• Francisca Rosas Instuto de Ciências Biomédicas Abel Salazar (ICBAS) — Universidade do Porto
  • Ivone Silva Instuto de Ciências Biomédicas Abel Salazar (ICBAS) — Universidade do Porto; Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar Universitário do Porto
  • Rui de Almeida Instuto de Ciências Biomédicas Abel Salazar (ICBAS) — Universidade do Porto; Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar Universitário do Porto
Keywords: lymphedema, lower limbs, medical treatment


Background: LLL is characterized by protein-rich interstitial fluid accumulation due to lymphatic system insufficiency, resulting in progressive non-pitting edema. Primary and secondary lymphedema are distinguished by the absence or presence of an external trigging factor, respectively. Diagnosis is based on clinical examination combined with imaging modalities. The non-surgical approach of LLL is based on preventive measures, lifestyle interventions and life-long compression modalities, aiming to reduce
the edema congestion and to improve patient quality of life.

Objectives: The present literature review aims to compile current scientific knowledge on the various domains of the non-surgical treatments of LLL.

Methods: Search was performed in PubMed database, using the following medical subjects heading (MeSH) terms: “lymphedema”, “lower limbs” and “medical treatment”. Research and review articles indexed in the last 10 years and written in English language were selected. Animal experimentation works and single case-reports were excluded. Other materials searched comprised reference books in the area of Vascular Surgery, namely Rutherford Vascular Surgery — 9th Edition, 2018. 

Development: The non-surgical treatment of LLL is characterized by a multifaceted approach, including mechanical reduction of limb swelling, alternative medical devices and pharmacological therapy. Complex decongestive therapy is recognized as the standard of treatment and its compression modalities include drainage massages, pneumatic compression, bandaging systems, compression garments and physical exercise. Compression therapies differ in the degree and time of pressure applied and can be performed by healthcare professionals or by the patient himself. The duration of treatment stages varies and it may
include hospital and outpatient regimens. Positive treatment outcomes include increased skin elasticity, limb volume reduction, pain relief, increased functional capacity and improved quality of life.

Conclusions: Compression modalities have been shown to be effective in reducing limb volume, increasing tissue elasticity and improving the physical, psychological and aesthetic aspects of patient life. However, sustained volume reductions depend mostly on patient diligence. Intensive and outpatients approaches do not compromise treatment efficacy and high pressures therapies are effective and well tolerated. Current lymphedema non-surgical treatment lacks long-term results and urges more effective therapeutic alternatives.


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1. Rockson SG, Tian W, Jiang X, Kuznetsova T, Haddad F, Zampell J, et al.
Pilot studies demonstrate the potential benefits of antiinflammatory
therapy in human lymphedema. JCI insight. 2018;3(20).
2. Sicard GA. Rutherford's Vascular Surgery and Endovascular Therapy.
Journal of vascular surgery. 2018;68(5):1611-2.
3. Jiang X, Nicolls MR, Tian W, Rockson SG. Lymphatic Dysfunction,
Leukotrienes, and Lymphedema. Annual Review of Physiology.
4. Adamczyk LA, Gordon K, Kholova I, Meijer-Jorna LB, Telinius N, Gallagher PJ,
et al. Lymph vessels: the forgotten second circulation in health and disease.
Virchows Archiv : an international journal of pathology. 2016;469(1):3-17.
5. Mortimer PS, Rockson SG. New developments in clinical aspects of lymphatic
disease. The Journal of Clinical Investigation. 2014;124(3):915-21.
6. Ho B, Gordon K, Mortimer PS. A Genetic Approach to the Classification
of Primary Lymphoedema and Lymphatic Malformations. European
journal of vascular and endovascular surgery : the official journal
of the European Society for Vascular Surgery. 2018;56(4):465-6.
7. Moffatt CJ, Franks PJ, Doherty DC, Williams AF, Badger C, Jeffs E, et al.
Lymphoedema: an underestimated health problem. QJM : monthly
journal of the Association of Physicians. 2003;96(10):731-8.
8. Taradaj J, Rosinczuk J, Dymarek R, Halski T, Schneider W. Comparison of
efficacy of the intermittent pneumatic compression with a high- and
low-pressure application in reducing the lower limbs phlebolymphedema.
Therapeutics and clinical risk management. 2015;11:1545-54.
