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Physical therapy 'could reduce cost of lymphedema treatment'

2012-01-11T11:34:00.001-08:00

9 January 2012

Early diagnosis and treatment of breast cancer lymphedema by a physical therapist could significantly reduce the cost and need for intensive rehabilitation, according to latest research.

Scientists writing an article published in the January issue of the journal Physical Therapy for the American Physical Therapy Association (APTA) suggested that a prospective surveillance model for the treatment of breast cancer-related lymphedema was significantly lower in cost compared to a traditional model of impairment-based care.

APTA member and spokesperson Nicole Stout, who led the programme, said: "This study begins to paint a picture of evidence showing that prevention of chronic conditions such as lymphedema - using rehabilitation models of care - may result in significant cost savings."

Researchers found that the prospective surveillance model cost around $636.19 (£411.83) a year compared to $3,124.92 for the traditional treatment of advanced lymphedema, also known as a lymphatic obstruction.

The condition is a blockage of the lymph vessels that drain fluid from tissues throughout the body and could affect the workings of the immune system.

Posted by Jeanette Royston

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Exercise Class for Female Cancer Patients Offers More than Fitness

2011-12-26T11:20:00.001-08:00

When Newark resident Violet Williams was diagnosed with breast cancer in 2006, all of her immediate family who might provide support lived out of state, leaving her to face her treatment alone.
Throughout her treatment and recovery at The Frederick B. Cohen Cancer Center for Blood Disorders at Newark Beth Israel Medical Center, Williams took advantage of several support programs, including Recovery Fitness, a free, all-female exercise class for cancer patients.
"Those groups really carried me through the whole thing," Williams said. "Both the support group and the exercise class helped me mentally and physically to recover and get my strength back."
Recovery Fitness, offered at NBIMC on Mondays and Wednesdays at the new Beth Fitness Center, helps female cancer patients to have fun, get strong and reduce stress. It is one of only a few such programs in the state to specifically offer exercise classes tailored to the needs of female cancer patients. Recovery Fitness is made possible by grants from The Jewish Women’s Foundation of New Jersey and Eisai Co., Ltd., which were made through the Newark Beth Israel/Children’s Hospital of New Jersey Foundation.
"I like everything about it," said Williams. "Just being there and mingling with the other cancer patients is helpful, especially for the newly diagnosed women who can get a bit of hope from the ones who have been through it already."
Williams, who also suffers from Lymphedema, a condition of fluid retention and tissue swelling caused by a compromised lymphatic system, says that she has seen improvement in her arms with much better range of motion and less joint pain.
The class' instructor, Carol Michaels is a Certified Cancer Exercise Specialist who meets with each participant individually to learn about problem areas and to find ways to benefit each person. Goals of the class include increasing muscle mass, decreasing body fat, increasing flexibility, strength, posture and balance, strengthening the heart and bones, reducing stress and increasing self-confidence.
Many cancer patients experience secondary complications as a result of their cancer, such as frozen shoulder after a mastectomy and stiffness and discomfort as a result of lymph node dissection, Michaels said.
"Some female cancer patients experience the added aggravation of chronic conditions after treatment, and through this exercise program they can increase their range of motion and feel stronger again," said Dr. Alice Cohen, director of the Frederick B. Cohen Comprehensive Cancer and Blood Disorders Center. "Exercise improves function and also helps with overall stress reduction."
Studies have shown that exercise can aid in the recovery process during cancer treatment as well as to possibly decrease the likelihood of cancer recurrence, said Cohen.
Most importantly, Recovery Fitness offers a warm environment for patients who are at all different levels of recovery.
"This isn’t boot camp," said Michaels. "The exercises are safe and gentle and we have an appreciation for every fitness level. Someone might be able to work out with weights while another person sits in a chair to lift hers. It is very individualized."
Michaels said the group becomes, in effect, a support group with each person learning from one other and offering words of encouragement.
"Many people do not feel comfortable returning to their gyms right after surgery or treatment," she said. "Gym classes can be large and impersonal. At our class, the participants can even remove wigs and head wraps without feeling self-conscious. Gaining confidence through support is part of the whole recovery process."
After a year of participation, Williams plans to continue with the program.
"I even lost a few pounds," she said. "I’m going to keep going."
– Staff reports

http://newarknj.patch.com/articles/exercise-class-for-female-cancer-patients-offers-more-than-fitness

Manual Lymph Drainage and it’s Role in the Treatment of Lymphedema

2011-12-26T11:18:00.001-08:00

By Joachim Zuther, on December 21st, 2011

Manual lymph drainage (MLD) is one of the main components of complete decongestive therapy (CDT). In combination with compression therapy, skin and nail care and decongestive exercises, MLD performs the crucial role of re-routing stagnated lymphatic fluid, which is essential in the treatment and management of primary and secondary lymphedema. This gentle manual treatment technique is based on four basic strokes, which were first described by Dr. Emil Vodder (1896-1986), PhD.
The goal of MLD is to stimulate healthy lymph vessels and lymph nodes, which generally are located adjacent to the area of non-functioning or blocked lymphatic drainage, and to re-route the lymph flow around these blocked areas into more centrally located healthy lymph vessels and nodes. This is achieved with specific stretches and manipulations – a common denominator in all MLD strokes – to the skin and those structures located directly beneath the skin, the subcutaneous tissues.
The resulting increase in lymphatic activity in the healthy areas creates a “suction effect”, which stimulates the accumulated fluid present in lymphedema to move into an area with normal lymphatic drainage.

What is the difference between MLD and traditional massage?
It is unfortunate that the term massage is often wrongly used to describe MLD. The origin of the word massage is derived from the Greek massain (to knead) and is used to describe such techniques as effleurage, petrissage, vibration, etc. Massage techniques traditionally are applied to treat ailments in muscle tissues, tendons and ligaments, and in order to achieve the desired effect, these techniques are generally applied with considerable pressure.

Cross section through skin, subcutis and muscle layer

MLD on the other hand is a very gentle manual technique, designed to have an effect on fluid components and lymphatic structures located in superficial tissues, i.e. the skin and the subcutis. Lymphedema almost exclusively manifests itself in the subcutis, which is a layer of connective tissue between the skin and muscle tissues.
The only commonality between MLD and traditional massage is that both techniques are applied manually. There are significant differences in technique, pressure and indications for which these two therapeutic measures are used.
There are a number of reasonable explanations why MLD and massage are often confused with each other. One is that there is a tendency to call any hands-on manual therapeutic technique a form of massage; the other is that massage can be very helpful if applied to treat edema.
However, lymphedema and edema are two very different conditions and it is important to understand the differences. Although both conditions involve swelling, edema and lymphedema have very different causes and are treated differently. A previous blog post “When is it Lymphedema?” compares these two conditions:
Additional Resources:
http://www.lymphedemapeople.com/thesite/edema_or_lymphedema.htm

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Update on Lymphedema: Exercise After Breast Cancer Treatment Is OK

2011-12-26T11:16:00.001-08:00

By Heidi Anne Duerr, MPH | December 20, 2011

Lymphedema, swelling caused by a blockage in the lymphatic system, can occur as a result of surgical or radiation therapy associated with breast cancer treatment. Since some research has shown that exercise after breast cancer treatment has been associated with developing lymphedema, clinicians often advise patients to avoid exercising. But is this truly necessary?

To better understand the actual risk, Dr Marilyn L. Kwan, research scientist at the Kaiser Permanente Northern California Division of Research, and colleagues conducted a systematic literature review of contemporary studies. After applying exclusion criteria, Kwan et al. identified 19 articles for review and synthesis. The researchers rated the evidence in the studies utilizing the Oncology Nursing Society Putting Evidence into Practice Weight-of-Evidence Classification.

Of the included studies, seven examined the effects of resistance exercises, seven examined regimens including aerobic and resistance exercises, and the remaining five studies looked at other exercise modalities. Kwan et al. found that slowly progressive exercise of varying modalities was not associated either developing or exacerbating lymphedema associated with breast cancer. Further, the studies indicated that, with careful supervision, patients should be allowed to participate in such exercise regimens. However, data from the studies examining combined aerobic and resistance exercise did not yield as conclusive results or recommendations. While the studies showed that these exercise regimens appeared to be safe, confirmation of their safety requires larger and more rigorous studies.

“Strong evidence is now available on the safety of resistance exercise without an increase in risk of lymphedema for breast cancer patients,” Kwan and colleagues concluded. “With reasonable precautions, it is safe for breast cancer survivors to exercise throughout the trajectory of their cancer experience, including during treatment.”

“Exercise can be beneficial and not harmful for breast cancer survivors,” Dr Jane Armer, one of the study’s co-authors and director of nursing research at the Ellis Fischel Cancer Center at Sinclair School of Nursing, explained in a statement to the press. “Each individual should balance the pros and cons of the activity she chooses, but keep in mind that being sedentary has risks and being active is beneficial in many ways, including possibly reducing the risk of cancer recurrence.”

References:
Kwan ML, Cohn JC, Armer JM, et al. Exercise in patients with lymphedema: a systematic review of the contemporary literature. J Cancer Surviv. 2011;5(4):320-3.
Craven S. MU researchers recommend exercise for breast cancer survivors, lymphedema patients. University of Missouri Press Release. Nov. 30, 2011.

New Stanford registry to track lymphedema in breast cancer patients

2011-12-13T10:17:00.001-08:00

Cancer, Research, Stanford News, Women's Health

New Stanford registry to track lymphedema in breast cancer patients

John Stafford on December 12th, 2011 No Comments

Increasing numbers of women are surviving breast cancer, but some of the therapies used to treat the cancer can cause a serious side effect: lymphedema. That disorder is, unfortunately, often misdiagnosed or ignored in breast-cancer survivors, so Stanford researchers are launching a registry to aid in better understanding the problem. As my co-worker explains:

…The information and records of breast cancer survivors gathered in the registry will be used in a study to determine whether early diagnosis of lymphedema can help treat and, possibly, prevent it.
“There is early evidence to suggest that prompt diagnosis may reduce the severity or eliminate this problem,” said Stanley Rockson, MD, the Allan and Tina Neill Professor of Lymphatic Research and Medicine, the lead investigator of the study. “If you take a wait-and-see treatment approach, by the time the lymphedema becomes noticeable, it can be quite advanced. Caught earlier, it may be more manageable, or even reversible.”

Head over to our release for the rest of the story.

New registry will track lymphedema among breast cancer patients

2011-12-13T07:44:00.000-08:00

http://www.healthcanal.com/cancers/24492-New-registry-will-track-lymphedema-among-breast-cancer-patients.html

BY TRACIE WHITE - More and more woman are surviving breast cancer, but lifesaving surgical and radiation therapies can cause a grave side effect: an incurable chronic condition called lymphedema that involves swelling of the arms and often debilitating pain and discomfort.

Stanley Rockson

While this disorder frequently has been ignored, misdiagnosed and untreated in breast-cancer survivors, that’s beginning to change.
In an effort to find better treatment and preventive strategies for lymphedema, researchers at the Stanford University School of Medicine are launching a patient registry to study breast-cancer-related lymphedema. The information and records of breast cancer survivors gathered in the registry will be used in a study to determine whether early diagnosis of lymphedema can help treat and, possibly, prevent it.
“There is early evidence to suggest that prompt diagnosis may reduce the severity or eliminate this problem,” said Stanley Rockson, MD, the Allan and Tina Neill Professor of Lymphatic Research and Medicine, the lead investigator of the study. “If you take a wait-and-see treatment approach, by the time the lymphedema becomes noticeable, it can be quite advanced. Caught earlier, it may be more manageable, or even reversible.
“Oncologists and surgeons are becoming more aware of the need, and there are new technologies that help with early diagnosis.”

A leading expert in lymphatic diseases, Rockson, who directs the Center for Lymphatic and Venous Disorders at Stanford, helped establish the first patient registry and tissue bank for patients with lymphatic disorders in 2009.
For this new study, Stanford researchers hope to recruit an estimated 1,000 breast-cancer survivors for the Stanford National Breast Cancer Lymphedema Registry.
“Members of the American Society of Breast Surgeons will have the opportunity to collaborate in this project,” according to a statement from the society. “Member surgeons can choose to help Stanford in the identification of patients to be enrolled in the registry and will facilitate participation through the society's web-based quality reporting initiative.”
Participants will periodically update information about any symptoms, test results or treatments in 15-minute online sessions. They’ll give approval for their surgeons to provide their treatment information to the registry. Identifying information will be removed.
Currently, there is no cure for lymphedema, a disorder that arises in 15-60 percent of breast cancer survivors. A lifelong problem of disrupted lymph circulation characterized by fatigue, limb swelling and loss of the integrity of the skin, the condition’s severity can range from mild discomfort to disabling disfigurement, pain and loss of function.
When lymph circulation is delayed or interrupted, swelling and inflammation can result from a traffic jam of lymph that builds up in the limbs. There are multiple sources of blockages but often they are caused by tumor removal surgery, radiation treatment or lymph node biopsy. The only available treatments are physical therapies, including skin massage, drainage and pressure bandages, though the long-term effectiveness of these therapies has not been carefully studied.
Patients interested in enrolling can log into the Stanford National Breast Cancer Lymphedema Registry website at: http://breastcancer-lymphedema.stanford.edu. For more information, patients can call (650) 723-1396 or email lymphatic@stanfordmed.org.
Stanford University Medical Center integrates research, medical education and patient care at its three institutions - Stanford University School of Medicine, Stanford Hospital & Clinics and Lucile Packard Children's Hospital. For more information, please visit the Office of Communication & Public Affairs site at http://mednews.stanford.edu/.

Treatment of various secondary lymphedemas by microsurgical lymph vessel transplantation

2011-12-06T17:37:00.000-08:00

Felmerer G, Sattler T, Lohrmann C, Tobbia D.
Microsurgery. 2011 Nov 24. doi: 10.1002/micr.20968. [Epub ahead of print]

Source
Division of Plastic Surgery, Department of Trauma Surgery, Plastic and Reconstructive Surgery, University of Medicine, Göttingen, Germany; Department of Plastic, Aesthetic and Hand Surgery, Klinikum Kassel, Kassel, Germany; Department of Radiology, University of Freiburg Medical Centre, Freiburg, Germany. gunther.felmerer@med.uni-goettingen.de.

