Reducing Circumference and Volume in Upper Extremity Lipedema: The Role of Complex Decongestive Physiotherapy

Abstract

Objective:

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

Methods and Results:

All participants included in the study were included in a treatment protocol consisting of CDP and IPC. The Perometer 400 NT was used in the measurement of upper extremity volume and circumference before and after treatment. The measurements were performed in four reference points. According to the Perometer results before and after CDP, statistically significant reduction was found in the circumference of 3 of the 4 points of measurements performed in each of the left and right upper extremities. When the volume assessments were compared, it was seen that statistically significant reduction was found in the volume of both limbs.

Conclusion:

A treatment program consisting of CDP and IPC can be effective in reducing the circumference and volume of the arm in patients with upper extremity lipedema. So, CDP applications can help prevent the development of complications such as lipolymphedema, hypertension, and heart failure.

Clinical Trial Registration number: NCT04643392 https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S000AF9B&selectaction=Edit&uid=U00055NT&ts=2&cx=-3oevdw

Introduction

Lipedema which causes excessive accumulation of fat in the subcutaneous tissue is a rare, progressive disease. This disease generally affects women following puberty or early adulthood and usually results in the slow increase of the circumference of the legs and/or arms, bilaterally. In a typical presentation of lipedema, the enlargement of the lower extremities is disproportionately greater than that of the trunk and upper extremities.¹ The feet are not involved and the arms are less commonly affected. The swelling does not improve with elevation or weight loss.²

When first described in 1940, lipedema was thought to exclusively affect the lower extremities.³ However, as the disease has been recognized over the years, lipedema has been reported to affect the upper extremities.⁴ The incidence of lipedema in the upper extremities varies greatly between studies. While Cornely stated that the arms are affected in 80% of women with lipedema, a systematic review by Cordero et al. showed that in 31% of the patients, lipedema is located in the upper extremities.⁵ Upper extremity lipedema with no involvement of the lower extremities is an extremely rare incident.⁶

In the literature, different classifications are used to define lipedema. The first of these are the columnar and lobar types proposed by Fonder et al.⁷ Another classification has been proposed by Dr. Schingale.⁸ In Dr. Schingale's classification, there are five types of lipedema: in type I, adipose tissue is increased on the buttocks and thighs. In type II, the lipedema extends to the knees. In type III, lipedema extends from the hips to the ankles. In type IV, the legs and the upper extremities are also involved, and type V is defined as lipolymphedema.⁸

After a mean of 10 years suffering from lipedema, the lymphatics likely become insufficient. In addition to the direct impairment of lymph vessels (fragility and compression by fat), high-volume insufficiency leads to increased edema. However, literature also states that lipolymphedema can develop at any stage of the disease due to dysfunctional lymphatics.⁹

Due to the hypertrophy in adipose tissue, the link between lymphatic dysfunction and the progression to lipolymphedema, lipedema is conservatively treated with physiotherapy, manual lymph drainage (MLD), and compression also known as complex decongestive physiotherapy (CDP). Furthermore, the consensus of the International Society of Lymphology has stated that intermittent pneumatic compression (IPC) is an optional treatment, which may be applied as an adjuvant therapy to CDP. When the literature is reviewed, although there is a study examining the effect of CDP applications on the measurement and volume of the lower extremity in lipedema patients,¹⁰ there is no study investigating the effects in upper extremity lipedema. The aim of this study is to examine the effect of CDP applications on upper extremity circumference measurement and volume.

Materials and Methods

Patients

This study is a clinical trial investigating the results of CDP interventions on upper extremity lipedema. Participants consisted of subjects who were diagnosed with upper extremity lipedema by a lymphologist and were admitted to a private lymphology clinic. The inclusion criteria were set as being between the ages of 18 and 65 years, having a diagnosis of upper extremity lipedema, and being willing to participate in the study. Patients were excluded if they had an accompanying diagnosis of lymphedema, if they had deep vein thrombosis, and if they had any disease which causes edema in the upper extremities. Before enrollment in the study, all patients were individually examined to rule out the presence of vein thrombosis using physical examination and color Doppler ultrasonography. Informed consent forms were obtained from the subjects stating that they were willing to participate in the study. This study was approved by the Ethics Committee of Gazi University with the approval number of 2020-376, and the authors conformed to the ethical guidelines of the 1975 Declaration of Helsinki.

