Complete Decongestive Therapy (CDT)

Introduction[edit|edit source]

The best global treatment oflymphedema, according to the international guidelines of the International Society of Lymphology is CDT (complete decongestive physiotherapy)^[1]。许多研究表明，CDT对改善淋巴水肿症状的有效性，例如肿胀和疼痛^[2]。

这是一个密集的程序，结合了许多不同的治疗方法，包括绷带，compression服装，manual lymphatic drainage,锻炼和自我照顾。作为一种技术，CDT起源于欧洲和澳大利亚，但现在在美国变得越来越普遍。

CDT

• 可以有效减少淋巴水肿的体积，
• Improve patients’ mobility
• Increasequality of life。
• 包括两个阶段。
  1. I期（密集阶段）包括动员流体和增殖结缔组织减少的引发。
  2. II期（维护阶段）保持肿胀减少，并旨在优化结缔组织还原。^[1]

成分[edit|edit source]

Complete decongestive therapy (CDT) consists of:

1. 手动淋巴引流（MLD）：一种刺激淋巴系统的浅皮肤拉伸技术。
2. Compression: Layered bandaging with foam or specially fitted garments that support the area to control swelling.
3. 练习：通过压缩，特殊运动将有助于将淋巴泵出肿胀的区域。
4. Skin护理：保持皮肤清洁和保湿将有助于防止infections淋巴水肿通常会发生这种情况。
5. Self-Care Management and Training: Learning how to manage lymphedema at home^[2]。

Phases[edit|edit source]

活性相（阶段1）

• 第一阶段由动员流体和增殖结缔组织减少的启动^[1]。
• The number of weeks depends on the amount of swelling and tissue firmness.
• 每周4至5天完成一小时的疗程，以完成一小时的疗法。
• Bandages with foam are worn about 23 hours per day and often only removed to bathe.

维护阶段（第2阶段）

• Maintenance phase maintains the swelling reduction and aims for optimization of connective tissue reduction
• Phase 2 should last for months or for years.^[1]
• Elastic compression garments that fit like a second skin are worn during the day.
• 晚上，通常会佩戴带有泡沫的绷带，以减少日常白天肿胀。
• 锻炼s are done while wearing compression.
• Self manual lymphatic drainage is done for 20 minutes per day^[2]。

Manual Lymphatic Drainage[edit|edit source]

see这里手工淋巴引流

Compression Therapy[edit|edit source]

压缩疗法是治疗淋巴水肿的非常重要的工具。

• Even when MLD is performed correctly, swelling does not decrease without compression (in most cases).
• Compression bandages should remain on the extremities until the next session of MLD.

用于压缩疗法的产品是低螺丝绷带和弹性服装（弹性长袜/袖子/手套）。^[1]

1. 绷带是第2阶段和3期淋巴水肿（中度至重度淋巴水肿）的支柱。绷带涉及通过用多层包裹在手臂或上半身上创建柔软的铸件。这是完整的缺乏疗法的主要组成部分。

下面的7分钟视频通过了该技术。

^[3]

绷带是一种还原疗法，这意味着它使肢体较小。当手臂绷带时，肌肉每次使用手臂时，都会被多层软铸件“固定”（这被称为工作压力）。在绷带上或使用手臂作为正常活动进行规定的锻炼，会产生一种内部抽水动作，将液体从组织中移出并进入淋巴系统的血管。绷带铸造有助于防止液体流回肢体，并软化皮肤下的组织。

2. Compression garments are designed to keep a continuous pressure on the swollen/affected area to assist the drainage of fluid and minimize swelling. Image R: Lymphedema compression sleeve, displayed on mannequin

• External compression provides a counter force to the working musculature (ie working pressure). Working pressure helps to prevent re-accumulation of fluids which were evacuated during intensive complete decongestive therapy (CDT) and conserve the results achieved during manual lymphatic drainage (MLD)^[4]。

研究studies have not yet looked at the effectiveness of compression sleeves alone in treating lymphedema. However, studies find them an effective as part of the overall treatment plan^[2]。Eg:

• 袖子戴在手臂上
• 无指的手套或手套（没有单独的手指开口），经常戴袖子
• Support bra for the chest area or a vest for the entire trunk area

All of the garments are made of flexible fabric. Sleeves are tighter at the bottom than they are at the top creating the graded pressure that keeps the lymph moving out of the arm. There is a variety of fabrics available: Some feel softer, others stiffer, and some may include materials such as wool or latex.

绷带与压缩袖

绷带的工作方式不同于压缩套管，后者支持淋巴的流动，即从肢体流出并消耗掉淋巴结。袖子施加所谓的静止压力，这意味着当手臂处于静止状态时，压力更高。当您移动手臂时，弹性织物随之而来，这实际上会降低压力量。压缩套筒可能足以容纳轻度淋巴水肿，但是更先进的病例需要绷带绷带，然后才能使用压缩套筒。绷带通过减少肢体体积而作品^[2]。

锻炼[edit|edit source]

Initial exercises consist of gentle stretching and活动范围锻炼s (helping the muscles contract and relax, which is thought to help push the lymph along) and also strengthen the lymphatic system. eg making a fist and extending fingers; doing wrist curls; or gentle punching motions to extend and flex the elbow.