Abstract
Chronic lymphedema is a debilitating complication of cancer diagnosis and therapy and poses many challenges for health care professionals. It remains a poorly understood condition that has the potential to occur after any intervention affecting lymph node drainage mechanism. Microsurgical lymph vessel transplantation is increasingly recognized as a promising method for bypassing the obstructed lymph pathways and promoting long-term reduction of edema in the affected limb. A detailed review of 14 patients with postoperative lymphedema treated with autologous lymph vessel transplantation between October 2005 and November 2009 was performed. In this report, the authors gave an account of their experience in utilizing this operative method to alleviate secondary lymphedema including upper limb, lower limb, genital, and facial edemas. Lymph vessel transplantation enhanced lymphatic drainage in patients with secondary lymphedema. In the upper and lower extremities, three patients had completed symptomatic recovery and another nine patients achieved reasonable reduction of lymphedema, four of these needed no further lymph drainage or compression garments and the remaining maintained their improvement with further decongestive therapy with or without compression garments. The patients with facial and genital edemas also experienced significant symptomatic improvement. The authors were able to establish long-term patency of the lymph vessel anastomosis by magnetic resonance lymphangiography. © 2011 Wiley Periodicals, Inc. Microsurgery, 2011.

http://www.ncbi.nlm.nih.gov/pubmed/2211 ... t=Abstract

Mohawk College Offers Lymphedema Program

2011-12-06T17:33:00.000-08:00

Submitted by LymphedemaDepot on Dec 05, 2011

Lymphedema is one of the most feared and least understood complications of breast cancer treatment. Mohawk College in Hamilton, Ontario, is offering a day-long overview that will prepare the student to understand the causes of lymphedema as well as its treatment and management.
John Mulligan, RMT/CLT-LANA will present an Overview of Lymphology and Lymphedema Management at Mohawk College at the Mohawk/McMaster Institute of Applied Health Sciences Hamilton Campus in the Applied Health Sciences building, on Saturday February 4th, 2012, 9:00 a.m. to 4:30 p.m.
This unique one day workshop will explore the different types and stages of lymphedema, clinical pathways for treatment and the need for skilled care. Topics include basic lymphology, differentiating among different types of edema, the role and mechanics of compression, manual lymph drainage and complex decongestive therapy. We will also discuss the International Lymphedema Framework Movement, research resources and educational opportunities in the field of lymphology.
This one-day introduction to the basics of lymphedema and lymphedema management will immediately give the attendees a solid base of knowledge of the lymphatic system and disorders of the lymphatic system.
For more information visitwww.LymphedemaDepot.com and click on EVENTS in the left-side menu. This will bring you to the Mohawk online course catalogue where register for the daylong overview. To locate the course listing, simply go to page 53 of the catalogue. To register, click on Registration Information.
For further assistance contact John Mulligan directly at john@lymphedematherapist.com.
For more information about Mr. Mulligan and his practice, please visit www.LymphedemaTherapist.com.

MLD/CDP Manual Lymphatic Lymphedema Certification course, February 14-19th, 2012

2011-12-03T16:46:00.000-08:00

The course layout would be as follows:

Module I: 30 hours/home study. Start as soon as you can. It consists of a paperback book to read, questions to answer, and CD's to listen to.

Module II: Tuesday/Wed the 14th-15th, of February, 8am-6pm, (plus a few hours of practice/homework in the evenings)

Module III: Thursday the 16th-19th, 8am-4:30pm, except for Sunday, we release at 2pm. The students just starting Module II on Tuesday the 14th will continue until 6pm

Module IV: Compression bandaging portion, April 19th-22nd. 8am-4:30pm

See the attached document for costs, and content/objectives and then let me know what questions you have!. Looking forward to having you. We have a great time and the classes are very relaxed.

email me for complete course details: carmenethompson@gmail.com

Great article on Lymphedema of the Trunk and Breast, by Joachim Zuther

2011-12-03T16:44:00.000-08:00

Lymphedema Affecting the Breast and Trunk

By Joachim Zuther, on October 5th, 2011

Lymphedema affecting the chest, breast and posterior thorax, also known as trunkal lymphedema, is a common problem following breast cancer surgery, but is often difficult to diagnose, especially if the patient does not also present with lymphedema of the arm, or it may be dismissed as a side-effect of breast cancer surgery, which will resolve by itself over time.
While trunkal lymphedema is often not reported, poorly documented and available studies are not easy to compare, the literature suggests an incidence of up to 70% of lymphedema affecting the trunk and/or breast following breast cancer treatment.
Given the fact that the breast, anterior and posterior thorax and the upper extremity share the axillary nodes as regional lymph nodes, it is predictable that disruption of lymphatic drainage pathways by partial or complete removal of axillary lymph nodes, with or without radiation therapy can cause the onset of swelling in the chest wall and breast on the same side. The swelling can either be subtle or quite obvious in presentation and may be present with or without swelling in the arm.
The disruption of the natural lymphatic drainage pattern is further complicated by scars on the upper trunk wall following lumpectomy, mastectomy, and reconstructive breast surgery, biopsies or drain sites. Fibrotic tissues in the chest wall or armpit following radiation treatments may further inhibit sufficient lymphatic drainage.
Certain breast reconstructive procedures, such as the TRAM-flap reconstruction also disrupt lymphatic drainage in the abdominal area, which may cause the onset of additional swelling in the lower trunkal (abdominal) area.
Like lymphedema in the extremities, swelling affecting the breast, chest and posterior thorax is typically asymmetrical in appearance if compared with the other side. However, there are often other symptoms present prior to the onset of visible swelling, which may include altered sensation (numbness, tingling, diffuse fullness and pressure, heat), pain and decreased shoulder mobility. Once lymphedema is visibly present, the swelling may include the entire thorax wall, or may be localized to the armpit, the scapula, the area over the clavicle or around mastectomy/lumpectomy scar lines, around the reconstructed breast or implants, or it may be limited to the breast tissue only.
The breast in patients who underwent lumpectomy or reconstructive surgery may be larger and heavier, or the shape and height of the breast tissue may change due to fibrotic tissue, resulting in added psychological distress due to problems involving clothing, bra fit and body image issues.
Post-operative swelling following breast cancer surgery is to be expected and generally lasts up to about three months; it appears almost immediately following surgery and places additional stress on the lymphatic system by contributing to the lymphatic workload. The difference between “normal” post-operative edema and lymphedema is its perseverance following the completion of treatment, and the presence of changes in tissue texture, such as lymphostatic fibrosis.

skin fold caliper

While several methods are available to assess trunkal and breast edema (skin fold calipers, bioimpedance), subjective examination of the anterior and posterior aspect of the thorax and breast focused on the observation of signs of swelling (asymmetry, bra strap and seam indentations, orange peel phenomenon, changes in skin color), palpation of the tissue texture and comparison of skin folds between the affected and non-affected side, remain the most practical means for assessment of lymphedema affecting the trunk. Serial photographs depicting the anterior and posterior view are helpful tools in assessing changes before and after treatment.
Most of the symptoms associated with trunkal lymphedema can be treated successfully with Complete Decongestive Therapy (CDT), to include Manual Lymph Drainage (MLD), especially if combined with self-MLD, skin care, exercises and compression therapy. Fortunately, trunkal swelling responds well to treatment, often with markable improvement within 10 treatments. Treatment may be necessary only during the initial period following breast cancer treatment to facilitate edema removal and wound healing, or it may be applied at a later point; trunkal lymphedema with or without the involvement of the arm may appear at any time following surgery for breast cancer.
Manual Lymph Drainage: In case of localized trunkal lymphedema without involvement of the arm, MLD techniques concentrate on the neck, the anterior and posterior aspects of the upper trunk, as well as the inguinal lymph nodes, followed by techniques focused to redirect lymphatic fluid from congested areas into areas with sufficient lymphatic drainage. If necessary, additional techniques aimed to soften fibrotic tissues may also be applied.
For patients who underwent TRAM-flap procedures, careful attention should be given to address scar tissue that could lead to trapping of lymphatic fluid.
During the initial stages of the treatment, patients should be instructed in self-MLD and encouraged to perform self treatment for at least 20-30 minutes daily.
Skin Care: Patients who have lymphedema are susceptible to infections of the skin; areas between skin folds or the underside of the breast are particularly prone to skin damage and infections. Edematous areas should be kept clean and dry and suitable ointments or lotions formulated for sensitive skin, radiation dermatitis and lymphedema should be applied.
Exercises: Trunkal lymphedema is often associated with restrictions in thorax and shoulder movements, which should be evaluated by a Physical or Occupational Therapist. Specific exercises addressing these issues and to increase range of motion and function with daily activities should be performed.
Depending on the location and quality of scars, mobilization of adhered scar tissue by a qualified therapist may be necessary to improve range of motion. Breathing and aerobic exercises further facilitate decongestion by improving drainage in superficial and deep lymphatic pathways.
Compression Therapy: Oftentimes compression of the affected area may be challenging due to tenderness of the tissue, or irritated skin secondary to

compression bra

radiation therapy. However, in order to address fluid accumulation and to avoid worsening of the swelling, the application of compression bandages and/or compression bras or vests is very important. Compression bandages are applied circumferentially around the chest with special care not to impair blood supply to grafts and/or healing scars.
Due to the lack of muscle pump activity in the trunkal area, the use of wide-width (15-20cm) medium and long-stretch bandages is preferable over the normally used short-stretch bandages for lymphedema affecting the extremities.
Custom cut or commercially manufactured foam pads or foam chips may be inserted underneath the bandages or compression bra/vest to increase localized pressure in areas of excess fluid pooling, or to soften localized fibrotic tissue. Flat foam pieces can be used to shape and stabilize the compression bandages and to distribute the pressure evenly over a greater surface area.
The patient should be fitted with a specially designed lymphedema bra or compression vest following decongestion of the trunk to assist with maintaining the positive results of CDT. Compression bras and vests have minimal seams and wide straps, are available as off-the-shelf or custom-made garments and ensure that the trunk and breast tissues are properly supported. Compression bras and vests should fit comfortably, provide sufficient support around the trunk and not squeeze breast tissue; pockets to accommodate a prosthesis can be sewn into these garments.
Patients using regular bras or sports bras should make sure to avoid narrow bra straps and obtain bra strap pads or wideners, if necessary, to avoid restriction of lymphatic pathways on the shoulder.
Additional Resources:
http://www.stepup-speakout.org/breast_chest_trunckal_lymphedema.htm
http://www.lymphoedema-uk.com/journal/0101_breasttrunk.pdf

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Welbox For Cellulite Reduction and Lymphatic Stimulation

2011-09-12T13:23:00.000-07:00

Product Description and Benefits:

Clinically proven, the Wellbox Lipomassage LPG Machine revitalizes deep tissue action and stimulates the skin to repair itself for a wide variety of beauty, health and wellness treatments. Easy-to-use and operate at home, Wellbox Lipomassage can be used on the face and body to reduce the appearance of cellulite and trim one's figure, achieve smoother, softer skin, restore firmer skin with more elasticity, soften and reduce lines, wrinkles, and sagging skin, and silken and soften the skin for glowing, radiant complexion. The Wellbox Lipomassage Cellulite & Fat Reduction Device is based on the most efficient non-invasive professional technique cleared by the FDA for reduction in the appearance of cellulite. Used by leading spas, plastic surgeons and celebrities such as Paris Hilton, Celine Dion and Sharon Stone, Well box is also a highly effective post-operative healing device to use following liposuction, tummy tuck, or any facial or body plastic surgery to help stimulate circulation, reduce swelling and bruising, treat lumpiness that can occur following surgery, break down hardened fibrosis tissue, and achieve a smooth finish on one's surgically operated body. Wellbox Lipomassage also relieves the body of aches and pains, and when used on the face, it can help achieve a radiant appearance through its delicate exfoliation mechanism and achieve rejuvenated skin through its optimized microcirculation mechanism that oxygenates and brings precious nutrients to the skin. Wellbox features five high-performance, interchangeable treatment heads that cater to all skin types and sensitivity levels. Designed for use in the comfort and convenience of your home, Wellbox is compact, lightweight, and portable. For frequent travelers, the sleek, compact machine comes fully equipped with a training video and universal adapter.

From microdermabrasion to gym equipment, the trend toward professional-grade beauty technology with at-home convenience is transforming the beauty and health industries. Scientifically proven and world renowned, Wellbox Lipomassage™ is a home-use version of the professional Lipomassage machine currently found in medical spas and cosmetic surgeon's offices.

Click here to see Wellbox Before/After Pictures

Clinically proven, Wellbox's revitalizing deep tissue action stimulates the skin to repair itself for a wide variety of beauty, health and wellness treatments.

Stimulate fat metabolism, even in diet & exercise-resistant fatty areas
Fight cellulite, stubborn fat retention and figure flaws
Nourish and revitalize aging skin
Restore youthful, radiant skin
Beautify and redefine the figure
Relieve tension, aches and pain
Soothe and relax the entire body
Silken and soften skin for a flawless, radiant complexion
Experience dramatically younger-looking body
Re-energize skin for a healthy glow

Regardless of age, gender or ethnicity, Wellbox personal Lipomassage is the only real, scientifically proven home solution to effectively fight body imperfections on a cellular and structural level.

How does Wellbox fight cellulite and promote weight loss?

Often referred to as the "orange-peel" or "cottage-cheese" effect, cellulite plagues over 90% of women today. ‘Love Handles,' ‘muffin top' and ‘saddlebags' are all affectionate terms for the stubborn fatty areas that accumulate on the waist, hips and thighs. Although age, lifestyles, hormonal factors and body types may predispose certain woman to such cellulite and fat retention, all women -even young, thin women and devoted followers of stringent exercise and nutritional regimens - are at risk.

Though not directly responsible for providing weight loss, recent studies have shown that Lipomassage directly and quantifiably ‘reboots' fat cell metabolism for a more slenderized, streamlined waistline and a redefined physique. With Lipomassage, ‘superficial trapped fat' (stored fat resistant to diet, exercise and not addressed by surgical procedures) is actually expelled from fat cells. Wellbox's Lipomassage action is the most effective home-solution to fight cellulite and fat on a cellular and structural level.

For thirty million Americans, though, beauty - or the lack thereof- is more than skin deep. Women suffering from such by-products of poor circulation as unsightly veins, swelling and heavy-leg syndrome are concerned with much more than having a bikini-ready body. Revitalizing blood circulation, Wellbox reduces the feeling of tingling, cramps, pressure and heaviness. Flushing the system of waste products as well as removing and preventing fluid retention, Wellbox soothes, refreshes and energizes legs as it diminishes the visible signs of unhealthy skin.

How can Wellbox help me before or after my cosmetic surgery?