Assessment

The Perometer 400 NT is an optoelectronic scanner, which has been designed for the measurement of limb circumference and volume. The device has a square frame of 47 × 47 cm, which is used to surround the perimeter of the limb. On two adjacent internal edges of the Perometer, infrared light emitting diodes are located and on opposite edges, infrared light sensing diodes are located. While performing the measurement, the limp is placed in the frame and the frame is moved once over the limb and back in about 3 seconds. While measuring the upper extremity, a handle is gripped allowing easy measurement of the limb. The limb interrupts the emitted infrared beams that would normally be sensed by the light sensing diodes and for the measured segment, two perpendicular diameter measurements are obtained. 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. The Perometer has been reported to be a valid and reliable method for lymphedema patients.¹¹

For every patient, the circumference and volume measurements of the upper limbs were measured with the Perometer at baseline and discharged from the clinic.

The Perometer measurements in the present study were performed in the certain four reference points: (1)

Circumference point “cD”: located at the midpoint between the wrist and elbow

(2)

Circumference point “cE”: located at the middle of the elbow

(3)

Circumference point “cF”: located at the middle of the upper arm across the biceps muscle

(4)

Circumference point “cG”: the measurement taken around the upper arm at the axilla

Intervention

The patients were treated with a protocol consisting of CDP and IPC. The treatment protocol consisted of four stages:

(1)

Forty-five minutes of MLD on the right/left upper extremity (according to the Földi method).¹² To maintain blood pressure at a normal level, only one upper extremity was included in treatment each day. Thus, the extremities were treated every other day.

(2)

Thirty minutes of IPC application. IPC was applied for 30 minutes immediately after the MLD.

(3)

Moisturization of the upper extremity.

(4)

Multilayered short-stretch bandage application: Normally bandage applications for edematous problems are initiated from the fingers, however, lipedema never affects the hands.¹³ Thus, the bandage was applied starting from the wrist level.

Each patient received this treatment protocol for 5 days a week until they were discharged from the clinic. All patients fully completed all components of the treatment routine daily. Alongside this routine, the patients were advised to exercise (walk) regularly every day. The treatment was performed by a physiotherapist who was certified with MLD Combined Decongestive Physiotherapy from the Földi College. The physiotherapist had been treating lipedema patients for over 5 years. After the daily treatment protocol was completed, patients wore standard or individually sized compression grade II or III medical compression stockings for the rest of the day.

Statistical analyses

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

Results

The study was conducted with a total of 14 patients with lipedema. All of the patients were female and had type IV lipedema according to Dr. Schingale's classification.⁸ The mean age of the patients was 47.57 ± 12.16. The mean height and weight of the participants was 161 ± 5.82 cm and 115.78 ± 36.76 kg, respectively. The body mass index of the patients was 40.89 ± 11.79, and they were classified as morbidly obese. The participants underwent an average of 22.5 ± 5 days of treatment.

When the circumference 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 4 points measured in both of the upper extremities (p < 0.05, Table 1). The reduction can be seen in Table 1.

Table 1.

Comparison of Perometer Results of Upper Extremity Circumference Measurement

	Before treatment n:14 Median (IQR 25/75)	After treatment n:14 Median (IQR 25/75)	P
Left cD	29.6 (24.1/33.6)	27.2 (24.3/30.4)	0.021
Left cE	32.8 (30.1/40.2)	31.8 (30.5/37.1)	0.039
Left cF	39.3 (34.5/46.2)	37.2 (34.6/42.4)	0.005
Left cG	40.5 (37.6/45.3)	39.9 (37.2/44.3)	0.142
Right cD	29.6 (24.4/32.7)	26.8 (23.8/28.9)	0.013
Right cE	33.3 (30.6/39.1)	33.3 (29.5/35.3)	0.006
Right cF	37.8 (34.4/45.9)	37.6 (33.2/42.7)	0.082
Right cG	41.5 (37.7/44.3)	40.9 (36.8/43.8)	0.016

Significant results are shown in bold.

p < 0.05.

IQR, inter quartile range.

When the volumetric assessments performed with the Perometer were compared before and after CDP, it was seen that statistically significant reduction was found in the volume of both upper extremities (p < 0.05, Table 2). The reduction can be seen in Table 2.

Table 2.

Comparison of Perometer Results of Upper Extremity Volume

Extremity volume	Before treatment n:14 Median (IQR 25/75)	After treatment n:14 Median (IQR 25/75)	P
Left	4152 (3050/4747)	3638 (3049/4225)	0.023
Right	3743 (3086/4847)	3685 (2975/4454)	0.041

p < 0.05.