9. Rockson SG, Rivera KK. Estimating the Population Burden of Lymphedema.
Annals of the New York Academy of Sciences. 2008;1131(1):147-54.
10. Salani R, Preston MM, Hade EM, Johns J, Fowler JM, Paskett EP, et al. Swelling
among women who need education about leg lymphedema: a descriptive
study of lymphedema in women undergoing surgery for endometrial
cancer. International journal of gynecological cancer : official journal of the
International Gynecological Cancer Society. 2014;24(8):1507-12.
11. Rockson SG. Update on the biology and treatment of lymphedema.
Current treatment options in cardiovascular medicine. 2012;14(2):184-92.
12. The diagnosis and treatment of peripheral lymphedema: 2013
Consensus Document of the International Society of Lymphology.
Lymphology. 2013;46(1):1-11.
13. Cheville AL, McGarvey CL, Petrek JA, Russo SA, Thiadens SR, Taylor ME.
The grading of lymphedema in oncology clinical trials. Seminars in radiation
oncology. 2003;13(3):214-25.
14. Baddour LM, Bisno AL. Non-group A beta-hemolytic streptococcal cellulitis.
Association with venous and lymphatic compromise. The American
journal of medicine. 1985;79(2):155-9.
15. Park SI, Yang EJ, Kim DK, Jeong HJ, Kim GC, Sim YJ. Prevalence and
Epidemiological Factors Involved in Cellulitis in Korean Patients With
Lymphedema. Annals of rehabilitation medicine. 2016;40(2):326-33.
16. Dixon JB, Weiler MJ. Bridging the divide between pathogenesis and
detection in lymphedema. Seminars in cell & developmental biology.
17. Scarsbrook AF, Ganeshan A, Bradley KM. Pearls and pitfalls of radionuclide
imaging of the lymphatic system. Part 2: evaluation of extremity
lymphoedema. The British journal of radiology. 2007;80(951):219-26.
18. Unno N, Inuzuka K, Suzuki M, Yamamoto N, Sagara D, Nishiyama M, et al.
Preliminary experience with a novel fluorescence lymphography using
indocyanine green in patients with secondary lymphedema. Journal
of vascular surgery. 2007;45(5):1016-21.
19. Cornish BH, Bunce IH, Ward LC, Jones LC, Thomas BJ. Bioelectrical impedance
for monitoring the efficacy of lymphoedema treatment programmes.
Breast cancer research and treatment. 1996;38(2):169-76.
20. Cemal Y, Jewell S, Albornoz CR, Pusic A, Mehrara BJ. Systematic review of
quality of life and patient reported outcomes in patients with oncologic
related lower extremity lymphedema. Lymphatic research and biology.
21. Damstra RJ, Halk A-B, Damstra RJ, Halk B, van den Berg JP, Born Y, et
al. The Dutch lymphedema guidelines based on the International
Classification of Functioning, Disability, and Health and the chronic
care model. Journal of Vascular Surgery: Venous and Lymphatic
Disorders. 2017;5(5):756-65.
22. The diagnosis and treatment of peripheral lymphedema. Consensus
document of the International Society of Lymphology. Lymphology.
23. Hodgson P, Towers A, Keast DH, Kennedy A, Pritzker R, Allen J. Lymphedema
in Canada: a qualitative study to help develop a clinical, research, and
education strategy. Current oncology (Toronto, Ont). 2011;18(6):e260-4.
24. Schaverien MV, Aldrich MB. New and Emerging Treatments for Lymphedema.
Seminars in plastic surgery. 2018;32(1):48-52.
25. Zhou Q, Guo R, Wood R, Boyce BF, Liang Q, Wang YJ, et al. Vascular
endothelial growth factor C attenuates joint damage in chronic
inflammatory arthritis by accelerating local lymphatic drainage in
mice. Arthritis and rheumatism. 2011;63(8):2318-28.
26. [Medical compression in the treatment of lymphedema. Haute
Autorite de Sante]. Annales de dermatologie et de venereologie.
27. Cemal Y, Pusic A, Mehrara BJ. Preventative measures for lymphedema:
separating fact from fiction. Journal of the American College
of Surgeons. 2011;213(4):543-51.
28. Brown L. British Lymphology Society conference 2017: Getting the
basics right. British journal of community nursing. 2017;22(11):557-8.