Having adequate blood supply before, during and after any surgery - whether for breast or buttock augmentations, liposuction, thigh and tummy tucks, or the like - is vital for a positive outcome and speedy recovery time. Hematomas, Seromas, hyperpigmentation and permanent bruising are all related to circulatory deficiencies. After surgery, residual blood collects in tissues, waiting to be broken down and reabsorbed. Although very rare, in severe cases, lack of blood supply may also result in necrosis (dead tissue), which causes major infections and even gangrene. More commonly, fibrosis results - the formation of scar-like structures in lymphedema affected tissues - causing tissue to harden, losing softness and flexibility. With reduced circulatory exchanges, cells are prevented from receiving essential nutrients and worse, protein deposits form and aggravate the condition. With this impaired circulation, the lymph cannot drain properly and there is a greater risk of swelling, tissue infection and skin problems, not to mention a much longer healing time. To reduce tissue swelling, bruising and numb, hardened fibrosis tissue, proper lymphatic circulation is vital.

Plastic Surgeons use a professional version of Lipomassage technology to dramatically boost circulatory exchanges - venous and lymphatic - thereby preventing post-surgical trauma, unhealthy connective tissue and structural irregularities. Like the FDA-cleared professional machines, Wellbox improves lymphatic and local blood circulation.

Combined with Wellbox's astounding aesthetic and therapeutic results, the relaxing, pain-relieving effects loosen stiffness, calm and de-stress the entire body for improved healing and wellness.

Wellbox is highly beneficial even for persons who are not candidates for surgical augmentation. Life-sustaining blood must circulate freely; working within the lymphatic system; it is responsible for oxygenating tissues and purifying the body to flush out wastes. Rejuvenating circulation and accelerating the process of metabolic exchanges, Wellbox benefits the body's largest organ - skin. Pampering and relaxing the body and the mind, Wellbox gives skin a radiant glow and makes it feel nourished, refreshed and smooth.

Wellbox provides consumers with a comprehensive, non-invasive mini-spa for the face and body that is simple, stylish and safe. The ideal gift for men and women alike, Wellbox is smart and simple to operate, offering a user friendly display with simple settings for each pre-programmed application. Fully equipped with a detailed instructional video and five high-performance, interchangeable treatment heads, Wellbox caters to all skin types and sensitivity levels. Designed for the comfort and convenience of the home, Wellbox is compact, lightweight and portable. For frequent travelers, a universal adapter is also included.

Three Treatment Heads for Targeted Results:

Wellbox technology comes with interchangeable, high-performance treatment heads. Designed for all skin types and sensitivity levels, they treat a variety of beauty, health, sport and well-being needs.

1) Treatment Head 45 millimeters:

Developed from mechanical ROLL technology, this is the largest treatment head. Press once to start frontal rotation and press a second time to start rear rotation. As the treated area is gently pulled up, tissue fibers are stimulated, drained, and made suppler. This head is designed primarily for large bodily surfaces, such as the chest, thighs, buttocks, and back.

2) Treatment Head 30 millimeters:

Developed from mechanical ROLL technology, this is the medium-sized treatment head. Consult the Wellbox user manual for objective-specific programs and continuous vs. rhythmic treatment settings. This head is designed primarily for medium-sized bodily surfaces, such as arms, forearms, and calves.

3) Treatment Head 15 millimeters:

Developed from mechanical ROLL technology, this is the smallest treatment head. Applying targeted, in-depth action, these rollers gently lift tissues to mobilize, drain, sculpt, and relax every inch of skin they touch. This head is designed primarily for small bodily surfaces, such as palms, knees, ankles and foot arches.

4) Treatment Head Developed from LIFT technology:

- Largest treatment head: Small valves perform steady micro-pulsation, giving constant stimulation to each and every millimeter of treated skin. Like natural skin calisthenics, this workout truly restructures skin at a cellular level. Move the treatment head slowly for maximum comfort and stimulation. This head is designed primarily for use on body parts that require a firming treatment, such as the face (excluding the eyes), neck, and décolleté.

- Smallest treatment head: Tenderly lifting the skin, the constant movement of the small valves provides the gentlest of deep tissue stimulation. The LIFT effect is a gradual one; as the underlying support network is reinforced, skin becomes visibly firm and smooth. This head is primarily designed for use on the most delicate and sensitive body parts, such as fine lines, crow's feet, and laugh lines.

Can Wellbox Work In Any Country? Wellbox comes with electrical adaptors that allow the device to work in any country.

www.amazon.com

Manual Lymphatic Drainage Certification Courses beginning October, 2011

2011-08-09T10:01:00.000-07:00

Course offerings from Lymphatic Care Specialists, LLC
Lymphedema Treatment Center, Blacksburg, VA, OR
Provided On-site at YOUR Facility!

Introduction to Manual Lymphatic Drainage-An Overview-8 CEUs

Manual Lymphatic Drainage-Basic Body and Face Sequence- 8 CEUs

Introduction to Compression Bandaging & Garment Fitting-15 CEUs

Kinesio Taping for edema disorders: Lymphedema and Orthopedic Trauma-8 CEUs

Three-day Alternative Techniques for Lymphedema and Swelling disorders course: 24 CEUs
TBA

Three day Manual Lymphatic Drainage Techniques for Orthopedic Conditions: 24 CEUs
TBA

Three day Manual Lymphatic Drainage for Autoimmune Conditions: 24 CEUs
TBA

Two day Comprehensive Visceral Organ Manual Lymph Drainage: 16 CEUs

Three day Manual Lymphatic Drainage and CDP therapy with special populations: 24 CEUs
TBA

Three day Manual Lymphatic Drainage for Aesthetics/Post Plastic Surgery: 24 CEUs

Three day Manual Lymphatic Drainage for head, neck, and genitalia: 24 CEUs

Full MLD/CDP 140 hour certification program. Accredited by the National Lymphedema Network.

My 2011 Certification Class

2011-07-12T12:02:00.000-07:00

2011-07-12T06:28:00.001-07:00

Carmen,
Thanks for the information.

I’m doing great. My cardiologist thinks he figured out why my legs have started swelling. A lower chamber of my heart has narrowed. It is probably scar tissue from a past surgery. Since I’m doing well, no plan to fix it right now.

Thanks once again for the education about lymphedema. It has really improved my quality of life. The swelling in my legs had been gradual over the years and I didn’t realize how bad it had gotten until you fixed me.

Julie

Pharmaceutical Options in the Treatment of Lymphedema

2011-07-07T12:21:00.001-07:00

By Joachim Zuther, on July 5th, 2011

The use of drugs in the treatment of lymphedema in the Western Hemisphere is generally limited to antibiotics, which are used to prevent and treat infections commonly associated with lymphedema. As stated in the Position Paper of the National Lymphedema Network, lymphedema should not be treated exclusively with drugs or dietary supplements.
Following is a list of medications, which are mentioned for possible use in the treatment of lymphedema.
DiureticsThese drugs promote excess fluid in the body to be excreted. Although diuretics may be beneficial in the short-term, and may be indicated in those cases when lymphedema is associated with systemic conditions (ascites, hydrothorax, protein-loosing enteropathy), they may be harmful and contribute to the worsening of lymphedema-related symptoms if used long-term.
Here is why: Lymphedema is an abnormal accumulation of water and protein molecules in the body’s soft tissues, which is caused by a dysfunction of the lymphatic system. Swelling (edema) other than lymphedema may be caused by a variety of conditions, such as congestive heart failure, renal diseases, or venous insufficiencies. These swellings do not contain a higher level of proteins in the accumulated fluid, and are defined as edemas.
Diuretics used for lymphedema are limited to remove the water content of the swelling, while the protein molecules remain in the soft tissues. The dehydration effect of diuretics causes a higher concentration of the protein mass in the edema fluid, which may cause the tissues to become more fibrotic and increase the potential for secondary inflammations. In addition, the remaining proteins characteristically draw more water to the swollen areas as soon as the diuretic looses its effectiveness and may cause the volume of the lymphedema to increase.
The 2009 Consensus Document of the International Society of Lymphology states: “Diuretic agents are occasionally useful during the initial treatment phase of complete decongestive therapy (CDT). Long-term administration, however, is discouraged for its marginal benefits in treatment of peripheral lymphedema and potentially may induce fluid and electrolyte imbalance”
BenzopyronesThese drugs include Coumarin, Hydroxyethylrutin and flavonoids (Diosmin) and have been shown to promote the breakdown of proteins present in lymphedema. Research has shown that their practical usefulness in the treatment of lymphedema is questionable. The United States and Australia abandoned the use of Coumarin due to liver toxicity and lack of effectiveness.
Diethylcarbamazine (DEC) and AlbendazoleThese medications are used in the treatment of lymphatic filariasis, which is very rare in the United States, but endemic in more than 80 countries in the

Lymphatic Filariasis

tropics and subtropics. Filariasis is caused by threadlike, parasitic filarial worms that live almost exclusively in humans. It is estimated that over 120 million individuals are affected by this disease, which is transmitted when a mosquito bites an infected person and then goes on to bite others, thus infecting them with the parasites. During the worms lifetimes inside the host’s lymphatic system they produce dilation and damage to the lymphatics, restricting the normal flow of lymph, causing swelling, fibrosis and infections to lymph vessels and nodes (lymphangitis, lymphadenitis), leading to often extreme swellings. The goal of these drugs is to eliminate the parasitic worms, so the transmission of the disease by mosquitoes can be interrupted.

Endemic Countries for Filariasis

Antibiotics and AntimycoticsBacterial (dermato-lymphangio-adenitis [DLA]) and fungal infections of the skin and nails are common in patients with lymphedema. These complications can be treated effectively with broad spectrum antibiotics and antimycotic drugs. In cases where cellulitis is a frequent complication, prophylactic antibiotic treatment may be indicated.

2011-05-17T07:34:00.001-07:00

National Lymphedema Network

Lymph e-Channel vol. 4

May-June 2011

In This Issue

· Welcome

· Therapist's Article

· Patient Perspective

· MySassySleeve

· Sponsor A Patient

· Educate Your Legislator

Patients: We want to share
your stories!

Don't forget to send us
a short paragraph of
your experiences with lymphedema for us to publish! You can also send us photo to accompany your article if you are interested.

All submissions should go torobin@lymphnet.org.

Net Pals / Pen Pals

Looking to correspond with with a special person in a faraway (or not so faraway) place who also has lymphedema? Look no further than the NLN Lymphedema Pen Pals/NetPals Network!

Net Pals / Pen Pals

Position Papers

Diagnosis & Treatment of Lymphedema

New! Breast Cancer Related Lymphedema

Risk Reduction

Exercise

Air Travel

Quick Links

National Lymphedema Network

Cafepress Store

Welcome to Lymph e-Channel

Dear friends of the NLN,

My staff and I are thrilled to send you our latest issue of Lymph e-Channel. In this May/June edition you will find a range of inspirational and educational articles contributed by therapists and patients. This month we highlight a perplexing phenomenon - cording. Cording frequently occurs shortly after breast cancer surgery, and it is only in the last decade that practitioners have seriously addressed these unknown painful symptoms. Jodi Winicour, a lymphedema therapist and expert in BC rehabilitation, shares her knowledge and guidance on this subject. Dr. Nancy Hutchison, the chair of the NLN Medical Advisory Committee, recently invited her state representatives to visit her hospital where she educated them about lymphedema. One of her patients even showed the representatives her leg and demonstrated self-care. We are lucky to have a knowledgeable LE doctor who makes time to advocate for patients rights, and we hope that you will organize a similar meeting in your community.

In our patient perspective, Margaret Omori recounts her initial dismay with her lymphedema diagnosis following BC surgery, but also how she found a positive outlook from it all. Margaret and her sister, Monica, created a fashionable lightweight stretchable coverlet which adds a "sassy" flair to her sleeve. The sisters are co-founders of "MySassySleeve" company and their brand of colorful and fun coverlets are shared in our product review section. I am also excited to introduce a new regular feature to e-Channel - patient stories from our Marilyn Westbrook Garment Fund (MWGF). The MWGF directly impacts a patient's life and in this issue we share the story of one beneficiary, Ms. Gray.

Hopefully these stories inspire you to share your own experiences and go out and make a difference in your communities. This issue is full of interesting articles and information, and I hope you take the time to read and thoroughly enjoy this Lymph e-Channel.

In Good Health,

Saskia RJ Thiadens, RN

Executive Director, NLN

Painful Cording of the Arm

by Jodi Winicour PT, CMT, CLT-LANA
*References listed at the bottom of issue.

If you have upper extremity lymphedema caused by breast cancer surgery or treatments, you may have experienced a painful and bothersome condition called axillary web syndrome, or AWS. [Figure 1] Unfortunately, most lymphedema certification programs do not have the time to teach the treatment of AWS, which leaves lymphedema patients well treated for their swelling conditions but inadequately cared for regarding their cording. As few as 6% [1] to as many as 72% [2] of women who have had lymph nodes removed from their armpit (axilla) will develop AWS. Considering the pain it causes along with its frequent relationship with lymphedema, knowledge of its characteristics, onset and treatment is necessary to provide safe, holistic care for breast cancer survivors.

AWS characteristics:

AWS has certainly been around since the first radical mastectomies of the early 1900s, but the phrase "Axillary Web Syndrome" was coined in 2001 by Alexander Moskovitz, MD et al. [1] He describes painful cords of tissue that originate in the axilla, run along the inside of the upper arm to the elbow, and sometimes even to the wrist or the base of the thumb. These cords are made more taught by reaching out to the side and frequently can be seen as well as felt. Painful cording typically limits overhead and forward reaching along with elbow and forearm movements which makes activities such as cooking, cleaning, exercise, reaching and dressing difficult or impossible during the more painful stages.

How and when does AWS happen?

Typical onset of cording is 2 to 4 weeks after axillary node removal. [1, 2, 4, 5] Some with AWS have so much pain that it is difficult to use their arm while others feel that stretching and massage techniques are very helpful. Studies consistently report that the AWS will resolve on its own between 3 and 4 months after onset, but therapists who treat AWS have noted it lasting up to 1 year or longer without treatment. Untreated AWS may cause problems during the planning period for radiation therapy in those not needing chemotherapy. If unresolved, the cording can make CT scanning for radiation planning a very painful procedure which can delay the start of radiation therapy. It is much less common to see AWS after chemotherapy is completed, which is typically 3 to 6 months post surgery, but it does occur.

What is the stuff called AWS?

