued member of Lymphland International Lymphedema Support Online. |
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