Michelini S., Failla A., Moneta G., Michelotti L.*, Santambrogio F.*, Calabrese S.*
Combined physical treatment in patients with lymphedema: which and how?
The european journal of lymphology- Vol.XII;Nr.41 Sp.Co 1.2004-38

S. Giovanni Battista Hospital Vaclav Vjta Rehabilitation Center
The clinical experience acquired on 2500 patients along 15 years of vascular rehabilitation activity, shows that physical combined treatment in lymphedema provokes different clinical reactions in each case in relation with the clinical stage, the tissutal suprafascial component, the alternative pathways in each patient but, above all, in relation with the times of application and the modalities of execution of therapeutic techniques.
Manual lymphatic drainaige, considering the common „terminus“ of lymphatic pathways coming from lower limbs and the different „terminus“ of lymphatic pathways coming from upper limbs, must be performed bilaterally in lower limbs (also in unilateral lymphedema) and unilaterally in upper limbs. In patients underwent a double mastectomy with a double large arm, over then the treatment of  the  arms, must be also stimulated back and lateral alternative pathways.
In the lower limbs bilateral lymphedema (especially in presence of absence or damage of lateroiliac lymphonodes), through the lateral back alternative pathways, lymph must reach armpit and supraclavear  lymphonodes. Sequential pressure therapy, best in primary lymphedemas, must be bilaterally executed in lower limbs, unilaterally in upper limbs.
In all cases must be taken into consideration all the local contraindications (inflammations) and the systemic contraindications (cardiac lack of balance, arterial hypertension).
Elastic compression represent the main tool of treatment, especially in those patients where can be performed an adequate muscular work during the day. It will be unelastic in multilayer in valid subjects in monolayer in less valid or bed rest patients
Isotonic gymnastic, best if executed with elastocompression on, wants to activate the main groups of muscles of the limbs in order, also, to restore muscular trophysm when there is a lack of balance of it.
In case of consequences of radiotherapy, with neurological peripheral damage, we meet also muscular tone and trophysm deficit and also in this case isotonic gymnastic is useful. Ultrasound therapy (5W cm2 of intensity) is employed in presence of sclerosis of derma or fibrosis (usually in declivous sides) due to a greater protein interstitial concentration. Times  of treatment goes from 5 to 30 minutes a day.
Respiratory gymnastic completes the treatment promoting the return of lymphatic fluids through an indirect mechanism of pressure gradients between the libs and the abdominal and mediastinic areas, all with the participartion of diaphragm movements.
In conclusion, physical combined treatment is frame in a complete project that develops around the patient and request personalized techniques and times of application for each clinical case.