2.1 Physiotherapy techniques for postoperative lymphedema

Postoperative lower limb lymphedema is frequently addressed through Western medical interventions designed to enhance lymphatic and blood circulation while simultaneously inhibiting the growth of fibrous tissue [12]. These interventions encompass various physiotherapy techniques, such as comprehensive decongestive therapy (CDT), thermal therapy, and low-frequency electrical stimulation [13, 14]. CDT is a widely recognized clinical approach recognized for its safety and efficacy in managing early to moderate lymphedema. It entails a combination of manual lymphatic drainage, compression bandaging, and physical exercises. Cheng Qun et al. [15] observed a significant reduction in limb circumference and tissue fluid among 89 patients [15]. Furthermore, Huang Lemei et al. [16] demonstrated that the combination of enhanced negative pressure drainage and CDT therapy was more effective than traditional methods, resulting in improved efficiency, reduced time and costs, and better clinical outcomes [16]. In summary, these physiotherapy methods, mainly CDT, have proven effective in managing lymphedema and improving patient outcomes.

2.2 Thermal and electrical therapies

Far-infrared radiation substantially alleviates pain and swelling and enhances limb function [17]. This finding was corroborated by Wang Xiaodu et al. [17], who demonstrated that the combination of far-infrared radiation with bandaging was more effective in reducing lymphedema and improving patient symptoms. Their research indicated good patient tolerance and minimal side effects based on clinical and in vitro studies [17]. This study conducted a controlled trial investigating the impact of low-frequency neuromuscular electrical stimulation on post-cervical cancer surgery or radiotherapy lymphedema [17]. Their results suggested that this treatment improved lymphatic flow and alleviated symptoms. CO₂ laser therapy, digital subtraction angiography (DSA)-guided lumbar sympathetic nerve block, and microwave combination therapy have shown potential in enhancing limb lymphatic circulation. These treatments not only help alleviate swelling but also reduce psychological stress and anxiety. In summary, thermal and electrical therapies effectively relieve symptoms and improve lymphatic circulation in managing lymphedema.

2.3 Pharmacological and surgical interventions

Regarding pharmacological treatment, Western medicine primarily utilizes diuretics, vascular-active drugs, interferons, and antibiotics. For instance, hepatic side sodium, heparin sodium, and bacitracin can effectively inhibit limb complications without adverse outcomes within a short timeframe [18, 19]. Additionally, preserving the exterior iliac terminal lymph nodes and injecting Pseudomonas aeruginosa into the pelvis can significantly inhibit lower limb lymphedema and pelvic lymphoid cysts. A study involving four creams tested on patients with lower limb lymphedema revealed that condyline gel cream provides rapid relief from itching without considerable side effects, effectively alleviating skin symptoms [4]. Pharmacological and surgical interventions have shown significant improvements in managing lymphedema, particularly in reducing swelling and enhancing functionality.

Recent developments in surgical treatments for lymphedema have greatly improved patient outcomes [20]. LVB, which connects lymphatic vessels directly to veins, has shown promise in enhancing lymphatic drainage and reducing limb swelling in patients with early-stage lymphedema [21]. Similarly, VLNT, involving transplanting healthy lymph nodes into the affected area, has demonstrated potential in promoting spontaneous lymphangiogenesis and improving long-term outcomes.

3.1 Oral administration of TCM

The development of lymphedema is closely linked to various factors, like ulcers, toxins, individual constitution, and the presence of pathogenic influences, all of which can vary from person to person. Consequently, TCM treatment strategies are specifically tailored to address each patient’s unique symptoms and conditions, adhering to the principles of syndrome differentiation and targeted intervention.

According to Professor Cui Gongjian, Damp-Heat Obstruction Syndrome is primarily caused by a deficiency in spleen qi, which impairs the spleen’s functions of transformation and transportation. The invasion of wind-damp-heat evils may further exacerbate this deficiency [27]. The resulting imbalance leads to the accumulation of dampness and heat, giving rise to symptoms such as swelling, heaviness, and stagnation, often observed in cases of lower limb lymphedema [28].

Wu Jianping utilized Professor Cui’s therapeutic method to eliminate dampness and stasis, integrating it with complementary techniques, like baking and bandaging, to treat lower limb lymphedema [29]. This approach proved highly effective, leading to significant reductions in limb swelling and improvements in lymphatic flow. Furthermore, Li Jin et al. [30] conducted a clinical study investigating the efficacy of a combination of diosmin and Dioscorea pills in patients with lower limb lymphedema induced by damp heat [30]. The findings indicated that this combination had a markedly higher efficacy rate (86.67%) compared to the control group, highlighting the therapeutic potential of these herbal remedies in tackling the underlying pathogenic factors associated with damp-heat and improving patient outcomes [31, 32]. Professor Wu Qiansheng emphasized the intricate relationship between “qi, blood, dampness and heat” in this condition, advocating for formulas that address damp-heat stasis during the acute phase and promote qi and blood during the recovery phase to consolidate the foundation.