Although there are few tissue samples of AWS that have been looked at under the microscope, we do know that AWS can be hardened and enlarged lymphatic vessels that are filled with lymphatic fluid. This fluid cannot exit the arm normally through lymphatic pathways to the axilla due to lymph node removal. [1, 5, 10] AWS may also be small veins near the skin that are clotted or hardened. [1] In some cases, the webbing is hardened and clotted lymphatic fluid that causes inflammation of the vessels and makes them stick to the fatty tissues of the arm resulting in pain when moving or stretching the arm.

What increases my risk of having AWS?

While weight gain [11,13], obesity [11,13] & higher Body Mass Index (BMI of 25-26 kg/m2 [2,12,13]) have been associated with the onset of lymphedema, a lower BMI of 23[2] and 25.1 [ 3]) have been associated with the onset of AWS. These are confusing findings especially considering that both lymphedema and AWS seem to be caused by the axillary node removal and tissue scarring. Thinner women have both the increased risk of AWS and difficulties with shoulder movement after lymph node surgeries for breast cancer, while their risk for lymphedema should be lower than heavier women. [2, 11, 13]

What can I do about AWS?

While studies written by physician researchers state that AWS will resolve on its own, therapists around the world who frequently treat AWS agree that gentle massage, manual lymphatic drainage techniques and range of motion exercise can accelerate pain relief and tissue healing. Physical therapy may shorten the natural course of AWS to 6-8 weeks. [3] In some cases, the AWS presents with a mild lymphedema of the forearm. While traditional CDT (Complete Decongestive Therapy) techniques may reduce the lymphedema, it may become a chronic condition unless the AWS is treated.

Soft tissue techniques for cording include very gentle tissue "bending" or "traction" techniques applied along the taut cord in a comfortable position of stretch. Localized thumb and whole handed MLD techniques along the cording is also useful. Do combine active stretching with massage techniques to further improvements and do not be surprised if a "pop" is heard along the cording during your gentle treatments or during stretching. This "pop" will usually ensure immediate pain relief during movement but can also lead to lymphedema on rare occasions. Please avoid being overly aggressive (causing pain) during your treatments as this can cause an inflammatory reaction that may increase the lymphedema risk of your affected arm.

Knowledge of safe and effective techniques to hasten the resolution of AWS is necessary in the treatment of those recovering from breast cancer treatments and arm lymphedema. Hopefully reading this article will help to ease you or your patients' discomfort and increase your awareness of the treatments that are available.

Jodi Winicour PT, CMT, CLT-LANA

Longmont United Hospital, Longmont, Colorado.

Jodi is a full time clinician specializing in the treatment of lymphedema and cancer related dysfunction. She also is a Lymphedema Certification and Breast Cancer Rehabilitation Course instructor for Klose Training & Consulting.

Contact her at: Jodi@KloseTraining.com

Be Sassy!

by Margaret Omori

I didn't know enough, in the summer of '04, to be devastated by the news that I had developed lymphedema. I didn't know about the physical limits that would forever dictate how much I could lift, or the precautions that I would have to take in order to work in my garden. I didn't count on the huge financial burden that accompanied that diagnosis. The cost of multiple, custom-made compression garments that had to be factored into our family budget every three or so months or the expense of periodic "tune-ups" with my therapist. And I certainly wasn't prepared for the emotional toll that living under the cloud of this chronic condition would take on me or my family. The fact of the matter is: I am a breast cancer survivor and I have lymphedema.

Believe me, I'm thrilled to BE a survivor, grateful for the wonderful medical care that I received, and thankful to the dedicated professionals; the doctors, therapists and fitters who have successfully treated and continue to help me manage my condition. But what I most wanted, after I had battled and beat the breast cancer beast, was to look and feel like my old self. Needless to say, wrapping my arm in multiple layers of cumbersome bandages and wearing bland compression garments not only served as a constant reminder of my cancer battle, my self-esteem was assaulted on a daily basis! Facing endless questions from well-meaning strangers asking, "How did you hurt yourself?" or, "Why are you wearing a bandage?" made me feel less like a "survivor" and more like a casualty.

Discouraging? Yep! Depressing? You bet! And that would have been the end of my story had it not been for a timely gift in the form of some pirate tattoos (full disclosure: I'm a huge Johnny Depp fan!). The novelty of imagining my affected arm covered entirely in bold tattoos not only made me laugh, it gave me the courage to envision turning a negative into something positive. I thought, why not create something stylish and fun to wear over the dreaded "bandage"? Since wearing a compression sleeve draws attention anyway, why not do it in a way that attracts smiles instead of sympathy? Instead of feeling self-conscious, why not sassy? Thus inspired, my sister and I created a line of vibrant, tattoo-like coverlets called "MySassySleeve." Our goal is to provide an affordable and fashionable coverlet to help women regain a positive self-image and to change how others interact with us.

While lymphedema wasn't on my radar back in '04, it is now. My sister and I have joined our efforts with those in the medical community to actively raise awareness about lymphedema. We've helped advocate to get more comprehensive coverage for patients with lymphedema. And, most gratifyingly, we've raised funds through our business to aid those in need to purchase medical compression wear. Along with the talented artists, local manufacturers and others who help to create our product, our shared goal is to make a difference in the lives of those with lymphedema... one sleeve at a time.

MySassySleeve

Therapist Review:

by: Guenter Klose, MLD/CDT Certified Instructor, CLT, founder of Klose Lymphedema Care in Lafayette, CO., Executive Director of Klose Training and Consulting.

When Monica (co-founder of MySassySleeve) introduced me to her decorative coverlets and brought several samples in to our office, I was happy to see such a fresh and innovative product offered for people with lymphedema. It is exciting that patients who wear compression garments to manage their lymphedema now have a design choice with these interchangeable, non-medical sleeves. Instead of feeling like they need to hide their compression sleeve under a jacket or long-sleeved shirt, they can wear these light-weight, stretchable coverlets over their garment to add a bit of light-hearted fun.

I often hear from many of my patients that having to wear a medical garment is not only unattractive but makes them feel self-conscious. We immediately saw emotional benefits in patients who wear the MySassySleeve coverlets. By drawing attention to the colorful, tattoo designs and away from the medical looking therapeutic compression sleeve, my patients have rediscovered their self-esteem and self-confidence. They feel good about themselves and that has empowered them.

While MySassySleeve is only decorative and does not manage lymphedema, it certainly provides an emotional, feel-good benefit that medical garments alone cannot provide. Congratulations on a wonderful and beneficial product.

Fitter Review:

"The best part of having MySassySleeves for my customers is the spontaneous moment of surprise and joy they create. The bright colors and bold designs immediately transform a medical product into a fashion statement, and in the same moment transform a patient's experience from 'a little bit awful' to 'a little bit fun'. The tattoo patterns ARE sassy and we've watched so many women change their thinking from 'Not for me.' to 'Why NOT me!?'

And you have to love the smile that goes along with trying something just a little outside their comfort zone. We have spent many years providing our customers with outstanding therapeutic garments- We are now delighted to provide them with the opportunity to see their compression sleeve as a blank canvas for their newest accessory!"

Claudia Boyle

Van Driel's Medical Support Wear

Patient Reviews:

"What MySassySleeve is doing is so wonderful! It will make wearing my dull and boring compression sleeve so much fun to wear. It will also make me want to wear it more often which will benefit my condition. I will wear it proudly...thanks again!"

Emmie B.

"I am very excited about the MySassySleeve. Great idea- the fact that you are not trying to compete with medical grade sleeves but compliment them is perfect! I brought them to two breast cancer care education nurses and they loved them!"

Syndi S., CMF, BOC, ABC

Wilmette, IL

This Product Review is a paid advertisement.

Marilyn Westbrook Garment Fund

The Marilyn Westbrook Garment Fund (MWGF) holds a special place in the hearts of the NLN staff. It gives us the opportunity to not only help our patients, but connect with them on a personal level and see firsthand the profound impact the fund has on their lives. Because of this, we have decided to share their stories with you. In every issue of Lymph e-Channel, we will feature the story of a MWGF patient. We hope you find them as inspiring and courageous as we do.

Ms. Gray is a breast cancer survivor who developed lymphedema shortly after her surgery in 2007. Initially, she was able to afford a sleeve and gauntlet, but the cost of replacing these garments was a burden for her. Instead, Ms. Gray continued wearing the same sleeve and gauntlet for the next two years. No longer providing adequate compression, her sleeve started rolling down, cutting off the circulation in her arm. Ms. Gray's swelling progressively worsened as a result. Fortunately, Ms. Gray's therapist told her about the MWGF and she quickly contacted us. With Juzo's generosity, we were able to supply Ms. Gray with a new set of garments.

"I wish to take this opportunity to thank you for all your efforts on my behalf and to thank the organization for financially supporting my need. At the time of the initial application I did not know what to do about getting a new sleeve and gauntlet. And everyday the old one was getting more and more uncomfortable. It is very comforting to know that there are people and organizations that help when you need it and with what you need.

I can only say thank you again, though that seems to be very little for the great thing you have done for me!

Sincerely yours, G. Gray"

Ms. Gray's case is not unique. Across the country, there are many patients that need lymphedema garments. For many of us, the benefit of proper garments is clear - they are crucial to the success of lymphedema therapy.

You can help!

This year we plan to raise at least $25,000 to continue the work of the MWGF. As part of our Sponsor-A-Patient Campaign, a $50 pledge will support one patient by:

Sponsoring a patient's application including a yearly membership to the NLN
Covering program costs to administer and continue to grow the fund.

Click Here to make a donation to the MWGF.

For only $50 you can positively affect someone's life. But don't feel limited by one amount; you can make a contribution in any amount. Large or small, every dollar supports a patient. Check back frequently to track our progress on the thermometer! (Donors can also choose to have their name and/or logo listed)

On behalf of the many patients, therapists, affiliated clinics, and the NLN staff, we thank you from the bottom of our hearts.

Federal Health Policy Staffers Visit Sister Kenny Rehabilitation Institute to Learn About Lymphedema

April 26, 2011

On Tuesday, April 26, leaders from Allina and the Sister Kenny Rehabilitation Institute in Minneapolis, MN met with the health policy staffers from the offices of Senator Amy Klobuchar, Senator Al Franken and Congressman Keith Ellison to talk about lymphedema.

Erika Nelson, Sen. Klobuchar's office, Bethany Snyder, Sen. Franken's office and Mike Siebenaler, Congressman Ellison's office learned about lymphedema, proper treatment of the disease, innovative work being led by the Sister Kenny Rehabilitation Institute, and the challenges faced by providers and patients due to the lack of Medicare and some private insurance coverage.

Nancy Hutchison, MD, Medical Director of the Sister Kenny Lymphedema and Cancer Rehabilitation Program and chair of the Medical Advisory Committee of the National Lymphedema Network, gave a presentation about lymphedema, the gaps in coverage for lymphedema and the need for federal legislation.

The group heard the facts and read the statistics but what really drove the message home was the presence and story of Kris Maser, a Sister Kenny Rehabilitation Institute patient with lymphedema. Maser, a wife, mother, attorney and cancer survivor, has been a patient of Dr. Hutchison's for several years and wanted to help educate our officials on this disease. She told them her personal story, showed them what lymphedema looks like and demonstrated how she has to wear several types of garments, compression bandages and home lymphatic drainage to control her lymphedema.

It is Allina's hope that The Lymphedema Diagnosis and Treatment Cost Savings Act will once again be introduced at a federal level that starts to address some of the many concerns around this disease. The Health Policy staffers for the Minnesota Senators Klobuchar and Franken and Congressman Ellison stated that the information was very helpful. They recommended that other lymphedema providers and patients around the country hold similar meetings with their legislators and staff.

Learn more about lymphedema and the care provided by certified professionals at Sister Kenny Rehabilitation Institute on Allina.com.

The Sister Kenny Rehabilitation Institute at Allina Hospitals & Clinics is a national leader in lymphedema treatment. It has one of the largest lymphedema programs in the United States and is the only physician- directed multisite, multi-hospital lymphedema program in Minnesota with programs at eight Allina hospitals and nine Sister Kenny outpatient centers, with over 30 Certified Lymphedema Therapists on staff.

References from Painful Cording of the Arm:

Moskovitz AH, Anderson BO, Yeung RS, Byrd DR, Lawton TH, Moe RE. Axillary web syndrome after axillary dissection. Am J Surg. 2001; 181:434-439.
Leidenius M, Leppanen E, Krogerus L, von Smitten K. Motion restriction and axillary web syndrome after sentiniel node biopsy and axillary clearance in breast cancer. Am J Surg. 2003;185(2):127-130.
Lacomba MT, Orlando M, Coperias Zazo J et al. Axillary Web Syndrome after axillary dissection in breast cancer: a prospective study. Breast Cancer Res Treat 2009; 117: 625-630.
Craythorne E. Axillary Web Syndrome or Cording, a Variant of Mondor Disease, Following Axillary Surgery. Arch Dermatol, 2009; 145(10): 1199-1200
Reedjik M, Boerner S, Ghazarian D et al. A case of axillary web syndrome with subcutaneous nodules following axillary surgery. The Breast. 2006; Vol. 15, 411-413.
Lauridson MC, Christiansen P, Hessov I. The effect of physiotherapy on shoulder function in patients surgically treated for breast cancer: A randomized study. Acta Oncologies, 2005; 44: 449-457.
Opie EL. Thrombosis and occlusion of lymphatics. Journal of Medical Research 1913; 29: 131-146.
Kepics JM., 2004. Physical therapy treatment of axillary web syndrome[online]. Look Smart, Rehabilitation in Oncology. Available from:http://www.findarticles.com/p/articles/mi_qa3946/is_200401/ai_n9370189[Accessed 25 November 2005].
Mera K, Terasaki K, Kanzaki T, et al. Mondor's Disease of the Neck. Journal of Dermatology, 2009; 36: 179-180.
Marcus RT, Pawade J, Vella EJ. Painful lymphatic occlusion following axillary lymph node surgery. Br. J. Surg. 1990; Vol 77, 683.
Petrek JA, Senie RT, Peters M et al. Lymphedema in a Cohort of Breast Carcinoma Survivors 20 Years after Diagnosis. Cancer, 2001; 92, (6) 1368-1377.
Sagen A, Karesen R, Risberg MA. Physical Activity for the Affected Limb and Arm Lymphedema after Breast Cancer Surgery. A Prospective, Randomized Controlled Trial with Two Years Follow-up. Acta Oncologica, 2009; 48: 1102-1110.
Shaw C, Mortimer P, Judd PA. A Randomized Controlled Trial of Weight Reduction as a Treatment for Breast Cancer-related Lymphedema. Cancer, 2007; 110 (8) 1868-1874.
Boneti C, Korourian S, Diaz Z et al. Scientific Impact Award: Axillary Reverse Mapping (ARM) to Identify and Protect Lymphatics Draining the Arm During Axillary Lymphadenectomy. The American Journal of Surgery, 2009; 198, 482-487.

