cheng's lymphedema grading tool to assess the severity of extremity lymphedema based on objective limb measurements and providing appropriate options for management. i. grading severity of upper extremity lymphedema in different stagesseverity of lower extremity lymphedema in different stages grade 1: spontaneously reversible on elevation. mostly pitting edema. grade 2: non-spontaneously reversible on elevation. mostly non-pitting edema. grade 3: gross increase in volume and circumference of grade 2 lymphedema, with eight stages of severity given below based on clinical assessments. ii. staging as described by the fifth who expert committee on filariasis, and endorsed by the american society of lymphology., the staging system helps to identify the severity of lymphedema. with the assistance of medical imaging apparatus, such as mri or ct, staging can be established by the physician, and therapeutic or medical interventions may be applied: stage 0: the lymphatic vessels have sustained some damage that is not yet apparent. transport capacity is sufficient for the amount of lymph being removed. lymphedema is not present. stage 1 : swelling increases during the day and disappears overnight as the patient lies flat in bed. tissue is still at the pitting stage: when pressed by the fingertips, the affected area indents and reverses with elevation. usually, upon waking in the morning, the limb or affected area is normal or almost normal in size. treatment is not necessarily required at this point. stage 2: swelling is not reversible overnight, and does not disappear without proper management. the tissue now has a spongy consistency and is considered non-pitting: when pressed by the fingertips, the affected area bounces back without indentation. fibrosis found in stage 2 lymphedema marks the beginning of the hardening of the limbs and increasing size. stage 3: swelling is irreversible and usually the limb(s) or affected area becomes increasingly large. the tissue is hard (fibrotic) and unresponsive; some patients consider undergoing reconstructive surgery, called "debulking". this remains controversial, however, since the risks may outweigh the benefits and the further damage done to the lymphatic system may in fact make the lymphedema worse. stage 4: the size and circumference of the affected limb(s) become noticeably large. bumps, lumps, or protrusions (also called knobs) on the skin begin to appear. stage 5: the affected limb(s) become grossly large; one or more deep skin folds is prevalent among patients in this stage. stage 6: knobs of small elongated or small rounded sizes cluster together, giving mossy-like shapes on the limb. mobility of the patient becomes increasingly difficult. stage 7: the person becomes "handicapped", and is unable to independently perform daily routine activities such as walking, bathing and cooking. assistance from the family and health care system is needed. grades lymphedema can also be categorized by its severity (usually referenced to a healthy extremity): grade 1 (mild edema): involves the distal parts such as a forearm and hand or a lower leg and foot. the difference in circumference is less than 4 cm and other tissue changes are not yet present. grade 2 (moderate edema): involves an entire limb or corresponding quadrant of the trunk. difference in circumference is 4–6 cm. tissue changes, such as pitting, are apparent. the patient may experience erysipelas. grade 3a (severe edema): lymphedema is present in one limb and its associated trunk quadrant. circumferential difference is greater than 6 centimeters. significant skin alterations, such as cornification or keratosis, cysts and/or fistulae, are present. additionally, the patient may experience repeated attacks of erysipelas. grade 3b (massive edema): the same symptoms as grade 3a, except that two or more extremities are affected. grade 4 (gigantic edema): in this stage of lymphedema, the affected extremities are huge, due to almost complete blockage of the lymph channels. differential lymphedema should not be confused with edema arising from venous insufficiency, which is caused by compromise of the venous drainage rather than lymphatic drainage. however, untreated venous insufficiency can progress into a combined venous/lymphatic disorder. treatment while there is no cure, treatment may improve outcomes. this commonly include compression therapy, good skin care, exercise, and manual lymphatic drainage (mld), which together is known as combined decongestive therapy. mld is most effective in mild to moderate disease. in breast cancer-related lymphedema, mld is safe and may offer added benefit to compression bandages for reducing swelling. most people with lymphedema can be medically managed with conservative treatment. diuretics are not useful. surgery is generally only used in those who are not improved with other measures. garments lymphedema compression sleeve on a mannequin once a person is diagnosed with lymphedema, compression becomes imperative in the management of the condition. garments are often intended to be worn all day but may be taken off for sleeping unless otherwise prescribed. elastic compression garments are worn on the affected limb following complete de-congestive therapy to maintain edema reduction. inelastic garments provide containment and reduction. available styles, options, and prices vary widely. a professional garment fitter or certified lymphedema therapist can help determine the best option for the patient. bandaging compression bandaging, also called wrapping, is the application of layers of padding and short-stretch bandages to the involved areas. short-stretch bandages are preferred over long-stretch bandages (such as those normally used to treat sprains), as the long-stretch bandages cannot produce the proper therapeutic tension necessary to safely reduce lymphedema and may in fact end up producing a tourniquet effect. compression bandages provide resistance that assists in pumping fluid out of the affected area during exercise. this counter-force results in increased lymphatic drainage and therefore a decrease in size of the swollen area. intermittent pneumatic compression therapy intermittent pneumatic compression therapy (ipc) utilizes a multi-chambered pneumatic sleeve with overlapping cells to promote movement of lymph fluid. pump therapy should be used in addition to other treatments such as compression bandaging and manual lymph drainage. pump therapy has been used a lot in the past to help with controlling lymphedema. in some cases, pump therapy helps soften fibrotic tissue and therefore potentially enable more efficient lymphatic drainage. however, reports link pump therapy to increased incidence of edema proximal to the affected limb, such as genital edema arising after pump therapy in the lower limb. current literature has suggested the use of ipc treatment in conjunction with kinesiotape (kt) is more effective in the overall reduction of lymphedema as well as increasing shoulder rom than the traditional treatment of ipc paired with complete decongestive therapy. kinesiotape (kt) is an elastic cotton strip with an acrylic adhesive that is used commonly used to relieve the discomfort and disability associated with sports injuries, but in the context of lymphedema, this increases the space between the dermis and the muscle which increases the opportunity for lymphatic fluid to flow out naturally. the use of ipc treatments with kt tape as well as subsequent lymphatic drainage has proven to significantly reduce the circumference of lymphatic limbs in patients experiencing lymphedema secondary to breast cancer postmastectomy. exercise in those with lymphedema or at risk of developing lymphedema, following breast cancer treatment, resistance training did not increase swelling and decreases in some, in addition to other potential beneficial effects on cardiovascular health. moreover, resistance training and other forms of exercise were not associated with an increased risk of developing lymphedema in people who previously received breast cancer-related treatment. compression garments should be worn during exercise (with the possible exception of swimming). physical therapy treatment of patients with lymphedema may include trigger point release, soft tissue massage, postural improvement, patient education on condition management, strengthening, and stretching exercises. exercises may increase in intensity and difficulty over time, beginning with passive movements to increase range of motion and progressing towards using external weights and resistance in various postures. surgery the treatment of lymphedema is usually conservative, however the use of surgery is proposed for some cases. suction assisted lipectomy (sal), also known as liposuction for lymphedema, may help improve chronic non pitting edema if present. the procedure removes fat and protein and is done along with continued compression therapy. vascularized lymph node transfers (vlnt) and lymphovenous bypass are supported by tentative evidence as of 2017 but is associated with a number of complications. laser therapy low-level laser therapy (lllt) was cleared by the us food and drug administration (fda) for the treatment of lymphedema in november 2006. according to the us national cancer institute, lllt may be effective in reducing lymphedema in some women. two cycles of laser treatment were found to be reduce the volume of the affected arm in approximately one-third of people with postmastectomy lymphedema at three months post-treatment. epidemiology lymphedema affects approximately 200 million people worldwide.