during the study: same day of the week and thus also the same routines, working hours, etc., no holiday periods with variations in load or MLD frequency in all study phases. Discussion of the results We sampled objective (circumference and volume of the legs) as well as subjective parameters (pain and QOL) after each treatment month with the three modalities MLD+IPK, IPK alone, MLD alone and compared to baseline, where patients had been treated for at least one year with MLD alone (always with compression, before and during the study). Considering the objective measurements, the deviations from baseline were minimal. The only – very small – signif- icant differences were found at the ankle circumference (circumferential change 0.8%; Cohen’s d<0.1). This dis- crete difference did not influence the calf volume, where no significantly different values were assessed. The subjective results are based on two aspects: The pain and discomfort reported in the standing position after tak- ing off the compression (VAS 0–10), and on the QoL mea- sured by the Lymph-ICF questionnaire [8]. The pain and discomfort values do not differ significantly from each other; at most, a tendency towards a slightly bet- ter value under treatment with both procedures can be noted in the graph. The graph itself, compared to all the other “line per patient” graphs in this publication, shows a high variability of curves. There are three patient lines drawing “a house-roof” – starting low (left point), having two higher pain-values at MLD alone and IPC alone and then again, a lower one at IPC plus MLD (pink and brown line very large outliers, dark green less; Figure 2E). The two large outliers, who have significantly more complaints with IPC or MLD alone, but not with MLD+IPC, could perhaps be interpreted as a nocebo effect in the expectation of treat- ment with IPC+MLD. Both patients were randomized to the IPC group first and received MLD+IPC only at month 3. The QoL-results are based on the Lymph-ICF question- naire [8] show that the patients suffer primarily from limi- tations in mobility and physical performance, but also from mental aspects (Table II). With a mean value of 2.6±2.0, these are not very pronounced complaints in the overall collective, as is to be expected in the maintenance phase of lymphoedema. Figure 2F shows that all these values are better after the treatment phases than at the beginning of the survey. This is surprising for the “MLD only” phase, as it involves the same therapy as before the study. It could correspond with a so-called Rosenthal-effect during the study, i.e. the sole improvement in satisfaction due to the positive expectation in the additional therapy option. This effect is greater in the two “therapy” phases (“MLD+IPC” and “IPC alone”) than in the “control” phase (MLD alone). The last day of the study, patients were asked questions about their satisfaction with the three different options (MLD alone, ICP alone or both), from a medical, QoL and organization point of view. These results are very vari- able. Some patients would like to receive both procedures, others only MLD or only IPC – this also depends on per- sonal circumstances, such as the compatibility between therapy and work. Overall, the treatment with IPC, as well as the combination of both procedures is very well accepted. Conclusions Lymphatic therapy is more than just decongestion or com- pression therapy. However, IPC seems to be a sufficient substitute for manual lymphatic drainage therapy, at least for a certain period of time. It would therefore be optimal to aim for a combination of both, possibly with one or two MLD per month and IPC at home in between. This would have the advantage that the patients could be guided by the therapist to open the lymphatic channels by self- massage on the neck and the lymph therapist, as an impor- tant professional in the therapy of lymphoedema, would ensure the regularly necessary contact with the patient. A visit to the doctor would then only be necessary every 12 months in the maintenance phase or on the recommen- dation of the lymph therapist. In a system like Germany, where both the visit to the doc- tor and the visit to the therapist are paid for by the health insurance companies and where IPC is also financed if indi- cated, this is a simple way of saving resources and relieving Table III. Comparison of costs of MLD vs. IPC Time MLD Cost per session times / week Cost MLD per year 4 Dr. visists/ year Total Cost 1 Year 10-year Costs MLD 10 years IPC plus MLD* Money Saving option 30 29.23 € 1 1,519.96 € 80 € 1,599.96 € 15,999.60 € 7,207.60 € 55.0% 29.23 € 2 3,039.92 € 80 € 3,119.92 € 31,199.20 € 76.9% 45 43.83 € 1 2,279.16 € 80 € 2,359.16 € 23,591.60 € 8,959.60 € 62.0% 43.83 € 2 4,558.32 € 80 € 4,638.32 € 46,383.20 € 80.7% 60 58.45 € 1 3,039.40 € 80 € 3,119.40 € 31,194.00 € 10,714.00 € 65.7% 58.45 € 2 6,078.80 € 80 € 6,158.80 € 61,588.00 € 82.6% Notes. Calculation of the costs for the maintenance therapy per year and in 10 years based on German prices 2022 considering MLD/IPC and the visit to the specialist every 3 months to prescribe MLD treatment (which is 20 Euro per visit at the specialist in Germany, this was not a calculating mistake!). Compression garments are not included, as they should be offered anyway and are not subject of change. The price per IPC Device lies between 3,000–3,500 Euro depending on the cuffs needed, including 10 years guaranty – we took “worst-case-price” of 3,500 Euro once for the calculation for 10 years. *Including IPC device, one visit to the doctor per year, 12 MLD per year. Vasa (2023), 52 (6), 423–431 . 2023 The Author(s) Distributed as a Hogrefe OpenMind article under the license CC BY 4.0 (https://creativecommons.org/licenses/by/4.0) 430 E. Mendoza & F. Amsler, Effect of MLD and IPC in lymphedema https://econtent.hogrefe.com/doi/pdf/10.1024/0301-1526/a001090 - Wednesday, November 29, 2023 2:49:54 AM - IP Address:93.208.161.46