National Lymphedema Network, Inc.
116 New Montgomery Street, Suite 235
San Francisco, CA 94105
Hotline: 1.800.541.3259
Tel: 415.908.3681

Certification program info 2012

2011-05-07T14:47:00.000-07:00

Lymphatic Care Specialists, LLC

Carmen Thompson, B.S., LPTA, CMT, CLT

P.O. Box 1411

Christiansburg, VA 24068

540-357-2084

www.lymphedemahope.com

Carmen@lymphedemahope.com

Thank you for your interest in our IMLD/CDP certification program. We are happy to present our program as there is tremendous need for lymphatic drainage and lymphedema therapists in all areas of the country.

Courses are 8-5, Thurs, Fri, and Sat, and 8-2 on Sunday.

Certification includes all workbooks, hardback text, upper extremity and lower extremity bandaging kits, lab fees, certification exam and 140 ceu’s. Cost is $2495 for all four modules.

Advantages of our program: Our certification class is unique in that we offer perspectives on the varying treatment techniques and hand techniques taught by the different schools of thought in MLD. Another advantage is that our course is offered in sections and there is ample time between modules to practice techniques, study and to come to the next module prepared with applicable questions. If you take the course in Blacksburg, you also have the advantage of hands-on practice with actual in/outpatients in our clinics. There is no substitute for practice and feedback from actual clients! Lastly, we also study manual lymphatic drainage applications for many other indications than just lymphedema. We study lymphatic organ drainage and full body MLD to stimulate the immune system and bring relief to many suffering with auto-immune conditions such as lupus, chronic fatigue and fibromyalgia. We are recognized as an approved provider of MLD/CDP training programs by the National Lymphedema Network, www.lymphnet.org.

Basic MLD certification is available with modules I-III this will qualify practitioners to work extensively with conditions of the lymphatic system excluding disorders where there is a direct lymphatic pathology, i.e. cancer treatment of the lymph nodes, lymphnode removal, and types of edemas that require bandaging. This is ideal for those who work outside of a direct medical setting, i.e. massage therapists, and aestheticians.

Conditions that you would be able to safely treat with the certification include: Whole-body tissue detoxification, symptoms of lupus, arthritis, RA, osteoarthritis, Lime’s disease, chronic fatigue, fibromyalgia, aesthetics, cellulite, lymphatic facial detoxification, wrinkles, scarring, swelling due to surgical procedures and trauma and much more.

Complete MLD/CDP training is recommended if you want to treat more complex medical patients such as oncology patients, patients that have had lymph nodes removed or radiated, those with extensive vascular edema with skin deterioration/ulceration. This is really key to seeing big reductions in you patients with visible swelling disorders.

We will be teaching the full MLD/CDP 140 hour certification program in two or four modules, depending on your area.

Modules II, III, and IV will all be live seminars.

The dates for all modules are as follows: More courses being added! Please email for details.

Module I: This will include an extensive background/instruction in lymphatic anatomy/physiology, and all of the basic manual techniques. This module is a home study that you may begin at any time.

Module II: This will be a live seminar that will move on from the general introduction of the lymphatic system and superficial treatment to lymphatic drainage of the deeper tissues. These techniques can give you profound results with your complex clients. Next date is October 15^th weekend, 2011.

Module III: This will be a live seminar that will include specific treatment techniques of lymphatic disorders. We will also spend time on marketing your services, documentation and building your program.

CDP Module IV: This module will cover all of the basic compression bandaging principles as well as a certified garment fitter training program. Some complex bandaging techniques will be covered as well. This is especially helpful when limbs are not uniform shape and helps relate techniques to real-life applications.

This course will be specifically designed for those who want extensive training on compression bandaging techniques that have been proved to be so beneficial for swelling disorders. We will learn how to properly and safely wrap upper and lower extremities, as well as compression techniques for the trunk, genitalia and face. Each therapist will have the opportunity to complete a certification as a compression “fitter” for one of the major garment retailers at no extra cost.

We will also include a review of the previous three modules in preparation for the certification exam and discuss what the national LANA exam certification entails.

The cost of the MLD/CDP program is $2495 and includes three DVD’s, two texts a handbook for each module, MLD/CDP testing and certification, and the certified fitter program. A non-refundable $50 deposit is required to hold your spot in the course, along with the registration form. An additional $500 is due sixty days before the time of each module, with the balance of $945 due before the last module. Please see the registration form for more details.

*********

Lymphedema is just one of many disorders that you will be taught how to treat and manage in our program. It is an accumulation of lymph fluid between the tissue layers. This presents as swelling, or edema. Lymphedema can be present anywhere in the body.

Lymph fluid is rich in protein making the edematous area very thick and heavy feeling.

Treatment is necessary to not only move the fluid out of the area, but also the protein. If it is not treated, over time, the lymphatic vessels will stretch out permanently and external compression and treatment will be necessary for a lifetime to maintain proper pressure in the valves to move fluid more normally.

Secondly, when the vessels are full of this protein-rich fluid, there is less oxygen in the vessels, decreasing the rate at which wounds, surgery sites and skin ulcerations heal. This also puts the patient at risk of cellulitis, or infection of the bloodstream.

Many people report the first signs and symptoms of lymphedema as a feeling of tightness, or heavy feeling, decreased flexibility in the joints, and clothing or jewelry fitting tightly. Some patients only report strange sensations such as tingling or a crawling feeling on the skin.

What causes it?

There are two primary types of lymphedema. The first is primary lymphedema, or from birth. This is a congenital form of lymphedema caused by a malformation of thelymph vessels or nodes. It may present itself at birth, or later in life. Often it occurs when there are other cognitive impairments at birth as well, i.e. Down’s syndrome.

Secondary lymphedema is caused secondary to lymph vessel destruction, or lymphnode removal secondary to a disease process or a surgery. Oncology care including radiation, chemotherapy, surgery, tumors, infection, compromise of the vascular and immune systems, burns, liposuction and general trauma can all be contributing factors of lymphedema.

Lymphedema does not necessarily develop right after surgery. It can develop decades later!

Lipidema is a condition that is often confused with lymphedema. The patient presents with symmetrical excess size and fat from the hips to the ankles. The patient often looks disproportionately thin on the top half of the body and at the ankles. The lymphatic present in a corkscrew pattern in a lipidema patient trapping fat molecules, resulting in larger appearance and tenderness to touch. Often there are also large lobules of fat on the inside of the knee.

What does the lymphatic system do?

The lymph system is responsible for creating a homeostasis of fluid between the tissues and the general circulation of the body. The system also has very important immune functions, acting to filter toxins from the body by removing bacteria, viruses, foreign objects, and mutant cells.

How is lymphedema treated?

Lymphedema is treated by one or more of the following: Manual therapy, often called Manual Lymph Drainage, compression bandaging, compression garments, a specific self-massage protocol and impeccable skin care. Treatment for lymphedema should be given only by a certified lymphatic therapist who has graduated from a 135 hour certification program.

The nationally recognized standard of care for lymphedema consists of manual lymphatic drainage, or MLD, compression therapy including a multilayered bandage and/or compression garments, and a self-care program consisting of skin care, self-massage and lymphedema exercises.

The massage is extremely light in pressure, engaging the skin layer only to stretch the skin and cause a contraction of the lymphangion to move fluid and protein through the one-way valve system of the lymphatics.

The bandaging component to care is designed to get a good amount of volume reduction in a relatively short period of time. A bandage is worn 24 hours a day and changed daily, or every other day depending on patient proximity to the clinic. The patient’s day to day motions will not be restricted with the garment.

An intermittent pneumatic pump is not recognized as the standard of care for lymphedema, but is occasionally used when a patient does not respond to MLD and bandaging therapy. The pump works to gradually move fluid from the limb in segments. The downside of the pump is that is moves only the fluid component, not the protein component. This sometimes creates a cyclical dependency on the pump for daily maintenance.

After volume reduction has been met in the limb, the results will need to be maintained by use of self-massage, compression garments, exercise or a combination of these.

Summary: There is basically an untapped market in lymphatic therapy which is extremely beneficial and completely uninvasive for the patient while financially lucrative for rehabilitation facilities. Swelling disorders of all types can be helped with MLD/CDP therapy as long as the patient does not have any of the contraindicated pathologies.

Practical Applications of Manual Lymphatic Therapy

A cost effective way to increase patient outcomes

¨ Clinical applications of Manual Lymphatic Therapy-How does it work?

¨ Understand the anatomy and physiology of the lymphatic system and how it impacts a variety of diagnoses

¨ Learn the proper manual lymphatic techniques to increase and influence thelymph flow in the body

¨ How to assess and document for optimum reimbursement and identify proper audiences for marketing

If you’ve been a therapist for sometime, you have probably experienced “burnout” from time to time. You see the same diagnoses and do the same type of treatment, day after day, with often moderate outcomes. Have you ever had a patient whose pain level did not respond no matter what you did? What about the total knee patient who’s swelling doesn’t leave the joint no matter how much E-stim, ice, and retrograde massage you do? Do you see patients that are limited in gait or exercise due to swollen limbs? Are there patients with wounds that won’t heal? Are you often referred patients with Chronic Fatigues Syndrome, or Fibromyalgia that can not tolerate traditional therapies?

Therapy specifically targeting the lymphatic system is cutting edge. Only recently has lymphatic therapy been addressed in this country in conjunction with rehabilitation. The results from this kind of work are so successful because they are significant, measurable, and very often, quickly achieved. You will look at your patients with a new set of glasses upon your return to the clinic.

Course Content:

I. What is Manual Lymphatic Therapy?

A. How does it work?

B. Indications for MLT

C. Contra-indications for MLT

D. History of lymphatic therapy

II. Overview of lymphatic anatomy

Superficial Lymphatic

A. Deep lymphatic system

B. Plane barriers

C. Microcirculation

III. Pathologies of the lymphatic system

A. Primary lymphatic conditions

i. Congenital Malformations

B. Secondary lymphatic conditions

ii. Post breast cancer

iii. Venous edema

iv. Post prostate and other oncology care

v. Post-trauma including orthopedic surgeries and conditions

vi. Oral/Dental and Aesthetic applications including popular lypo-lymph drainage.

IV. How is lymphedema diagnosed?

Lymphscintigraphy

Symptomatic diagnoses

V. Clinical Applications in special populations

A. Varicose veins

B. Wounds

VII. Manual Lymphatic Therapy-Strokes and techniques

A. What strokes to use and when?

B. Treatment sequences per diagnosis

VIII. Alternate forms of treatments for edema

A. Bandaging

B. Compression garments,

C. Circ aid, Reid Sleeve

D. Lymphedema pumps

E. Exercises with edema,

F. Self massage

IX. Marketing

X. Identifying when it is not lymphedema

A. Lipidema

B. Chronic venous insufficiency

C. Menstrual edema

D. Ascites

E. Arterial insufficiency

XI. Documentation for optimum reimbursement

XII. Garment Problem Solving

XIII. In-depth compression bandaging protocol.

Case Studies-Real Patient MLD/CDP observation/clinicals. Our setting affords us the luxury of having you observe real patients in a clinical setting.

What you will learn

¨ An in depth knowledge of the anatomy of the lymphatic system

¨ Who will benefit from MLT/and or/CDP therapy

¨ Flow chart for deciding the plan of care

¨ How to treat certain types of lymphatic conditions and contraindications

¨ How to affect patient outcomes in general rehabilitation by adding MLT

¨ How to document for maximum reimbursement

¨ How to market to target audiences

Who May Attend:

Physical Therapists

Physical Therapist Assistants

Occupational Therapists

Certified Occupational Therapy Assistants

Registered Nurses

Massage Therapists

Aestheticians

Physicians

Physician Assistants

Nurse Practitioners

Nursing Home Administrators

Course Director

Carmen Thompson, BS, LPTA, CMT, CLT, is a Licensed Physical Therapist Assistant and Certified Massage Therapist with a specialty certification in Lymphatic Therapy. She also has a Bachelor’s Degree in Health Care Management. She has worked in a variety of health care settings over the last 14 years both clinically and in rehabilitation administration. She has specialized in program development in long term care settings. Currently, she teaches Lymphatic Pathology at the Blue Ridge School of Massage in Blacksburg, Virginia and works exclusively as a lymphatic therapist providing in and outpatient therapy to clients with a large varieties of diagnoses. She has conducted local and state presentations on the necessity of education of breast cancer survivors and their health care workers in the prevention of lymphedema.

FAQ’s for the Course

FAQ's For Module II

Where: Place/Days Inn Blacksburg, VA 24 Conference Rate of $69 http://www.daysinn.com/DaysInn/control/Booking/property_info?propertyId=11245&as_srp=SP2&cid=carat_search-Days_Inn

There are a couple of people from the massage school willing to host students for low cost. You would be driving about 20 mins in. Please contact me for details.

We have people coming from Ohio, NC, TN, VA, FL, PA, and GA. Please let me know if you are interested in a ride/share. I will try to assist as able.

Airport: The closest airport is Roanoke Regional. You may take the SmartBus from Roanoke to Blacksburg. Please check the schedule at http://www.smartwaybus.com/.

Meals: Breakfast is provided if you stay at the hotel. We break for lunch for one hour. There are many reasonable lunch places close by.

What to bring: A massage table, or yoga/exercise mat, blankets, pillows, lab clothes (sports bra), shorts, washable marker, masking tape, and a 3 ring binder.

What you should have completed when you come to Module II:

A good foundation/knowledge of the “Foundations of Manual LymphDrainage” book. We will review thursday morning, then be ready to start with new material after lunch.

A good knowledge of the concepts from the “Foundations” questions/homework from Module I.

A good knowledge of the general hand strokes based on the “Manual LymphDrainage for Body and Face” DVD.

You should have a START of recording your 10 manual practice sessions. These do not have to be checked off on until the last module. (Forms will follow with Module I registration).

You should have in your possession and bring:

Practical Applications of Manual Lymphatic Drainage Workbook

Zuther, Hardback text

Manual Lymph Drainage DVD

National Lymphedema Network, info packet (white envelope)

“Foundations of Manual Lymph Drainage”, book and questions

Lymph Evaluation Hours document.

Please let me know if you do not have any of these items.