Li Nan et al. [29] identified the Phlegm-Coagulation and Blood Stasis Syndrome, which results from the internal accumulation of blood stasis and phlegm dampness. The application of a self-formulated Knee Red Soup, along with a cream designed for anti-swelling and pain relief, resulted in a treatment probability of 86.7% [29].

Professor He Fengjie Yang reported the Deficiency and Dampness Obstruction Syndrome, indicating that this condition often results from a spleen yang deficiency and dampness obstruction. Consequently, effective treatment should prioritize enhancing the spleen function, dispelling dampness, and clearing collaterals. In alignment with Professor He’s approach, Wang Haijing and colleagues demonstrated that a combination treatment involving the Wu Ling San and Wu Pi Drink formulas, alongside Tuina massage and topical applications, led to significant reductions in leg circumference and decreased recurrence rates during a one-year follow-up [33]. Research by Ding Yanyan and others revealed that adding Wu Ling San to the treatment regimen for lower limb lymphedema proved more effective than relying on diuretics alone, achieving a treatment efficiency of up to 83.3%. Furthermore, combining manual drainage with Fangji Fu Ling Tang yielded better results when paired with Diosmin tablets, suggesting that the multicomponent, multitarget and multi-pathway properties of Fangji Fu Ling Tang enhanced overall efficacy [34].

Professor Xiong Jibai highlighted the importance of improving qi, invigorating blood, and enhancing circulation to alleviate swelling in lymphedema treatment [34]. For cases characterized by qi deficiency and blood stasis, he recommended using Yang-nourishing and Five-returning Soup in conjunction with Fangji Fu Ling Tang to promote water elimination and reduce swelling while simultaneously strengthening qi, thereby achieving a balance between elimination and tonification [35]. Professor Liu Longmin regarded postoperative lower limb lymphedema as stemming from qi injury and blood depletion due to prolonged illness and surgical trauma. He advocated for the use of Si Miao Yong An Tang, a formula designed to tonify qi, invigorate blood, and facilitate the removal of water and stasis, thereby addressing the underlying causes of swelling and promoting recovery [35].

3.2 External application of Chinese medicine

The topical application of Chinese medicine entails the transdermal absorption of herbal remedies via acupuncture points, skin, and various bodily orifices [36]. This technique enables the therapeutic properties of the herbs to penetrate directly into the affected areas, allowing for targeted treatment [37]. Bypassing the digestive system provides a localized therapeutic effect that is particularly advantageous for conditions like lymphedema, where swelling and poor circulation are concentrated in specific regions [29, 38]. Acupuncture points act as pathways to enhance the delivery of medicinal properties, thereby improving the flow of qi and blood circulation. Herbs with anti-inflammatory, diuretic, and decongestant effects can effectively address fluid accumulation and help reduce swelling [39]. Furthermore, this approach is non-invasive and can be integrated with other treatment modalities, making it a versatile and complementary option in managing postoperative lymphedema and other related conditions [40, 41]. During the Qing Dynasty, Wu Shiji’s “Li Bo Era” encapsulated the essence of external therapies, stating that “The principles of external treatment mirror those of internal treatment; the medicines used externally are also used internally” [42]. The “Yellow Emperor’s Classic of Internal Medicine” outlines “18 external treatment methods”. Standard practices include the application of heat to open the pores, which facilitates the absorption of drug ions through the mucous membrane barrier of the skin. This process aids in reducing inflammation, alleviating pain, promoting blood circulation, and resolving blood stasis [39].

In TCM, lower limb lymphedema following surgery in patients with gynecological malignancies is classified as “edema” [43]. The “Nei Jing” states that “all diseases characterized by soreness, pain, swelling and shock are attributed to fire”, and modern practitioners have discovered that treating “heat with edema” can be highly effective [44]. Sha Rui et al. [45] applied Bingli powder to take advantage of the cooling properties of borneol, effectively dissipating heat and alleviating pain while serving as a “guide” to enhance membrane permeability and promote drug absorption [45]. On the other hand, Mirabilite penetrates the skin’s mucosal barrier in the form of sulfate ions, which works synergistically to reduce edema and relieve pain [30]. For early-stage lymphedema, Zheng Tongli employed a mixture of mannitol and ice chips (100:1) for topical application, harnessing the transdermal capacity of ice to rapidly absorb the medication and reduce heat and swelling [40]. Ye Min et al. [46] employed Ruyi Jinhuang Paste, which combines the heat-clearing and swelling-reducing effects of smallpox powder, along with the blood-activating properties of turmeric, dahurica and tiannanxing to relieve pus drainage and swelling [46]. Mixing with vinegar further helps dredge the meridians and directly targets the affected area, synergistically reducing edema and alleviating patient symptoms [45].

