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Comparative analysis of pumps for Lymphoedema
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Pumps have had a checkered history in treatment of lymphoedema ever since their introduction over 50 years back. Heralded as finally some treatment for a treatment of a previously untreatable disease, they fell into disrepute as a result of a steadily increasing incidence of complications. However, our results based on studies done in 1980-81 as well as recently had shown very good results with none of the described complications. So we are presenting an analytical look as to

Whether all pumps are really bad?

Or (more likely) whether some pumps are not that bad

History of pumps

1948 Customised Stockings (Joseph Conrad)

1951 Jobst Pump

1955 Accepted as mode of therapy (Brush,Stillwell)

1955 Massaging Pump (Wakin)

Then onwards - Lymphapress, Mercury Bath etc

80's Shift to Manual Massage

90's Pumps are bad (Casley Smith, Clodius)

The following types are available

Table 1 Results of AIIMS Study

Excellent	Good	Fair	Poor	TOTAL
Primary	5	12	2	0	19
Filarial	25	14	2	1	42
Non-Filarial	5	18	4	2	29
TOTAL	35	44	8	3	90
(Percentage)	(39%)	(49%)	(9%)	(3%)	(100%)

Table 2 Pump Types

Type (Chambers)	Brand	Cycle time
Monolocular (1)	Vipel, Jobst	120-240s
Trilocular (3)	Jobst	120 secs
Sequential (12)	Lymphapress	30 secs

Table 3 Comparison of Sequential and Simple Pumps

	Sequential	Simple
Mode of action	Centripetal Massage	? Internal Heat generation
Effective	Faster	Slower
Recommended for	Mild / Moderate Oedema	Higher Grades
Complications	Oedema of Thigh, Scrotum, other side	Much less reported
Cost per outlet (Rs)	50 - 60000/-	20 -25000/-
Manufactured in	Israel	India

Table 4 Comparison of Sequential and Simple Pumps continued

	Sequential	Simple
Time per cycle	30 Seconds	3 - 4 minutes
Number of chambers	12	1
Average inflation time per chamber	< 3 seconds	60 - 90 seconds
Peak Pressure obtained	100 mm Hg	160 mm Hg (Vipel)
Average pressure increment	35 mm Hg /Sec	3 mm Hg /Sec
Average time of peak pressure	10 seconds	60 seconds

Discussion

The objection to pumps according to Clodius has been "We do not know how they work" However, our and other's results show that they do work.

In all probability Sequential pumps work in a physiological way of pushing up tissue fluid. While this may be satisfactory for early lymphoedema or where there are adequate channels, forcibly pushing fluid up too fast (Note the average increment of pressure) - can overload the system and cause tissue damage where channels do not exist. Besides at the higher plane e.g,.in the thigh, the fluid just accumulates waiting to transfer for venous drainage This is the reason one gets oedema in the places where it did not exist before i.e the thigh, the other limb as well as problems like congestive failure and renal overload.

With a monolocular pump, the fluid cannot travel to the rest of the body on pressure alone. But the fact is that it does travel. We are hereby proposing a theory as to how it travels.

Pressure is known to create heat

There is an elementary level physics theory - called the universal gas equation -

PV/T = Constant

i.e. At constant volume (V), Rise in pressure (P) results in rise in temperature (T)

•Heat therapy is a known form of therapy for lymphoedema (the reason why Heat therapy is used in its treatment)

•Rise in temperature has an anti - inflammatory effect

Moreover, Heat therapy if given by radiation (i.e Dr Tambwekar's Electric Bulbs ) acts mostly on the epidermis and very little reaches the area where it is desired most, while Microwave radiation reaches all the planes - even the muscles where it is not required at all.

While heat generated as a result of circumferential pressure reaches exactly where it is required the most - i.e. the subdermal area of fibrosis - the area which will absorb the maximum pressure (this is due to an arch effect which will be explained in detail).

Miller's surmise that lymphatic flow stops beyond 60 -75 mmHg pressure is well taken, but if the fluid absorption is increased (either due to direct inflammatory action or activation of macrophages to lyse protein, we do not need these channels anyway).

Thus we have a theoretical explanation for the action of pumps in reducing oedema and this theory explains our premise that it is not the total pressure which is detrimental but rather the faster increment of pressure which is present in sequential machines. And the benefits are best if this pressure is applied gradually but kept over a longer time and yes one can use higher pressures with the safeguards of allowing time for circulation.

However, as these results (as those of heat therapy as well) are best in secondary Non malignant lymphoedema, we believe that some reabsorption does involve available lymph channels which have only a relative block.

In a recent study in Tamil Nadu, Compression therapy was found more effective than (Radiant) Heat, Interferential or combined therapies in treatment of lymphoedema probably because of the same arch effect as discussed above.

In Conclusion

Despite all theoretical objections, in practice pumps have been found effective. The reason why so far pumps have been advised only for Mild to Moderate lymphoedema seems more due to the ill effects of sequential pumps. Discontinuation of simple pumps for sequential had resulted in unavailability of an effective therapy