Snow Policy: If I81/I77 are closed the night before class begins, the coursewill be cancelled and rescheduled. If roads are otherwise hazardous, but passable there will be a judgement call by the course instructor. Please call in if there is doubt. My cell: 540-357-2084. I will also leave a message at the front desk of the hotel. Refunds will not be issued, but you will have credit to attend another course.

We are going to have a great group!!

Notes from participants:

> Got it. Carmen, thanks again for an excellent learning experience. I did a
> basic MLD on R leg with my Oncology client who was experiencing swelling.
> her doc had given her diuretics but without results. Following the session
> we could see visual improvement and reduced swelling. I opened the neck
> area, taught her belly breathing and opened all axillary and inguinal nodes
>
>
> Got it. Thanks again for the wonderful learning experience. I had the
> chance to do a basic MLD sequence on the R leg on an oncology client today
> for swelling, arthritis and P! The results were visually noticeable by the
> end of session. Her doctor had given her diuretics ( low dosage) but they
> weren't helping. She seemed pleased with the results. After opening the
> neck I instructed her in deep belly breathing, opened all axillary and
> inguinal nodes (although I'm sure just R inguinal would have been
> sufficient), then drained her R leg (prox to dist and back). I got to use
> basic strokes, arc strokes and rotary strokes. I really enjoyed this and
> felt excited to have such a quick opportunity following class to reinforce
> the learnings and do something helpful. Carmen the clinical experience was
> invaluable to help me acquire the confidence to try these techniques with my
> clients. You work so hard for us to help get us adequately trained and I
> appreciate it beyond what my words can say. This class has been worth every
> penny and all the effort (including the car misadventure)!
>
> Andrea
>
> Carmen,
> Thanks for sharing this with us. Opportunities to gain this insight
> combined with the clinical hands on makes your course heads and tails above
> the others. My expectations are so exceeded! But by no means stop. I
> apologize if I should not have done a reply all on the first response - the
> hour was late ;-).
>
> One other question I would have for the client is which organs have been
> affect by the LYMF as it can be localized or widespread. Since the onset
> can be from childhood into adulthood I would want to know how long (she
> thinks) she has had it. If it is localized then perhaps rerouting might be
> an option - depending on what else she reveals.
>
> I hope you have time to share more on this person with us.
>
> > For His Glory,
>
> Joan
>

Lymphatic Care Specialists, LLC Course Registration

Please complete and return via fax to: 1-540-301-0750.

Registration closes one month before course start with a maximum of 25 applicants for the first module.

Cancellation policy: Refunds can be received up to 30 days before the course start with the reduction of a $50 processing fee. Within 30 days of course start, the amount can be credited toward a future course.

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2011-05-01T17:44:00.001-07:00

website at www.LymphedemaTreatmentAct.org.

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Greetings! I’m pleased to announce two wonderful additions to our website:

we now have a Resources for Patients page,
and a sampling of submissions to “My Lymphedema Story” can now be read on our Blog!

I’d also like to thank all those who have distributed the Lymphedema Treatment Act information cards. Please don’t hesitate to request these at any time. We are reliant on your help to spread the word.

And with reintroduction of the Lymphedema Treatment Act growing nearer, we need your help to obtain the endorsement of several important organizations: the American Cancer Society, the American Physical Therapy Association and the American Occupational Therapy Association. If you have not yet contacted these groups please take a moment to do so using these suggested messages and links.

American Cancer Society, SEND TO:

http://action.acscan.org/site/PageServer?pagename=Website_feedback– choose “Federal Issues and Campaigns”;
http://www.cancer.org/Aboutus/HowWeHelpYou/app/contact-us.aspx– choose whatever category you feel is most appropriate.
Please include: I hope the American Cancer Society will promptly endorse the Lymphedema Treatment Act (formerly HR 4662) when it is reintroduced in the 112^thCongress.
What and how much you say in addition to that is up to you, but if your lymphedema is the result of cancer make sure to include that.

American Physical Therapy Association & the American Occupational Therapy Association, SEND TO:

APTA - advocacy@apta.org; ATTN: Government Affairs Department
AOTA- http://www1.aota.org/contactus/contact.asp?deptid=12; select Federal Affairs from the drop down submission form
Please include: I hope that your organization will promptly endorse the Lymphedema Treatment Act (formerly HR 4662) when it is reintroduced in the 112^thCongress.
If you are an OT or PT it is extremely important that they hear from members of their own organization so please identify yourself as such; and if you are a patient being treated by an OT or PT make sure you note that in your email and ask your therapist to also contact the APTA/AOTA.

Thank you for your support and please let me know if you have questions,
Heather Ferguson
info@LymphedemaTreatmentAct.org

Axillary Web Syndrome By Joachim Zuther, on April 28th, 2011

2011-04-29T20:35:00.001-07:00

A number of patients who underwent axillary lymph node dissection (ALND) in combination with breast cancer surgery experience postoperative pain and limited range of motion associated with a palpable cord of tissue extending from the axilla into the arm on the same side.
This condition is known as Axillary Web Syndrome (AWS), or Cording Syndrome is little known in the medical field, and I am happy to publish an article on this condition written by a long-time friend and colleague, Linda Koehler. Linda is an expert in this field and also covered this topic extensively in the latest edition of my textbook “Lymphedema Management”. I am very proud to have Linda contribute as she is also one of my previous students.
Axillary Web Syndrome (i.e. ‘cording’)
By: Linda Koehler, PT, CLT-LANA, PhD candidate
Description and Symptoms
Axillary web syndrome (AWS) is a condition which appears following cancer surgery with axillary lymph node removal (i.e. breast cancer or melanoma).^1,2 AWS usually occurs within 2-4 weeks following surgery though it has also been identified in patients months to years after surgery.^3-5 The incidence of AWS ranges from 6-72%.^1,3 AWS appears as a cord of tissue just underneath the skin located in the axilla (i.e. armpit) and may run down the inside of the arm towards the elbow. It sometimes extends down as far as the hand near the thumb and also has been indentified along the side of the trunk underneath the arm. Restrictions in movement and pain often accompany this condition. The cord becomes tight with movement of the arm especially with shoulder abduction (bringing the arm out to the side). If the cord runs down the arm, elbow extension (straightening the elbow) and wrist movements can also be limited in addition to restricted movements of the trunk.
A person with AWS tends to experience pain and pulling sensation with movement of the arm especially shoulder abduction because this movement puts tension on the cord. There is usually little to no pain when the arm is at rest. It is common for a person to have good movement in the arm following surgery but then movement becomes limited and painful when the AWS cord begins to develop. The sudden onset of pain and limited movement may lead to anxiety and stress in someone who is already dealing with a cancer diagnosis. AWS appears to occur more often in people who are slimmer for reasons unknown.^1,3 It is speculated the cord is easier to identify in a person with a slim build because there is less fatty tissue to conceal the cord. It is possible AWS is present in obese patients, but the cord is not detectable because it is covered by fatty tissue. Another theory is the cord may not be able to adhere to fatty tissue therefore is less likely to occur in patients who are heavier set.
Physiology
The cause of AWS is still unknown but appears to be associated with lymph node removal therefore having a possible lymphatic involvement. The literature reports there is a higher incidence of AWS and a more extensive AWS cord with a higher number of lymph nodes removed.¹ The AWS cord appears to extend further down the arm in patients with more lymph nodes removed. It is speculated the cord is caused by a blockage in a vessel, lymphatic or venous, or by tightness in the surrounding tissue.^1,3 Biopsies of the cord have identified it as being a vessel, both lymphatic and venous, with more evidence suggesting lymphatic vessel involvement.^1,5,6 More research is needed to identify the underlying cause and physiology of AWS.
Therapeutic Approach
Some people believe AWS completely resolves on its own within about three months after surgery therefore treatment is not necessary.¹ Others believe the cord may not completely go away which may lead to long term movement restrictions and functional problems.^5,7,8 It appears treatment to the AWS cord may improve movement and reduce pain sooner than no treatment.^4,5,9
Pain medications such as non-steroidal anti-inflammatory drugs (NSAIDS) may be recommended dependent on the amount of associated pain.¹⁰ Since pain is often experienced with certain movements, some patients will avoid moving the arm. Lack of movement could lead to other problems such as soft tissue tightness and joint problems therefore avoiding movement is not recommended. Movement of the arm is encouraged but minimal to no pain should be experienced during the movement.
Rehabilitation treatment such as physical therapy has been used to treat the movement restrictions caused by the cord.^{4,5,7,9,11-13} The techniques include gentle stretching of the cord and surrounding muscles and soft tissue to improve movement. Manual techniques have been described as skin traction, cord bending, myofascial release, soft tissue mobilization, and scar releases. Gentle manual techniques are recommended to avoid lymphedema or reddening of the skin. At times, the cord has been reported to break with manual techniques which results in an immediate increase in movement. The breaking of the cord may be felt and heard by the patient and/or therapist. It is unknown what is actually breaking but it is speculated it could be the cord or the supporting tissue around the cord. It doesn’t appear there are any negative effects from breaking the cord since the patient sustains the sudden gain in movement. It is highly recommended therapists should be cautious when using manual techniques and avoid being too aggressive. Breaking of the cord is mentioned only to inform patients and medical professionals about the possibility of the cord breaking with gentle manual techniques. It is not recommended aggressive treatment techniques be used to purposively break the cord.
Further research is needed to fully understand the phenomenon of AWS, the physiology, and treatment.
References:
1. Moskovitz AH, Anderson BO, Yeung RS, Byrd DR, Lawton TJ, Moe RE. Axillary web syndrome after axillary dissection. Am J Surg. 2001;181(5):434-439.
2. Severeid K, Simpson J, Templeton B, York R, Hummel-Berry K, Leiserowitz A. Lymphatic cording among patients with breast cancer of melanoma referred to physical therapy. Rehabilitation Oncology. 2007;25(4):8-13.
3. Leidenius M, Leppanen E, Krogerus L, von Smitten K. Motion restriction and axillary web syndrome after sentinel node biopsy and axillary clearance in breast cancer. Am J Surg. 2003;185(2):127-130.
4. Koehler LA. Axillary web syndrome and lymphedema, a new perspective. Lymph Link. 18(3): 9-10; 2006.
5. Josenhans E. Physiotherapeutic treatment for axillary cord formation following breast cancer surgery. Pt_Zeitschrift für Physiotherapeuten. 2007;59(9):868 – 878.
6. Reedijk M, Boerner S, Ghazarian D, McCready D. A case of axillary web syndrome with subcutaneous nodules following axillary surgery. Breast. 2006;15(3):411-413.
7. Kepics JM. Physical therapy treatment of axillary web syndrome. Rehabil Oncol. 2004;22(1):21-22.
8. Koehler LA. Treatment considerations for axillary web syndrome. Proceedings of the Seventh National Lymphedema Network International Conference, Nashville, TN; 25; November 2006.
9. Wyrick SL, Waltke LJ, Ng AV. Physical therapy may promote resolution of lymphatic cording in breast cancer survivors. Rehabilitation Oncology. 2006;24(1):29-34.
10. Cheville AL, Tchou J. Barriers to rehabilitation following surgery for primary breast cancer. J Surg Oncol. 2007;95(5):409-418.
11. Fourie WJ, Robb KA. Physiotherapy management of axillary web syndrome following breast cancer treatment: discussing the use of soft tissue techniques. Physiotherapy. 2009;95(4):314-320.
12. Torres Lacomba M, Mayoral Del Moral O, Coperias Zazo JL, Yuste Sanchez MJ, Ferrandez JC, Zapico Goni A. Axillary web syndrome after axillary dissection in breast cancer: a prospective study. Breast Cancer Res Treat. 2009;117(3):625-630.
13. Koehler LA. Axillary Web Syndrome. In: Zuther, JE. Lymphedema Management, The Comprehensive Guide for Patients and Practitioners. 2^nd ed. New York, NY: Thieme Medical Scientific Publishers; 2009:70-72.

National Lymphedema Network Breast Cancer Related LE-Position Paper

2011-04-28T07:54:00.000-07:00

Dear Colleagues and Friends of the NLN,

It is with great pleasure that I am forwarding the latest NLN Position Paper "Screening and Measurements for Early Detection of Breast Cancer Related Lymphedema" written by the NLN Medical Advisory Committee in response to recent developments in breast cancer related lymphedema. The NLN remains committed to the early detection and treatment of all types of lymphedema.

The urgency in writing this paper for breast cancer related lymphedema is due to evidence indicating that early detection of latent breast cancer related lymphedema offers an opportunity to identify and treat lymphedema more successfully at an earlier stage. The National Accreditation Program for Breast Centers (NAPBC) has adopted the NLN guidelines for early detection of breast cancer related lymphedema. This NLN Position Paper allows the guidelines to be available to all patients, providers, and advocacy groups regardless of where breast cancer treatment is received.

This is vital new information for breast cancer survivors at risk for lymphedema. Please disseminate this document to anyone with a need to know the latest recommendations for breast cancer related lymphedema. We encourage patients and advocacy groups to give the document to their medical providers. Medical providers seeking more information regarding these guidelines can contact the NLN at nln@lymphnet.org.

Additionally, we would like to share with you a new book "Dr Vodder's Manual Lymph Drainage: A Practical Guide," written by Hildegard Wittlinger and other family members. The book provides excellent review references, a practical guide with detailed illustrations and photographs, and is a great new edition for new student and seasoned certified LE therapist, and physicians. You can read the book review for more information."Dr. Vodder's Manual Lymph Drainage" can also be order through the NLN store.

