The Effects of Complex Decongestive Physiotherapy Applications on Lower Extremity Circumference and Volume in Patients with Lipedema

Abstract

Background:

The aim of this study is to investigate the effect of complex decongestive physiotherapy (CDP) plus intermittent pneumatic compression (IPC) applications on lower extremity limb circumference and volume in patients with lipedema.

Methods and Results:

In measurement of limb volume and circumference measurement, the Perometer 400 NT was used before and after treatment. The perometer measurements in this study were performed in the certain five reference points (cB, cC, cD, cE, and CF). All participants included in the study were included in a treatment protocol consisting of CDP and IPC. It was seen that statistically significant reduction was found in the circumference of 3 of the 5 points of measurements performed in the left limb, whereas statistically significant reduction was found in the circumference of 4 of the 5 points of measurements performed in the right limb. When the assessments of limb volume performed with the perometer were compared before and after CDP, it was seen that statistically significant reduction was found in the volume of both limbs.

Conclusion:

This reduction indicates that CDP is effective in the treatment of lower extremity lipedema. Clinicaltrials.gov with an ID of NCT04492046.

Introduction

Lipedema is a rare condition that almost exclusively affects women. The disease is characterized with bilateral symmetric abnormal accumulation of subcutaneous fat and orthostatic edema and is often mistaken for simple obesity.¹ In most patients, the hips, buttocks, thighs, knees, and lower legs are affected. Upper extremity involvement has been reported to be present in 80% of patients. The hands and feet are never affected.² The accumulation of subcutaneous fat and edema results in tenderness, pain, and sensitivity to touch and pressure. Patients also tend to bruise easily even after a minimal trauma. It has been reported that the complaint of pain increases with aging.³

The etiopathogenesis of lipedema is not fully understood; however, the causes are generally associated with either genetic factors or hormonal changes. It usually develops at puberty, but it can also develop or worsen later in life as a result of hormonal changes that may occur due to pregnancy, menopause, or gynecological surgery. Genetic background with familial predisposition has been described in 60% of lipedema patients.^4–6 The incidence of lipedema is 11% in the postpubertal female population.^7,8

The increase in subcutaneous fat due to lipedema is linked with microangiopathy and alterations in microcirculation, which lead to an increase in permeability and protein-rich fluid extravasation. In the prolonged courses of the disease, lymph vessels are unable to maintain their function, and alterations in microcirculation lead to impairments in lymph transport capacity, and thus lymph fluid is accumulated.³

There is no known cure for lipedema. However, conservative treatment with physiotherapy, manual lymph drainage (MLD), and compression, also known as complex decongestive physiotherapy (CDP), is used worldwide as a treatment regimen.⁹ MLD is an effective therapeutic method used in the conservative treatment of lipedema. Multilayered compression bandaging techniques play a crucial role in the further reduction of the volume of the limb and enhance the continuous pump mechanism through the active involvement of muscle contractions. The aim of CDP applications is to control edema, reduce pain and hypersensitivity leading to an increase in the level of physical activity, and thus improving the patients' quality of life.^10,11 The consensus of the International Society of Lymphology has stated that intermittent pneumatic compression (IPC) is an optional treatment that may be applied as an adjuvant therapy to CDP. IPC is a device that mimics the massage techniques used in MLD. The IPC is worn on the affected limb and activated to help push retained fluids back toward the core of the body.¹²

Measuring limb volume is essential in patients with lipedema to determine the effects of intervention. Many different methods are used to measure limb volume in the clinic. The measurement of limb circumference, the water displacement method, and the perometer are the most frequently used. The perometer is a reliable device that measures the volume of the limb through infrared light.¹³

When literature is examined, to the best of our knowledge, there is no study investigating the effects of CDP applications on lower limb circumference measurement in lipedema patients. Therefore, the aim of this study is to investigate the effect of CDP applications on lower extremity limb circumference and volume in patients with lipedema.

Materials and Methods

Patients

Participants who were admitted to the private lymphology clinic and were diagnosed with lower extremity lipedema by a lymphologist were included in the study. Patients were included in the study if they were willing to participate, between the ages of 18 and 65 years, and had a diagnosis of lower extremity lipedema. Before enrollment in the study, all patients were individually examined to rule out deep vein thrombosis using physical examination and color Doppler ultrasonography of the legs. Patients were excluded from the study in the presence of edematous disease in the lower extremity such as lymphedema or chronic venous insufficiency.