29. de Kraker ME, Stolk WA, van Oortmarssen GJ, Habbema JD. Model-based
analysis of trial data: microfilaria and worm-productivity loss after
diethylcarbamazine-albendazole or ivermectin-albendazole combination
therapy against Wuchereria bancrofti. Tropical medicine &
international health : TM & IH. 2006;11(5):718-28.
30. Kar SK, Dwibedi B, Das BK, Agrawala BK, Ramachandran CP, Horton J.
Lymphatic pathology in asymptomatic and symptomatic children with
Wuchereria bancrofti infection in children from Odisha, India and its
reversal with DEC and albendazole treatment. PLoS neglected tropical
diseases. 2017;11(10):e0005631.
31. Rabe E, Partsch H, Hafner J, Lattimer C, Mosti G, Neumann M, et al.
Indications for medical compression stockings in venous and
lymphatic disorders: An evidence-based consensus statement.
Phlebology. 2018;33(3):163-84.
32. Zaleska M, Olszewski WL, Durlik M, Kaczmarek M. A Novel Clinical Test
for Setting Intermittent Pneumatic Compression Parameters Based on
Edema Fluid Hydromechanics in the Lymphedematous Calf. Lymphatic
research and biology. 2015;13(3):208-14.
33. Partsch H. Compression therapy: clinical and experimental evidence.
Annals of vascular diseases. 2012;5(4):416-22.
34. Davis MJ, Davis AM, Lane MM, Ku CW, Gashev AA. Rate-sensitive
contractile responses of lymphatic vessels to circumferential stretch.
The Journal of physiology. 2009;587(1):165-82.
35. Mullins M, Bock K, Bhatia A. Extremit-Ease compression garment: A review
and cases. British journal of community nursing. 2017;22(Sup12):S41-s7.
36. Mariana VF, de Fatima GG, Maria Pde G. The effect of mechanical lymph
drainage accompanied with heat on lymphedema. Journal of research
in medical sciences : the official journal of Isfahan University of Medical
Sciences. 2011;16(11):1448-51.
37. Moortgat P, Anthonissen M, Meirte J, Van Daele U, Maertens K.
The physical and physiological effects of vacuum massage on the
different skin layers: a current status of the literature. Burns & trauma.
38. Ergin G, Karadibak D, Sener HO, Gurpinar B. Effects of Aqua-Lymphatic
Therapy on Lower Extremity Lymphedema: A Randomized Controlled
Study. Lymphatic research and biology. 2017;15(3):284-91.
39. Noh S, Hwang JH, Yoon TH, Chang HJ, Chu IH, Kim JH. Limb Differences
in the Therapeutic Effects of Complex Decongestive Therapy on
Edema, Quality of Life, and Satisfaction in Lymphedema Patients.
Annals of rehabilitation medicine. 2015;39(3):347-59.
40. Suehiro K, Morikage N, Yamashita O, Okazaki Y, Hamano Md K. Impact
of aggressive decongestion on the maintenance phase in combined
physical therapy for lower extremity lymphedema. Annals of vascular
diseases. 2011;4(4):306-12.
41. Pereira de Godoy JM, Pereira de Godoy HJ, Lopes Pinto R, Facio FN,
Guerreiro Godoy MdF. Maintenance of the Results of Stage II Lower Limb
Lymphedema Treatment after Normalization of Leg Size. International
Journal of Vascular Medicine. 2017;2017:5.
42. Stanisic MG, Gabriel M, Pawlaczyk K. Intensive decongestive treatment
restores ability to work in patients with advanced forms of primary and
secondary lower extremity lymphoedema. Phlebology. 2012;27(7):347-51.
43. Yamamoto T, Todo Y, Kaneuchi M, Handa Y, Watanabe K, Yamamoto R.
Study of edema reduction patterns during the treatment phase of
complex decongestive physiotherapy for extremity lymphedema.
Lymphology. 2008;41(2):80-6.
44. Foldi M. Treatment of lymphedema. Lymphology. 1994;27(1):1-5.
45. Pereira De Godoy JM, Amador Franco Brigidio P, Buzato E,
Fatima Guerreiro De Godoy M. Intensive outpatient treatment of
elephantiasis. International angiology : a journal of the International
Union of Angiology. 2012;31(5):494-8.
46. Niimi K, Hirai M, Iwata H, Miyazaki K. Ultrasonographic findings and the
clinical results of treatment for lymphedema. Annals of vascular diseases.
47. Hwang KH, Jeong HJ, Kim GC, Sim YJ. Clinical effectiveness of complex
decongestive physiotherapy for malignant lymphedema: a pilot study.
