Lymphedema Therapies During or After Cellulitis
Dear OncoLink "Ask The Experts,"
I have question about compression garment usage. I am currently treating cellulitis of an arm that has lymphedema and was told by my massage person that she could not do any lymphatic massage until a month after this clears up. Is this the same advice for wrapping and using a compression sleeve and gauntlet? Also, what about Arnica? Do you think this would help the swelling?
Linda McGrath Boyle PT, DPT CLT-LANA, Cancer Rehab Specialist and OncoLink Lymphedema Team Editor, responds:
We do not perform manual lymphatic drainage (MLD) immediately following diagnosis of an infection so as to allow the antibiotic enough time to eradicate the bacterial infection. At Penn, we will withhold manual lymphatic drainage for approximately 5-7 days or more, until all of the clinical symptoms of infection have resolved. If the infection is very aggressive and/or recurrent, we will hold manual lymphatic drainage until the patient has completed his/her course of antibiotics. We do not wait for one month.
The same theory applies to bandaging. We do begin bandaging before resuming MLD. The physiology behind that decision is that we are not "spreading the infection" throughout the body with a bandage. On the other hand, MLD involves increasing lymphatic transport to other areas of the body. This is contraindicated in the presence of infection. The effect of bandaging is most powerful to the locally involved quadrant. Additionally, it is common for the patient to experience an increase in limb volume as a direct result of the cellulitic infection. This is due to an increase in the local inflammatory response. It is also possible to note an increase in local tissue fibrosis (firmness of the arm). The local inflammation drives the deposition of additional scar tissue in the subcutaneous tissues. In other words, there can be a progression (worsening) of the lymphedema. It is therefore important to resume compression bandaging to the involved area as soon as medically indicated. We do not wait one month. Our medical director may instruct us to begin bandaging in as little as 48 to 72 hours, depending on improvement in clinical signs of infection.
Following a cellulitic infection, our team reassesses the involved area for volume, tissue texture, shape, and rate of refilling when compression is absent. It is common for our team to recommend a new compression garment, perhaps in a higher compression class. The goal of the garment is to prevent refilling of the arm during the daytime hours. At night, our patients bandage with foam and short stretch bandages. The bandaging reduces the arm volume and softens the tissue. This will allow the patient to fit well into their daytime compression garments. It is a great idea to perform a course of complete decongestive therapy following an infection in an attempt to prevent progression of the lymphedema.
If there has ever been any evidence of finger swelling, either consistent or transient, a compression glove replaces the gauntlet. Even a small amount of finger swelling can interfere with functional activities.
We are fortunate to have physicians available to our team for early identification and intervention of cellulitic infections. If you have lymphedema and notice any of the signs or symptoms of infection- redness, warmth/hot to touch, pain, body aches, fever of 100.5 F or above- you need to seek IMMEDIATE medical attention. Due to the inefficiency of your lymphatic system in that part of the body, your body is slow to respond and often unable to clear an infection. If your family doctor cannot see you within an hour or so, precede to the emergency room for treatment of the cellulitic infection.
I have seen no scientific evidence that proves that Arnica is an effective treatment in persons with lymphedema.
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