Written consents were obtained from participants before the study. The ethical approval was obtained from the Gazi University ethics committee (Approval number: 2020-377) and the authors conformed to the ethical guidelines of the 1975 Declaration of Helsinki.

Evaluation

In measurement of limb volume, the Perometer 400 NT was used. The device measures limb volume through infrared light, and it has been reported to be a quick and reliable method. The device has a square frame that is used to surround the perimeter of the limb. The frame incorporates 378 infrared light switches. On two adjacent internal edges of the perometer, diodes that emit infrared light are located. On opposite edges, infrared light sensing diodes are located. During assessment, the limb is placed in the frame. The limb interrupts the emitted infrared beams that would normally be sensed by the light-sensing diodes in the two planes. Thus, two perpendicular diameter measurements of the limb for the measured segment are provided. The device estimates the opposite two sides based on an elliptical cross section. As the frame is manually moved along the longitudinal axis of the limb, multiple measurements of diameter are captured at 4.7 mm intervals. These measurements of diameter are also used to calculate the volume of the limb.¹⁴

The perometer measurements in this study were performed in the certain five reference points: 1.

Circumference point “cB” is the smallest circumference of the ankle found closest to and above the ankle bone.

Circumference point “cC” is the largest circumference of the calf.

Circumference point “cD” is the smallest circumference below the knee but above the calf.

Circumference point “cE” is at the mid-patella level.

Circumference point “cF” is at the middle of the thigh.

Intervention

All participants included in the study were included in a treatment protocol consisting of CDP and IPC. Each patient received the following:

Forty-five minutes of MLD on both lower extremities (According to the Földi method¹⁵)

IPC for 30 minutes

Moisturization of the lower extremities

Multilayered short-stretch bandage application.

Alongside this routine, the patients were advised to exercise (walk) regularly every day.

Each patient received a 5-day course of treatment each week and this treatment routine was continued until the patients were discharged from the clinic. Immediately after MLD, patients received IPC for 30 minutes. All patients fully completed all components of the treatment routine daily. The treatment was performed by a physiotherapist who was certified with Manual Lymphdrainage Combined Decongestive Physiotherapy from the Földi College. The physiotherapist had been treating lipedema patients for >5 years. After the cessation of a treatment cycle, patients wore standard or individually sized compression grade II or grade III medical compression stockings.

At baseline and discharge, the circumference and volume measurements of the lower limbs were measured with a perometer.

Statistical analysis

Statistical analyses of the study were carried out with “statistical package for social sciences” (SPSS) version 21.0 (SPSS Inc., Chicago, IL) software. Categorical variables were noted in mean and standard deviations. The normal distribution of the data were analyzed with visual (histogram and probability graphs) and analytical (Shapiro–Wilk test) methods. Wilcoxon test was used before and after treatment since the data were non-normally distributed. The level of significance was set at p < 0.05.

Results

The study was concluded with a total of 23 participants. The mean age of the patients was 43.7 ± 15.5. The mean height and weight of the participants was 163.7 ± 6.4 cm and 99.3 ± 21.8 kg, respectively. The participants underwent an average of 24 ± 4 days of treatment.

When the assessments performed with the perometer were compared before and after CDP, it was seen that statistically significant reduction was found in the circumference of 3 of the 5 points of measurements performed in the left limb, whereas statistically significant reduction was found in the circumference of 4 of the 5 points of measurements performed in the right limb (p < 0.05, Table 1).

Table 1.

Comparison of Perometer Results of Lower Extremity Circumference

	Before treatment (n = 23), median (IQR 25/75)	After treatment (n = 23), median (IQR 25/75)	p
Left cB (cm)	27.2 (26.3/31.4)	27.4 (25.0/30.2)	0.053
Left cC (cm)	46.1 (43.0/50.9)	45.1 (41.9/48.3)	<0.001
Left cD (cm)	43.9 (40.4/48.5)	43.2 (39.4/47.7)	0.001
Left cE (cm)	46.4 (44.1/50.2)	46.2 (43.2/52.3)	0.023
Left cF (cm)	65.1 (59.2/70.2)	62.3 (58.4/66.4)	0.059
Right cB (cm)	27.4 (25.1/31.1)	27.2 (24.7/30.2)	0.366
Right cC (cm)	46.2 (42.8/50.4)	44.8 (42.6/47.7)	<0.001
Right cD (cm)	43.8 (41.3/50.0)	43.7 (39.7/48.6)	0.005
Right cE (cm)	47.4 (44.8/52.9)	46.8 (43.3/53.5)	0.012
Right cF (cm)	63.5 (58.9/70.9)	62.3 (58.7/68.7)	0.033

Significant results are shown in bold.

p < 0.05, p < 0.05.