Annals of rehabilitation medicine. 2013;37(3):396-402.
48. Feiskhanov AK, Maksimov AV. [Comprehensive physical antiedematous
therapy in treatment of patients with lymphedema]. Angiologiia i sosudistaia
khirurgiia = Angiology and vascular surgery. 2016;22(4):46-50.
49. uchi T, Dai M, Sanada H, Okuwa M, Nakatani T, Sugama J. Associations
between the treatments and outcomes of patients with upper and
lower lymphoedema in Japan: a cross-sectional observational study.
International journal of nursing studies. 2015;52(5):913-9.
50. Gianesini S, Tessari M, Bacciglieri P, Malagoni AM, Menegatti E,
Occhionorelli S, et al. A specifically designed aquatic exercise protocol
to reduce chronic lower limb edema. Phlebology. 2017;32(9):594-600.
51. Honigman L, Bar-Bachar O, Yarnitsky D, Sprecher E, Granovsky Y.
Nonpainful wide-area compression inhibits experimental pain. Pain.
52. Suehiro K, Kakutani H, Nakamura K, Morikage N, Yamashita O, Harada T,
et al. Immediate Changes to Skin and Subcutaneous Tissue Strains
Following Manual Lymph Drainage in Legs with Lymphedema. Annals
of vascular diseases. 2016;9(1):30-4.
53. Zaleska M, Olszewski WL, Durlik M. The effectiveness of intermittent
pneumatic compression in long-term therapy of lymphedema of lower
limbs. Lymphatic research and biology. 2014;12(2):103-9.
54. Olszewski WL, Jain P, Ambujam G, Zaleska M, Cakala M, Gradalski T.
Tissue fluid pressure and flow during pneumatic compression in lymphedema
of lower limbs. Lymphatic research and biology. 2011;9(2):77-83.
55. Miranda F, Jr., Perez MC, Castiglioni ML, Juliano Y, Amorim JE, Nakano LC,
et al. Effect of sequential intermittent pneumatic compression on both
leg lymphedema volume and on lymph transport as semi-quantitatively
evaluated by lymphoscintigraphy. Lymphology. 2001;34(3):135-41.
56. Cannon S. Pneumatic compression devices for in-home management
of lymphedema: two case reports. Cases journal. 2009;2:6625.
57. Phillips JJ, Gordon SJ. Intermittent Pneumatic Compression Dosage
for Adults and Children with Lymphedema: A Systematic Review.
Lymphatic research and biology. 2018.
58. Modaghegh MH, Soltani E. A newly designed SIPC device for management
of lymphoedema. The Indian journal of surgery. 2010;72(1):32-6.
59. Kaczmarek M, Olszewski WL, Nowak J, Zaleska M. The Hydromechanics of
Edema Fluid in Lymphedematous Lower Limb During Intermittent Pneumatic
Compression. Lymphatic research and biology. 2015;13(4):260-7.
60. Chang CJ, Cormier JN. Lymphedema interventions: exercise, surgery, and
compression devices. Seminars in oncology nursing. 2013;29(1):28-40.
61. Aldrich MB, Gross D, Morrow JR, Fife CE, Rasmussen JC. Effect of pneumatic
compression therapy on lymph movement in lymphedema-affected
extremities, as assessed by near-infrared fluorescence lymphatic
imaging. Journal of innovative optical health sciences. 2017;10(2).
62. Olszewski WL, Cwikla J, Zaleska M, Domaszewska-Szostek A,
Gradalski T, Szopinska S. Pathways of lymph and tissue fluid flow
during intermittent pneumatic massage of lower limbs with obstructive
lymphedema. Lymphology. 2011;44(2):54-64.
63. Zaleska M, Olszewski WL, Cakala M, Cwikla J, Budlewski T. Intermittent
Pneumatic Compression Enhances Formation of Edema Tissue Fluid
Channels in Lymphedema of Lower Limbs. Lymphatic research and
biology. 2015;13(2):146-53.
64. Zaleska M, Olszewski WL, Jain P, Gogia S, Rekha A, Mishra S, et al.
Pressures and timing of intermittent pneumatic compression devices
for efficient tissue fluid and lymph flow in limbs with lymphedema.
Lymphatic research and biology. 2013;11(4):227-32.