Discussion

The goal of this study is to investigate the effect of CDP plus IPC applications on upper extremity circumference and volume in patients with lipedema. To the best of our knowledge, this study is the first to examine the effects of CDP combined with IPC on upper extremity volume and circumference measurement in detail. As a result of the study, it was observed that there was a significant decrease in total arm volume and circumference measurement at many reference points of the upper extremity.

Constricted capillaries of obese lipedema patients may lead to increased peripheral resistance.¹⁴ This situation results in increased blood vascular leak and increased lymph formation.^12,14 Furthermore, lymphatic size and workload of the lymph system increases in lipedema patients.^14,15 This situation could cause an increase in extremity circumference measurement and volume in patients with lipedema. The reason for the decrease in extremity volume and circumference measurement in our study could be that CDP applications decreased the workload of the lymphatic system by increasing lymphatic circulation. MLD may be one of the reasons for this decrease because MLD has shown to reduce lymphatic stasis, increases protein resorption, and opens lymphatic collaterals.¹⁶ Also, we know that MLD increases arm lymphatic flow.¹⁷ Further publications are needed to understand which component of CDP is the cause of this decrease.

Excess fluid in the interstitial tissue may induce growth of lipedema fat.¹⁸ Also, abnormal increase of interstitial fluid leads to hypoxia resulting in adipocyte cell death and the recruitment of macrophages. Fibrosis resulting from this event follows inflammation resulting in fat that is difficult to lose weight.^19,20 This situation results in overload of the lymphatic system and fluid collection in the tissue in patient with lipedema. CDP applications may slow the prognosis of the disease as the limb volume decreases.

Lipedema is a lifelong disease. The main goal in the treatment of this disease is to slow its progression. The decrease in the circumference and volume measurements reveals the effectiveness of CDP. Validity studies of the Perometer device in upper extremity measurements reveal that the device is a reliable method. To decrease the Perometer repeatability error rate, it was ensured that the patients were positioned correctly and they were instructed to not move during assessment.¹¹

If lipedema is not treated, complications can occur. These complications include eating disorders such as anorexia nervosa, bulimia nervosa, and generalized complications, including hypertension, diabetes, and heart failure.²¹ CDP applications may prevent these complications since it reduces the limb volume. In future studies, it will be useful to examine the long-term complications of patients who received complex draining physiotherapy and those who did not.

Lipedema patients may experience psychological reasons due to the need to exercise and diet continuously to reduce the amount of fat in the affected extremities or the appearance caused by the increased extremity volume. This may negatively affect the health-related quality of life of patients with lipedema.^8,22 Reducing the limb circumference and volume with CDP can improve health-related quality of life of patients with lipedema. It is very important to examine the effects of physiotherapy applications on quality of life in future studies. Furthermore, due to the similarity in the diseases, upper extremity functions, scapular dyskinesia, shoulder mobility, and proprioception should also be assessed in lipedema patient.^23–25

This study has some limitations. First, the number of participants included in the study is low because lipedema is rarely seen in the upper extremities. Furthermore, lipedema patients may often be diagnosed with obesity and may not be aware of lipedema.²⁶ Thus, these patients do not refer to lymphology clinics and cannot receive treatment. In addition, the duration of treatment pre- and postintervention varied between subjects. This was due to factors such as the disease onset of the patients and the fact that treatment efficacy of CDP may vary among patients. The effectiveness of CDP may occur earlier in some patients and later in some patients. Finally, the lack of a control group made it difficult for comparative analysis, however, the authors have found it to be unethical to not provide patients with a treatment and therefore this study lacks a control group.

Conclusion

Lipedema is a progressive disease that does not have a cure yet, and usually affects the lower extremities and less often the upper extremities. Currently, the best method of treating this disease is to slow the progression of the disease. Slowing the progression of the disease may prevent or delay the development of complications such as lipolymphedema, eating disorders, and hypertension.²² CDP applications can help prevent the development of such complications as it reduces the limb circumference and volume.

Footnotes

Acknowledgment

The authors thank Gokhan Yazici for his assistance in the study.

Authors' Contributions

Both authors have taken part in writing the article, reviewing it, and revising its intellectual and technical content.

Author Disclosure Statement

No competing financial interests exist.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author, M.V.Y. The data are not publicly available due to ethical restrictions.

Funding Information

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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