IQR, interquartile range; n, number of participants.

When the assessments of limb volume performed with the perometer were compared before and after CDP, it was seen that statistically significant reduction was found in the volume of both limbs (p < 0.05, Table 2).

Table 2.

Comparison of Perometer Results of Lower Extremity Volume

	Before treatment (n = 23), median (IQR 25/75)	After treatment (n = 23), median (IQR 25/75)	p
Left extremity volume	13,075 (11,543/16,198)	12,627 (11,587/15,080)	<0.001
Right extremity volume	13,463 (11,832/16,560)	12,824 (11,559/14,445)	<0.001

Significant results are shown in bold.

p < 0.05, p < 0.05.

Discussion

To the best of our knowledge, this is the first study to examine the effects of CDP applications and IPC on lower limb circumference measurement in patients with lipedema. Lipedema is characterized by abnormal deposition of subcutaneous fat in the lower limbs, which leads to swelling and enlargement of the lower limbs.¹⁴ As a result of this study, it was found that CDP applications lead to a significant decrease in the lower limb circumference measurement and volume. This reduction indicates that CDP is effective in the treatment of lower extremity lipedema.

In this study, we investigated the effect of IPC used alongside CDP. In the literature, there are studies that have also used IPC in lipedema patients.^11,16 Only one of these studies examined the effect of IPC on the leg volume of patients with lipedema. This study investigated whether CDP alone or combined with IPC improved the treatment outcome in a greater extent. Patients received either CDP (60 minutes) or CDP (30 minutes) plus IPC (30 minutes) once a day, for 5 days in each group. CDP consisted of compression bandaging, exercise, and skin care. The effect of the treatment was evaluated by the amount of reduction in limb volume. Significant reduction in mean lower extremity volume was seen in both groups, and the authors concluded that it was safe to use IPC in lipedema patients.¹⁷ Our results are similar to this study; however, in the mentioned study, limb volumes were measured using the Kuhnke's disk method.¹⁸ In our study, we used a more reliable measurement, the perometer, for volume measurement and, therefore, our study provides the literature with more objective results. As a result of our study, a significant decrease was observed in the lower limb volume as in this study.

In our study, MLD, which is a component of CDP, was used in the treatment routine. MLD could contribute to decreasing limb volume in lipedema patients. MLD reduces lymphatic stasis, increases protein resorption, and opens lymphatic collaterals.¹⁹ In literature, there are studies that support and studies that oppose the use of this method in lipedema. There are publications saying that the use of MLD is not indicated in lipedema because there is no lymphatic disorder.^20,21 In contrast, when literature is examined, studies that have shown the benefit of MLD can also be found. Bilancini et al. showed that lymphatic drainage was reduced in lipedema patients compared with healthy subjects.²² Since MLD increases lymphatic drainage, these patients may have shown a reduction in circumference measurement and limb volume.²³Furthermore, the study by Szolnoky et al. suggests that MLD prevents hematoma formation in patients with lipedema, and it is stated to stimulate lymphangiomotoric activity.¹¹ In addition, the study by Schneider states that patients with lipedema benefit from MLD in many aspects.²⁴ MLD is a critical component of CDP, and it was a crucial part of the CDP application treatment program in our study. When our results are examined, it can be seen that significant decreases in volume and circumference were observed after our treatment program. In our opinion MLD may have played an important part in the reduction of limb volume. However, further studies are needed to investigate the effects of MLD on lipedema patients.

The limitation of this study is that the lack of a control group made it difficult for comparative analysis to determine the amount of benefit obtained by CDP applications. Furthermore, the quality and success of MLD depends greatly on skills and knowledge of the therapist performing the drainage. Therefore, as it was in this study, the lymphatic therapist must be a qualified expert with experience in this field.

As lipedema worsens, in particular with an increase in leg volume, patients are more likely to experience dermatological (maceration, infection), lymphatic (cellulitis, lymphedema), and orthopedic problems (walking problems).²⁵ Depending on the results of our study, complex decongestive applications (CDP plus IPC) are beneficial in decreasing the volume and circumference of the lower limbs, and thus may be beneficial in decreasing the development of lipedema-related complications.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received.

References

Wold

, Hines

Jr , Allen

. Lipedema of the legs: A syndrome characterized by fat legs and edema. Ann Intern Med, 1951; 34:1243–1250.