65. Kitayama S, Maegawa J, Matsubara S, Kobayashi S, Mikami T, Hirotomi K,
et al. Real-Time Direct Evidence of the Superficial Lymphatic Drainage
Effect of Intermittent Pneumatic Compression Treatment for Lower
Limb Lymphedema. Lymphatic research and biology. 2017;15(1):77-86.
66. Farrow W. Phlebolymphedema-a common underdiagnosed and
undertreated problem in the wound care clinic. The journal of the
American College of Certified Wound Specialists. 2010;2(1):14-23.
67. Foldi E, Foldi M, Clodius L. The lymphedema chaos: a lancet. Annals
of plastic surgery. 1989;22(6):505-15.
68. O'Meara S, Cullum N, Nelson EA, Dumville JC. Compression for venous leg
ulcers. The Cochrane database of systematic reviews. 2012;11:Cd000265.
69. Partsch H, Flour M, Smith PC. Indications for compression therapy in venous
and lymphatic disease consensus based on experimental data and scientific
evidence. Under the auspices of the IUP. International angiology :
a journal of the International Union of Angiology. 2008;27(3):193-219.
70. Schuren J, Bernatchez SF, Tucker J, Schnobrich E, Parks PJ. 3M Coban
2 Layer Compression Therapy: Intelligent Compression Dynamics to
Suit Different Patient Needs. Advances in wound care. 2012;1(6):255-8.
71. Franks PJ, Moffatt CJ, Murray S, Reddick M, Tilley A, Schreiber A. Evaluation
of the performance of a new compression system in patients with lymphoedema.
International wound journal. 2013;10(2):203-9.
72. Zasadzka E, Trzmiel T, Kleczewska M, Pawlaczyk M. Comparison of
the effectiveness of complex decongestive therapy and compression
bandaging as a method of treatment of lymphedema in the elderly.
Clinical interventions in aging. 2018;13:929-34.
73. Brennan MJ, Miller LT. Overview of treatment options and review
of the current role and use of compression garments, intermittent
pumps, and exercise in the management of lymphedema. Cancer.
1998;83(12 Suppl American):2821-7.
74. Manduz S, Ada F, Ada Y. The level of awareness and the attitude of
patients recommended for use of compression stockings in Turkish
society, and investigation of the factors affecting their use. Patient
preference and adherence. 2018;12:399-407.
75. de Godoy J, #xe9, Pereira M, Lopes Pinto R, Pereira de Godoy AC, F d, et
al. Synergistic Effect of Adjustments of Elastic Stockings to Maintain
Reduction in Leg Volume after Mechanical Lymph Drainage. International
Journal of Vascular Medicine. 2014;2014:3.
76. Sawan S, Mugnai R, Lopes Ade B, Hughes A, Edmondson RJ. Lower-limb
lymphedema and vulval cancer: feasibility of prophylactic compression
garments and validation of leg volume measurement. International
journal of gynecological cancer : official journal of the International
Gynecological Cancer Society. 2009;19(9):1649-54.
77. Do JH, Choi KH, Ahn JS, Jeon JY. Effects of a complex rehabilitation
program on edema status, physical function, and quality of life in
lower-limb lymphedema after gynecological cancer surgery. Gynecologic
oncology. 2017;147(2):450-5.
78. Fukushima T, Tsuji T, Sano Y, Miyata C, Kamisako M, Hohri H, et al. Immediate
effects of active exercise with compression therapy on lower-limb
lymphedema. Supportive care in cancer : official journal of the Multinational
Association of Supportive Care in Cancer. 2017;25(8):2603-10.
79. Sagen A, Karesen R, Risberg MA. Physical activity for the affected
limb and arm lymphedema after breast cancer surgery. A prospective,
randomized controlled trial with two years follow-up. Acta oncologica
(Stockholm, Sweden). 2009;48(8):1102-10.
80. Cavezzi A, Paccasassi S, Elio C. Lymphedema treatment by means of an
electro-medical device based on bioresonance and vacuum technology:
clinical and lymphoscintigraphic assessment. International angiology :
a journal of the International Union of Angiology. 2013;32(4):417-23.
81. Elio C, Guaitolini E, Paccasassi S, Rosati N, Cavezzi A. Application of
microcurrents of bioresonance and transdermal delivery of active principles
in lymphedema and lipedema of the lower limbs: a pilot study.
Giornale italiano di dermatologia e venereologia : organo ufficiale,
Societa italiana di dermatologia e sifilografia. 2014;149(6):643-7.
Review Article