2011-04-25T11:18:00.000-07:00

Extra on the pathophysiology of lymphedema and lymphedema clinics

Posted in Diet, Eat, Food, Health | April 23rd, 2011

First – The function of the lymphatic system:
The core competencies of the lymphatic system are the elimination of excessive molecular weight proteins and immunological position (infections, cancer).
In the case of lymphedema, which remain excessive molecular weight proteins in the interstitial fluid, leading to an increase in interstitial oncotic pressure, leading to swelling.
The lack of substitution (the venous system is not able to remove these proteins), which explains the persistence of edema (engagement of proteins), and after diuretic therapy (which causes degradation of the effect on proteins).
Secondly – Implications of lymphedema:
This high protein promotes fibrosis and pores and skin infections.
The presence of proteins and stimulates collagen breakdown products of fibroblasts responsible exercise of fibrosis.
In lymphedema, there is a hyperplastic fibrosis, but no ulceration, in contrast to venous insufficiency.
Streptococcal bacterial cellulitis or lymphangitis often complicated lymphedema.
Lymphedema in the pores and skin changes are primarily the skin (increased strength, water retention), but subcutaneous (fat lobules of the subcutaneous tissue are larger).
Primary lymphedema of the child are often followed by lymphatic hypoplasia of width.
The networks are replaced to delay, in some ways, medical events take place, the place in an episode of genital life (puberty, pregnancy), trauma, surgery or irradiation.
Study of superficial lymphatic network in microlymphographie show expansion of the lymphatic system (primary lymphedema occurs after puberty) or with a complete superficial lymphatic aplasia (congenital lymphedema type I) or superficial lymphatic ectasia (congenital lymphedema Sun II).
Lymphedema scientific
Lymphoedema is very early in the neonatal period or at puberty or later, after 35 years.
The diagnosis is almost always easy in other parts of the newborn and infant (Chubby look at this age).
Secondary lymphedema is more proximal lymph congestion occurring constipation.
upper extremity is the classic “big guns” in the proximal radio-surgical treatment of early breast cancer.
Lymphedema usually with the first failure of the limbs begin.
Smaller branch, the event is of crucial importance to the top of the foot edema, which is “non-pitting” in the early forms, it is not constant.
The toes are stocky, with transverse folds marked, especially at the base.
Stemmer sign is pathognomonic of lymphedema of the lower extremity considered: it is a thickening of the skin and pores times, highlighted by pinching the top of the second toe.
Then deletes lymphedema talus (filling retromalleolar areas), what “public” one aspect of the leg.
This leads to fibrosis of the skin with fibrous papules, vegetation, and deep transverse wrinkles. Other displays are possible.
Lymphedema can be suspended up to the thigh.
It could be generalized to the genitals, or face.
In lymphoedema of the core members, only one will be reached to reduce each member or two more members, and members fall on the side of the same or opposite side.
Lymphedema of the lower extremities may reveal or accompany a enteropathy in a malformation of the lymphatic vessels (chyloed? Me, Waldmann syndrome or intestinal lymphangiectasia, lymphangiomatosis …) or an abnormality of the thoracic duct.
Kaposi’s sarcoma may occur before or accompanied by lymphedema.
In case of persistent venous insufficiency, lymphatic anomalies are observed.
The first dynamic lymphatic insufficiency, perhaps most of the time change in mechanics, lymph altered by venous stasis.
This could explain some anomalies scientific submit-thrombotic syndrome and untreated.
This could also explain the pathophysiology of fibrosis and a number of scientific anomalies seen in persistent edema, regardless of their activation …). (anasarca Elephantiasis Tropical

http://www.paparizouonline.com/extra-on-the-pathophysiology-of-lymphedema-and-lymphedema-clinics.html

2011-04-25T11:15:00.000-07:00

By the way. Friday I had a first visit with a hospice patient (I am a volunteer massage therapist) whose COPD is worsening. Nurse was hoping I could do anything for the crud he was unable to pull up from lower lobes. I spent 30 minutes beginning and ending with some focussed percussion. In between was 22 minutes or so of opening his clavicular lymph, the lung organ drainage and closing clavicular lymph. Within 7 or 8 minutes he coughed up enough crud so that he was impressed. When the nurse visited Monday he was still delighted to be feeling better and breathing better. Two fans ( at least) of the work! Yay!!! This is why I am doing this. Thank you, Carmen, from all concerned!

Diane

how to start a lymphedema support group

2011-04-12T08:01:00.001-07:00

www.lymphedemapeople.com/.../lymphedema_support_groups.htm

Lymphatic facilitation for upper extremety injuries

2011-03-29T09:07:00.001-07:00

http://www.nwata.org/storage/2011d10meeting/Lymphatic%20Facilitation%20-%20Pat%20Archer.pdf

National Lymphedema Network

2011-03-29T06:54:00.003-07:00

LymphLink Question Corner

January-March 2011
Catherine Tuppo, PT, MS, CLT-LANA

Q: Can you tell me if there are any new treatment techniques (discussed at the conference) that are being investigated for lymphedema?

A: While the standard of care remains Complete Decongestive Therapy (CDT) which incorporates skin care, manual lymph drainage, compression bandaging, compression garments, and exercise, presentations highlighted research investigating pneumatic compression, low level laser therapy (LLLT), aqua therapy, acupuncture, and surgery such as liposuction.

Researchers are studying the optimal design for pneumatic compression devices as well as protocols for application. Speakers discussed utilizing multi-chamber devices with varied methodologies. Several presented papers which utilized compression devices with both trunk and limb components for upper limb and lower limb edema, at lower compression settings. Another discussed tissue response at various compression settings for lower limb edema. Benefits were noted by each speaker based on the study methods presented.

The positive and negative effects of LLLT were debated in a pro and con session. Another speaker described a pilot study investigating the effects of treatment with LLLT and MLD. This pilot study (n=5) noted short-term improvements in tissue water and hardness with LLLT, but no long-term effects. The speaker clearly defined limitations of the study discussing that a more rigorous research protocol is needed with a larger subject population, before clinical inferences can be made.

One speaker discussed a study incorporating aqua therapy (pool exercise) for Phase 2 lymphedema treatment. Aqua therapy, in this context, was noted to improve adherence during the self management phase when compared to a conventional self management regime.

The use of acupuncture for lymphedema treatment has been considered somewhat controversial due to concerns for tissue injury and/or infection when the lymphadematous region (or area at risk) is utilized for insertion of the acupuncture needle(s). One paper investigated the rate of infection when acupuncture is applied to the involved or at risk lymphadematous segments. The speaker discussed that in this study (n=29), no incidents of infection were noted.

Several papers addressed the current state of surgical interventions for lymphedema management. One speaker reviewed liposuction as a treatment option for chronic lymphedema. The presenter noted that before an individual is considered a candidate for this type of surgery, he/she must have undergone the standard of care for lymphedema, CDT. After liposuction surgery, the speaker noted it is imperative that the patient wear custom compression garments at all times (24 hours a day, 7 days a week) in order for the limb reduction to be maintained. The patient may continue MLD and CDT after liposuction. More widely performed in Europe, liposuction for lymphedema management in the United States is less available.

It is exciting to see that research is moving forward in many areas. However, we must understand that additional research is needed in all of these areas before potential benefits and potential harms can be reliably demonstrated. Long-term follow up, case-control design, and larger subject populations will assist in bringing the rigor of the research forward.

Q: Have there been any further advances in the factors which may influence the development of breast cancer-related lymphedema?

A: Factors related to the development of breast cancer-related lymphedema continue to be studied in long-term research protocols. The influence of genetics on the development of secondary lymphedema is now being investigated. Specifically, researchers are interested in determining if there is a genetic predisposition for lymphedema in individuals who develop lymphedema after treatment for breast cancer.

Q: Is CDT or MLD (manual lymph drainage) effective for conditions other than lymphedema?

A: Therapists have been successfully applying the principles of CDT and MLD to other diagnoses. One presenter discussed the utilization of modified MLD, elastic taping and compression bandages, along with traditional modalities, for a patient after total knee replacement, noting improvements in edema, range of motion and pain. Another speaker discussed the beneficial application of MLD along with deep tissue massage (DTM) in the post-operative care of patients undergoing a variety of cosmetic surgeries involving different areas of the body (face, breast, abdomen, buttocks and thighs).

Q: Are there any new diagnostic imaging tests for lymphedema?

A: Lymphoscintigraphy and lymphangiography remain the primary diagnostic imaging techniques for lymphedema; however several studies discussed the use of NIR (Near Infrared Fluorescence Imaging) for visualization of lymphatic flow. NIR may have promise moving forward; however it is a costly test, and requires the injection of the imaging medium into the limb. Nonetheless, it does provide a dynamic view of lymphatic flow and may prove beneficial for use in investigational studies looking at the impact of various treatment techniques on lymphatic function.

Catherine Tuppo, PT, MS, CLT-LANA

Manual lymphatic drainage therapy in patients with breast cancer related lymphoedema

2011-03-24T10:46:00.000-07:00

http://www.biomedcentral.com/content/pdf/1471-2407-11-94.pdf

Course Comments

2011-03-14T18:42:00.001-07:00

Hi Carmen,
I took your continuing ed class in Saddle Brook, NJ last month. I have been curious about lymphatic drainage and wanted to learn some more about it to see if it would be something I should pursue further. I've decided I want to become certified. I wish I could come down to Virginia and take your course, but unfortunately that's not feasible.
Thank you Carmen for making my first exposure to lymphatic therapy such a positive one....it was a great class and it has inspired me.
Sincerely,
Laurie

2011-03-13T07:27:00.001-07:00

Carmen,
I hope you are doing well. My legs are doing great.

I have a question. When traveling instead of taking bandages to wrap or my overnight compression garments, can I just sleep in compression stockings? I’m going to visit my sister in California for a week. I don’t want to pack my overnight compression garments in my checked in luggage because of the cost of the garments in case they are lost and don’t want to stuff them in a carry- on bag because they are so heavy. I just wanted to make sure that compression stockings would work the same overnight to keep swelling down. If I’m traveling and in a car, I’ll take my overnight garments.

Thanks again for all the tips and products you educated me on. My legs feel better than they have in years.

Julie

Treatment of RIBP/Lymphedema by Joachim Zuther

2011-03-01T15:02:00.000-08:00

Treatment of RIBP in the Presence of Lymphedema

By Joachim Zuther, on March 1st, 2011

This is the second part of Radiation-Induced Brachial Plexopathy (RIBP) and Lymphedema. The last blog entry covered the causes and symptoms. This entry covers the treatment and how it relates to the presence of lymphedema.
How is RIBP treated?
Although surgical procedures to decompress the brachial plexus and re-vascularize the nerves and surrounding tissues have been described in the literature, the results are often unsatisfactory.
Unfortunately, RIBP is essentially an incurable condition and with the absence of satisfactory treatment, emphasis is placed on symptom control and therapeutic exercises specifically addressing the maintenance of movement in the paralyzed extremity for as long as possible. Physical and Occupational therapists work as part of a multi-professional team to address loss of function and flexibility, weakness, pain and lymphedema. Special adaptive equipment and techniques address basic functions of daily living and suggest ways to modify the home and workplace.
Special considerations to address RIBP in the presence of lymphedema:
Lymphedema management in patients with RIBP is more challenging, but absolutely necessary to help control pain and to decrease the volume of the extremity. Volume reduction lessens the impact of excess weight on the shoulder joint, prevents the build-up of additional fibrotic (scar) tissue and significantly lowers the risk of infections commonly associated with lymphedema. It is often necessary to adapt compression and exercise protocols to accommodate the special circumstances associated with RIBP.
Compression Bandaging: Many patients affected by RIBP experience impaired sensation on the skin and are often unable to provide accurate feedback related to their individual tolerance to pressure. Therapists applying compression bandages to the affected extremity during the initial sessions of Complete Decongestive Therapy should be very conservative with application pressure and use ample padding to avoid pressure sores; application pressure may be gradually increased in the absence of side effects.
Effective compression therapy for lymphedema partially depends on the extent of the interaction between the bandage layers and the musculature working against the resistance of the bandages; this is also known as the working pressure. With partial or complete loss of muscle activity, the working pressure of the bandage is reduced, making the bandage less effective. However, even if compression bandages are applied with less pressure and the day-to-day results of these bandages are not as noticeable, they are still effective in promoting lymphatic return by increasing the pressure in the tissues.
It is also important to consider that some RIBP patients wear arm slings to reduce the degree of subluxation and discomfort of the shoulder joint. In these cases, the elbow should be kept in 90 degrees of flexion during the application of compression bandages.
The possible presence of joint contractures caused by muscular atrophy and immobilization should be addressed with special bandage application techniques.
Compression Garments: The wearing of compression garments is essential to prevent lymphatic fluid from accumulating in the tissues and conserves the results achieved with Manual Lymphatic Drainage.
Compression sleeves and gauntlets are available in a number of compression classes. The level of compression within the different classes is determined by the value of pressure the garments produce on the skin; these pressure values are measured in units of millimeters of mercury (mmHg). For a compression garment to work effectively, the pressure needs to gradually decrease from the wrist to the shoulder. This gradient is necessary to avoid tourniquet effects and subsequent obstruction of lymph flow.
In general, compression levels provided by class 2 garments (30-40 mm/Hg) will be sufficient to prevent swelling in most patients affected by

Donning Device

lymphedema of the upper extremity. However, if lymphedema is combined with RIBP and partial or complete immobility with subsequent loss of normal muscle tone, a lower compression may be required in order to avoid tourniquet effects.
Patients need to be thoroughly educated in the use of donning devices for compression sleeves and alternatives for night bandaging (Solaris, CircAid, etc).
Exercises: Immobility is detrimental to the lymphatic return. In addition to support the return of lymph fluid, the main goal of the exercise protocol is to focus on mobility. Modifications to the usual decongestive exercise program may be necessary to address impaired motor function.

Arm Bike

Exercise protocols for RIBP with partial or complete loss of mobility are geared towards the development of strategies that compensate for lost muscle function by using those muscles that still have function. Specific exercises also help to maintain and develop any strength and control that remain in the affected musculature. This also helps to prevent further shortening of muscle fibers (contracture) and to maintain and regain range of motion in the arm. Elevating the arm as often as possible to promote lymphatic return is even more important in patients affected by RIBP.
Therapists and doctors may also suggest adaptive equipment that helps the patient to maintain a normal life. For a very comprehensive list if adaptive devices and coping tips, I would like to refer you to the RIBP page of the “Step Up – Speak Out” website.
Additional Resources:
BreastCancer.org Discussion Forum
Step Up – Speak Out
Medscape
Lymphedema People

Airplane Travel - NLN

2011-02-16T18:23:00.003-08:00

POSITION STATEMENT OF THE NATIONAL LYMPHEDEMA NETWORK

TOPIC: AIR TRAVEL

Air travel presents several considerations for individuals with lymphedema and for those at risk for lymphedema. It is the position of the National Lymphedema Network that:

␣ Individuals with a confirmed diagnosis of lymphedema should wear some form of compression therapy while traveling by air.

␣ Individuals at risk for developing lymphedema should understand the risk factors associated with air travel and should make a decision to wear compression based on their individual risk factors.