Cornely

Lipedema on the arms and legs [in German] Phlebologie 2011; 40:146–151.

Földi

, Földi

, Strössenreuther

RHK

, Kubik

, Strößenreuther

. Földi's Textbook of Lymphology: For Physicians and Lymphedema Therapists. Munich, Germany: Elsevier Health Sciences; 2012.

Child

, Gordon

, Sharpe

, et al. Lipedema: An inherited condition. Am J Med Genet Part A, 2010; 152:970–976.

Fife

, Maus

, Carter

. Lipedema: A frequently misdiagnosed and misunderstood fatty deposition syndrome. Adv Skin Wound Care, 2010; 23:81–92.

Mayes

, Watson

. Direct effects of sex steroid hormones on adipose tissues and obesity. Obes Rev, 2004; 5:197–216.

Wold

, Hines JR

, Allen

. Lipedema of the legs: A syndrome characterized by fat legs and edema. Ann Intern Med, 1951; 34:1243–1250.

Dayan

, Kim

, Smith

, et al. Lipedema—the Disease They Call FAT: An Overview for Clinicians. California, USA: Lipedema Simplified LLC; 2017.

Schmeller

, Meier-Vollrath

. Tumescent liposuction: A new and successful therapy for lipedema. J Cutaneous Med Surg, 2006; 10:7–10.

10.

Buck II

, Herbst

. Lipedema: A relatively common disease with extremely common misconceptions. Plast Reconstr Surg Glob Open, 2016; 4:e1043.

11.

Szolnoky

, Nagy

, Kovács

, et al. Complex decongestive physiotherapy decreases capillary fragility in lipedema. Lymphology, 2008; 41:161–166.

12.

Committee

. The diagnosis and treatment of peripheral lymphedema: 2016 consensus document of the International Society of Lymphology. Lymphology, 2016; 49:170–184.

13.

Deltombe

, Jamart

, Recloux

, et al. Reliability and limits of agreement of circumferential, water displacement, and optoelectronic volumetry in the measurement of upper limb lymphedema. Lymphology, 2007; 40:26–34.

14.

Tan

C-W

, Coutts

, Bulley

. Measurement of lower limb volume: Agreement between the vertically oriented perometer and a tape measure method. Physiotherapy, 2013; 99:247–251.

15.

Foldi

, Foldi

, Kubik

. Textbook of Lymphology, English ed. Munich: Elsevier, 2003.

16.

Szolnoky

, Varga

, Tuczai

, Dosa-Racz

, Kemény

. Lymphedema treatment decreases pain intensity in lipedema. Lymphology, 2011; 44:178–182.

17.

Szolnoky

, Borsos

, Barsony

, Balogh

, Kemeny

. Complete decongestive physiotherapy with and without pneumatic compression for treatment of lipedema: A pilot study. Lymphology, 2008; 41:40–44.

18.

Kuhnke

, Asdonk

. Lymph drainage and edema therapy using physical drainage treatment. Zeitschrift fur Lymphologie. J Lymphol, 1980; 4:67–75.

19.

Williams

. Manual lymphatic drainage: Exploring the history and evidence base. Br J Commun Nurs, 2010; 15(Suppl. 3):S18–S24.

20.

Langendoen

, Habbema

, Nijsten

, Neumann

. Lipoedema: From clinical presentation to therapy. A review of the literature. Br J Dermatol, 2009; 161:980–986.

21.

Reich-Schupke

, Altmeyer

, Stücker

. Thick legs–not always lipedema. J Dtsch Dermatol Ges, 2013; 11:225–233.

22.

Bilancini

, Lucchi

, Tucci

, Eleuteri

. Functional lymphatic alterations in patients suffering from lipedema. Angiology, 1995; 46:333–339.

23.

Tan

I-C

, Maus

, Rasmussen

, et al. Assessment of lymphatic contractile function after manual lymphatic drainage using near-infrared fluorescence imaging. Arch Phys Med Rehabil, 2011; 92:756–764. e751.

24.

Schneider

. Low-frequency vibrotherapy considerably improves the effectiveness of manual lymphatic drainage (MLD) in patients with lipedema: A two-armed, randomized, controlled pragmatic trial. Physiother Theory Pract, 2020; 36:63–70.

25.

Reich-Schupke

, Schmeller

, Brauer

, et al. S1 guidelines: Lipedema. J Dtsch Dermatol Ges, 2017; 15:758–767.