Postoperative damage, along with prolonged depletion of qi and blood due to illness, can allow pathogenic toxins to infiltrate the body. This invasion may damage blood vessels and collaterals, obstructing the flow of blood, qi and bodily fluids and resulting in an internal stasis of blood and dampness [34, 47]. The “Treatise on Blood Evidence” asserts that “long-term blood stasis can also transform into stagnant water”. In light of this concept, Professor Cao Jianchun advocates for addressing stasis before dampness, recommending the use of herbs such as peach kernels and safflowers to stimulate blood circulation, promote movement through the collaterals, and alleviate pain [48]. A formula incorporating herbs like dagger belly peel, donggua peel, and diaphanous peel is employed to cleanse the affected limbs. This method effectively activates blood flow, dispel dampness, and induces the movement of water [49]. The “Jin Kui Yao Yao” emphasizes that “blood impedes water”, highlighting the significance of harmonizing blood and water in treatment. In a clinical study, patients suffering from unilateral lower lymphedema were randomly assigned into two groups [41]. One group received blood-activating lotion through fumigation, whereas the control group was treated with magnesium sulfate wet compresses and oral medications such as Mai Zhi Ling.

3.3 Acupuncture treatment

The “Ling Shu-Meridian Vessels” states that “the meridians are pivotal in determining life and death, managing all diseases, and balancing excess and deficiency; they must remain unobstructed”. Their roles are crucial in disease onset, progression, and resolution [48]. “The Spiritual Pivot-Nine Needles and Twelve Originals” mentions that “fine needles should be employed to traverse the meridians, regulate the flow of blood and energy, and ensure the smooth movement within and without at the joint points”. This indicates that stimulating acupuncture points can modulate the flow of qi and blood, effectively unblocking the meridians to treat various ailments. Zheng Shuo et al. [50] utilized fire acupuncture at points such as Houxi, Taiyuan, Sun and Yinlingquan, combined with a comprehensive method to reduce swelling. This approach was designed to activate the meridians, warm the flow of qi and blood, expel pathogens, and enhance local microcirculation [50, 51]. As a result, it effectively alleviated limb soreness and weakness in patients, achieving a reported effectiveness rate of 93.9%, surpassing that of the control group [27]. Additionally, Lv Hongyan described a case in which a combination of warm acupuncture and pulse electrotherapy was employed for patients with water offense, yang deficiency, and cold-induced blood stasis [52]. By stimulating acupuncture points such as Blood Sea, Yinlingquan, Foot Sanli and A-Yi points, this method accelerated the circulation of lymphatic and blood fluids, enhanced metabolism, significantly reduced local swelling, and boosted the body’s immune function, ultimately achieving the therapeutic goals of supporting health and dispelling pathogenic factors [53].

In a comparative study assessing the efficacy of conventional treatments, Dong Dexi discovered that the use of suspended moxibustion at acupuncture points, in conjunction with intramuscular paste, significantly reduces the incidence of lower limb lymphedema [44]. Liu Yunjing attributed the onset of lymphedema to damage within pulse channels, resulting in localized swelling and numbness. The accumulated lymphatic fluid can be redirected along the acupuncture channels, thereby alleviating swelling in the injured limbs [54].

Acupuncture techniques, including fire acupuncture, warm acupuncture, and suspended moxibustion, have demonstrated considerable effectiveness in promoting circulation, reducing swelling, and enhancing immune function in patients with lymphedema [32]. By stimulating specific acupuncture points, these methods help clear blockages in the meridians, regulate the flow of qi and blood, and address underlying factors like blood stasis and the accumulation of dampness [54].

3.4 Tuina guidance

The management of “foot qi”, as described in the “Treatise on the Origin of Diseases”, is fundamentally based on enhancing qi circulation. Tuina, a traditional Chinese therapeutic technique, works on the body’s surface by utilizing specific maneuvers to press and manipulate relevant acupuncture points. This practice aims to clear blockages in meridians, stimulate the flow of qi and blood, nourish tendons and bones, and balance qi circulation, ultimately helping to reduce swelling [55]. In managing lower limb lymphedema after cervical cancer surgery, Lei Shaohua et al. [56] applied meridian massage techniques that concentrated on the acupuncture sites of the foot’s three yin meridians [56].

Traditional Chinese medicine provides various strategies for treating lymphedema. The “Medical Heart Formula” suggests that treatments for “foot odor” should be aligned with the seasons. In the spring and autumn, treatment approaches should balance strengthening and purgation, while in summer, the focus should be on promoting sweating and detoxification [53, 57]. According to the “Treatise on the Origin of Diseases”, “all foot diseases are believed to arise from wind and toxins”, underscoring the importance of treatments that expel these pathogens to maintain health. Contemporary lymphedema treatments emphasize addressing “deficiency”, following the principle that “all swelling and dampness pertain to the spleen”. Additionally, addressing “excess” through the elimination of dampness, blood stasis, and phlegm condensation enhances lymphatic and blood fluid circulation with the aid of medicinal herbs, thereby diminishing limb swelling [58, 59].