一旦症状改善并且淋巴水肿稳定，运动计划就会扩展到有氧运动（改善身体健康并减轻体重）。这种运动包括游泳，骑自行车，步行，跳舞^[1]太极和温柔yoga（首先，不包括在上半身上施加重量的位置），游泳和/或举重，取决于客户状态。

体重轻的运动不会影响淋巴水肿的体积。尽管起初肢体可能会肿胀，但在24小时后累积的液体量减少。这些练习应谨慎和重复的低重量（尤其是在开始阶段）进行的练习^[1]。

通常，结合了stretching, monitoredstrengthening锻炼s, and有氧活动建议使用，但必须个性化计划。如果客户拥有更雄心勃勃的健身目标，则可以逐步实现这一目标。

通常，如果患者在锻炼过程中佩戴或不穿压缩服装是可以接受的，前提^[1](如绷带、压缩套筒或其他压缩机ession garments)^[2]。

上肢淋巴水肿的运动示例（由训练有素的物理治疗师给出）

• 通过以中等速度的大型接头进行主动动员5分钟来热身活动；
• shouldergirdle mobilization-scapular retraction, protraction, depression, shoulder extension, elbow flexion and extension, wrist flexion and extension and ball squeeze;
• 胸饰and梯形肌肉stretching.
• Patients comfortably seated, relaxed, with hands over their腹部肌肉, and deep breathing through the nose and a prolonged expiration through mouth without any strenuous effort (diaphragmatic breathing)^[5]anddiaphragmatic breathingpractised in between exercises.

下面的9分钟视频显示了治疗师为上肢淋巴水肿所做的运动课。

^[6]

Skin Care[edit|edit source]

Proper skin care is paramount. The skin of patients with lymphedema is usually very sensitive, dry, and itchy due to disturbances of skin metabolism as a result of the macro-and microcirculation alterations making it susceptible to inflammation and infection. Due to the impaired healing process,皮肤损伤can lead to severe inflammation, infection (egcellulitis）甚至溃疡，使病情恶化，因此治疗和保护措施是皮肤护理的重要组成部分。

• 压缩疗法可能导致干燥，破碎和敏感的皮肤，容易受伤。这些服装的下侧是皮肤与压缩方式之间的相互作用（即医疗绷带和服装）造成的损害。损坏是由于：压缩绷带和服装的机械效应和吸收特性；直接与皮肤接触，从而导致角膜层的高机械压力；绷带和服装的纤维吸收了汗水和皮肤油，破坏了皮肤和保护酸层的正常薄水解层。
• 目的是使皮肤保持正常健康，或尽可能治愈。为了使皮肤保持柔韧性和耐用性，患者应选择温和的无肥皂清洁乳液，该乳液中性（pH = 7）或每天的useas井以及补充皮肤油的沐浴油。
• 患者应注意在洗澡或淋浴后，尤其是在深层皮肤褶皱后完全干燥皮肤，以最大程度地减少皮肤真菌感染的风险。清洁皮肤后，必须使用软药物来补充皮肤。皮肤护理产品应谨慎使用，并通过轻柔的按摩运动应用。
• Compression garments should not be applied if the products have not been fully absorbed.
• All skin infections should be treated and cleaned by a doctor.
• 在治疗过程中，应特别注意照顾辐射引起的任何次要皮肤病变。
• The physiotherapist should discuss the skin care with the physician prior to treatment.
• 多学科团队的持续合作对于对淋巴水肿的最佳治疗至关重要。^[1]

淋巴水肿的皮肤并发症（由多学科团队最好地管理）

• 感染：应立即对皮肤感染进行抗生素疗法和其他措施以及预防性干预措施。
• Ulcers: Lymphedema-associated ulcers are managed with a combination of wound cleansing, debridement, exudate management, peri-wound care, appropriate dressings, compression therapy and surgical wound coverage if necessary.^[7]

Self-Care Management and Training[edit|edit source]

Education regarding “Self care” (ie everything client does at home to reduce the risk of the lymphedema coming back or getting worse in the future) is vital. As a lymphedema therapist you should teach clients how to

• Put on and care for their compression sleeves and garments. Patients need to understand the need to replace the garments on a regular basis to maintain sufficient compression. Each garment should be washed daily to restore the compression and replaced after 3 to 6 months of continuous use, although very active patients may require these to be changed sooner^[8]。
• 保护手臂，手，胸部或其他身体部位免受切割，伤害，过度使用，极端温度以及其他可能增加淋巴产生的情况，这又会增加淋巴水肿的风险
• 教育感染的体征和症状，这是淋巴水肿的人的特别关注点
• 帮助计划并设置个性化的练习和/或体重控制计划
• 在家中教如何进行手动淋巴引流。如果“自国家”是合适的，并且客户可以管理技术。向客户的压力，要做的胜于建议，或者对MLD的按摩中风更具侵略性，可能是有害的^[2]。

结论[edit|edit source]

• 复杂的充气治疗（CDT）的目的是永久控制与淋巴水肿相关的体积和化生组织变化。这种多模式治疗方法被广泛用于控制慢性edemas，并成为一种在生命尽头管理难治性水肿的有效手段。它还可以帮助消除脸部，树干和生殖器。
• 许多研究表明，CDT显然是有益的。当由经过适当培训的治疗师管理时，CDT会达到并保持肢体量减少50％至70％^[9]
• Several other treatment modalities available for lymphedema include electrostimulation,针刺,Kinesio Taping,低级激光, deep oscillation, andultrasound。However, there is insufficient evidence currently to recommend their use. Pharmaceutical therapies, including利尿剂和苯并吡喃不建议进行淋巴水肿治疗^[8]。

Further Watching[edit|edit source]

这是一只好手表，例如28分钟。MLD和运动

^[10]

References[edit|edit source]