Rationale for the Use of Compression

The cabin pressure that is experienced during air flight is less than the atmospheric pressure on the ground. During flight, cabin pressure decreases from sea level to the low air pressure found at between 6,000 and 8,000 feet above sea level. The decreased pressure within the plane’s cabin may give rise to increased swelling in a lymphedematous limb as tissue pressures are physiologically altered. (1; 2) Changes in fluid production in the tissues occur when the external pressures exerted on the limb are changed. (3) Diminished pressure in the airplane cabin will result in a decrease in the fluid moved in to the lymphatic system. The fluid will remain in the extracellular spaces and an exacerbation of lymphedema may result. (4) The use of the compression garments will provide external pressure on the extremity to adequately support favorable resorption and decrease the potential for fluid accumulation in the tissue. (5) The use of compression may prevent worsening of pre-existing lymphedema and is recommended for those with lymphedema during air travel. (6) Compression bandages will potentially increase the interstitial tissue pressure and enhance the muscle pump in the lymphedematous extremity. The beneficial outcomes are two-fold. First, resorption of fluid at the capillary level is enhanced due to the compression. Second, the garment or bandages stimulate the lymphatic system, via the muscle pump, and uptake of extracellular fluid increases, helping to prevent an exacerbation of lymphedema.

Definition of Individuals At-Risk for Lymphedema

People at risk for lymphedema are individuals who have NOT yet displayed signs and symptoms consistent with a diagnosis of lymphedema but have a known insufficiency of their lymphatic system. This includes people who have undergone removal of lymph nodes or radiation therapy, which increases the risk for developing lymphedema. At-risk individuals have altered lymphatic function that may impede the body’s ability to take up excess fluids that escape into the tissues. Individuals at risk should pay close attention to changes in sensations of their extremities, such as heaviness, fullness of aching that may signal the onset of lymphedema from an airline flight.

People who are at risk for lymphedema should take precautions when flying and should consider compression to the affected limb. A medical compression garment should be recommended and sized by a health care practitioner who is experienced in garment fitting.

Other Considerations for Air Travel

In addition to alterations in air pressure, several other factors may contribute to an exacerbation of lymphedema during travel. Air travel is sedentary in nature, which causes blood and lymphatic circulation to slow. This may precipitate an exacerbation of selling as fluid pools in a dependent extremity. All individuals traveling by plane are advised to move their limbs frequently to help prevent swelling. Standing and moving around the cabin frequently will encourage improved uptake of extracellular fluid and help prevent further accumulation of fluid in the tissues.

NLN ♦ 116 New Montgomery Street, Suite 235 ♦ San Francisco, CA 94105 Tel: 415-908-3681 ♦ Fax: 415-908-3813 Infoline: 1-800-541-3259 ♦ Email: nln@lymphnet.org ♦ Online: www.lymphnet.orgNLN Position Paper: Air Travel Page 2 of 4

Lifting and carrying heavy luggage may cause stress on muscles in an involved or high-risk limb, increasing the risk of swelling. Bags with shoulder straps can cut across lymphatics in an upper extremity increasing the risk to an affected arm. Using roller bags or having assistance with bags is strongly encouraged.

Another factor influencing fluid dynamics in an extremity is dehydration during travel. (8) Ambient air in the passenger cabin of a plane is dry and may increase the potential for dehydration. Without adequate fluid intake the blood capillary pressures may alter. Dehydration of the lymphedematous limb may increase protein concentration in the tissues resulting in increased ultrafiltration of fluid from the blood into the extracellular spaces and potentially contributing further to swelling in the affected limb.

Based on the risks described above, the National Lymphedema Network offers the following guidelines for air travel:

For Individuals With A Confirmed Lymphedema Diagnosis

Regarding Compression Garments, persons with lymphedema should:

␣ Obtain a well-fitted compression garment for air travel. ␣ Obtain the garment well in advance of the trip and wear it several times to ensure proper fit and

comfort. ␣ For most upper extremity lymphedema conditions compression of at lease 20-30 mmHg is

recommended. ␣ For most lower extremity lymphedema conditions, compression of at least 30-40mmHg is

recommended. ␣ A hand piece, either a glove or a gauntlet should be worn with the compression sleeve. ␣ Place the garment on before take-off. ␣ Leave garment on for 1-3 hours after deplaning to allow tissue pressures to equilibrate.

Regarding Compression Bandages

During air travel, certain individuals may require the added compression afforded by bandaging. These persons should:

␣ Be trained by a lymphedema specialist in appropriate bandaging techniques. ␣ Apply the compression bandages before flying. ␣ Leave the bandages on until you reach your final destination. ␣ While away from home, continue your regular schedule of garment and bandage wear.

For Individuals at Risk for Lymphedema

Each person must make an individual choice based on risk factors associated with their own medical history. The NLN recommends that at-risk individuals make an informed decision in conjunction with their health care provider. If an individual choose to obtain a compression garment, follow the recommendations as above.

For All Individuals Traveling

Regarding seat Assignment, Airport Regulations and Airline Choice:

␣ Persons with lower extremity lymphedema should consider a seat with increased leg room, such as a bulk-head or first class seat if possible.

␣ A note from your physician regarding your lymphedema may help answer security questions related to your bandages or compression garments.

␣ Newer jetliners such as Air Bus, A380 or Boeing Dreamliners are able to maintain higher cabin pressure with more humidified air, and may improve comfort.

NLN Position Paper: Air Travel Page 3 of 4

Regarding Activity

␣ Avoid carrying heavy bags or using shoulder straps on the affected arm. ␣ Use roller bags or obtain assistance for carrying, lifting and transporting luggage. ␣ Wear loose fitting, non-constricting clothing. ␣ Move about the cabin frequently if possible to enhance contribution of the “muscle pump”. ␣ Throughout your trip, try to avoid excessive activities of the type that tend to exacerbate your

swelling, take frequent breaks for rest and elevation, and get adequate sleep.

Regarding Dietary and Medical Concerns for Individuals with Lymphedema and Those At Risk

␣ Ensure adequate fluid intake during flight and throughout your trip. ␣ Maintain healthy eating habits, minimizing alcohol, caffeine and salty foods. ␣ Consider bringing antibiotics with you, especially when travelling outside the U.S. or if you have

a history of cellulitis in the affected limb. ␣ Wear a LYMPHEDEMA ALERT Bracelet (upper extremity) and/or necklace (lower extremity).

Note: The aforementioned recommendations are to serve as guidelines and cannot guarantee the prevention of Lymphedema in those at-risk, or worsening of Lymphedema in those with swelling. Each person’s medical status may affect their response to air travel. Consultation with a physician and/or a Lymphedema therapist prior to travel may be beneficial.

Treatment of Lymphedema- NLN

2011-02-16T18:23:00.001-08:00

POSITION STATEMENT OF THE NATIONAL LYMPHEDEMA NETWORK

By: NLN Medical Advisory Committee Updated February 2011

TOPIC: THE DIAGNOSIS AND TREATMENT OF LYMPHEDEMA

Introduction

Lymphedema is caused by an abnormality of the lymphatic system leading to excessive

build up of tissue fluid that forms lymph, known as interstitial fluid. Stagnant lymph fluid

contains protein and cell debris that causes swelling of affected tissues. Lymph is

responsible for transporting essential immune chemicals and cells. Left untreated,

lymphedema leads to chronic inflammation, infection and hardening of the skin that, in

turn, results in further lymph vessel damage and distortion of the shape of affected body parts. 1‐4,199,201

Interstitial fluid can build up in any area of the body that has inadequate lymph drainage and cause lymphedema. Lymphedema is a condition that develops slowly and once present is usually progressive.143,192 People can be born with abnormalities in the lymphatic system. This type of lymphedema is known as Primary Lymphedema. Depending on how severe the condition is, swelling can be present at birth or may develop later in life.198 Most lymphedema in the United States is Secondary Lymphedema. This type of lymphedema occurs from damage to the lymphatic system, commonly from cancer and its treatment but also from trauma to the skin such as from burns or infections. 5,189 Lymphedema after breast cancer has been studied the most, but lymphedema can occur as a result of other cancers, including melanoma, gynecologic cancer, head and neck cancer and sarcoma.76‐78, 185‐187 The overall risk of lymphedema for all cancers is reported to be 15.5%.186 The risk of developing lymphedema does not diminish over time but is a lifelong risk. 6, 143 Progressive lymphedema is complicated by recurrent infections, non‐healing wounds, discomfort or pain, difficulty with daily tasks, emotional and social distress.7‐9

Effective treatment for lymphedema is available. Early diagnosis is important since treatment is most effective when lymphedema is diagnosed at the earliest stage.188,193,194 Every patient with lymphedema should have access to established effective treatment for this condition. Lymphedema has no cure but can be successfully managed when properly diagnosed and treated.

NLN116 New Montgomery Street, Suite 235San Francisco, CA 94105 Tel: (415) 908‐3681Fax: (415) 908‐3813 Infoline: 1 (800) 541‐3259Email: nln@lymphnet.orgOnline: www.lymphnet.orgNLN Position Paper: The Diagnosis and Treatment of Lymphedema Page 2 of 31

Diagnosis of Lymphedema

Since lymphedema is progressive and early diagnosis leads to more effective treatment, the diagnosis of lymphedema at the earliest possible stage is very important. Treatment of lymphedema is based on correct diagnosis. Many conditions that cause swelling (edema) are not lymphedema. True lymphedema is swelling caused by abnormality in the lymphatic system. Lymphedema can also co‐exist with other medical and swelling conditions. Correct diagnosis of lymphedema may require evaluation by a physician or other health‐care provider with expertise in lymphedema who can, when needed, performspecializeddiagnostictesting.10,198 Diagnostictestsforlymphedemacome under the following categories:

 History and physical examination  Soft tissue imaging  Lymph vessel and lymph node imaging  Measures of volume  Changes in electrical conductance  Changes in biomechanical properties  Genetic testing  Other vascular imaging  Blood tests for other conditions that can look like lymphedema

History and Physical Examination

A history and physical examination by a health‐care provider who has experience with diagnosis and treatment of lymphedema is important for all patients with chronic swelling.193,194,198 Primary and Secondary lymphedemas have characteristic features that can be seen over time. The history should include age of onset, location(s) of swelling, pain and other symptoms, medications that can cause swelling, the course of progression of the swelling, and factors associated with swelling onset such as cancer, injury, or infection. A family history is important to the diagnosis of inherited forms of lymphedema. The physical examination includes an assessment of the vascular system (lymphatics, veins and arteries), skin and soft tissues in the swollen body part(s), palpation of lymph nodes, and looking for changes in body systems associated with various forms of inherited lymphedemas.181,182,202 Diagnostic tests and imaging must be paired with the information from the history and physical examination to make a correct diagnosis. For trunk, breast, genital, head and neck lymphedema, the history and physical examination is the currently accepted method of diagnosis.76,78

Soft Tissue Imaging

Magnetic resonance imaging (MRI), computed tomography (CT) and some types of ultrasound (US) are able to detect the presence of extra fluid in the tissues.159,160,170 Fluid that is outside of cells (extracellular) and also outside of vessels (extravascular) is called tissue fluid or interstitial fluid. Lymphedema is one type of interstitial fluid build up that occurs when fluid is not being removed effectively by the lymph vessels. MRI, CT

NLN Position Paper: The Diagnosis and Treatment of Lymphedema Page 3 of 31

and US can show the presence of increased interstitial fluid but cannot tell the cause. These imaging techniques have to be put together with history, physical examination and sometimes other imaging tests.194 Other conditions such as heart failure or low proteins in the blood from liver disease or malnutrition can cause fluid to build up in the tissues. MRI, US and CT scans may be required to determine the cause of lymphedema, especially if there is a concern that the lymphedema might be the result of an untreated cancer.

Lymph Vessel Imaging

Lymphoscintigraphy is a nuclear medicine study used for imaging lymph vessels and lymph nodes.195 Radio‐labeled particles of protein are injected just under the skin of the area of the body to be imaged. Usually technetium labeled sulphur colloid is used. Lymphoscintigraphy is accurate for detecting abnormalities of the lymphatic system in the extremities regardless of the cause.163,165,189 It demonstrates slow or absent lymph flow and areas of reflux (backflow). Lymphoscintigraphy can reveal abnormalities of lymph uptake in lymph nodes with some forms of lymphedema.168 Lymphoscintigraphy can predict response to treatment.167 Lymphoscintigraphy shows the main, larger lymph vessels and nodes. It shows the basic architecture of the peripheral lymphatic system. It does not show the deep transport lymph vessels carrying lymph from the nodes back to the blood circulation. Lymphoscintigraphy identifies lymphatic abnormalities at a late stage, after lymphedema has occurred. The type of lymphoscintigraphy done for the diagnosis of lymphedema is not available at all radiology departments. Most radiology departments, however, can do a form of lymphoscintigraphy used to identify the sentinel lymph node for cancers such as breast and melanoma. These studies for the sentinel lymph node are different from the lymphoscintigraphy studies done for diagnosis of lymphedema. Before undergoing a lymphoscintigraphy study the patient should inquire if the radiologist performing and reading the study has a large amount of experience with lymphoscintigraphy studies for the diagnosis of lymphedema. Lymphoscintigraphy, in combination with other vascular studies, can differentiate venous edema from lymphedema.190,196 Lymphoscintigraphy may not be necessary in some forms of secondary lymphedema where the diagnosis is clear from the history and physical examination or other imaging. In order to diagnose primary lymphedema, however, a lymphoscintigraphy must be done. Especially in children, a detailed study must be done that includes all potential areas of involvement and the contralateral normal limb or body part for comparison.166,169 These studies must be done by a radiologist familiar with primary lymphedema and genetic forms of edema. In children being evaluated for lymphedema, other vascular and imaging studies are necessary because primary lymphedema can occur in combination with many vascular abnormalities and other organ defects. The specific tests needed should be determined by a specialist in lymphedema.

A new technique for imaging lymph vessels is Near Infra‐Red Florescence Imaging (NIR) using a substance known as indocyanine green (ICG).82,171‐175 The ICG is injected into the skin and immediately imaged with a dynamic (real time) infrared florescence camera.

NLN Position Paper: The Diagnosis and Treatment of Lymphedema Page 4 of 31

With NIR‐ICG, even very small lymphatic vessels can be seen. The study is dynamic which means that the actual function of the lymphatic vessels can be analyzed. Diseased lymphatics that do not contract (or pulse) normally can be seen with NIR‐ICG. ICG is a green dye that has been used safely in other areas of the body such as the liver and eyes. It can be used in very small amounts to image the lymphatics. NIR‐ICG can diagnose lymphedema and find abnormalities at an early stage, possibly before swelling is obvious. Although this technique shows promise for the diagnosis of lymphedema, it is currently available at very few centers, most of which are involved in research.

Measures of Volume

Measures of limb (arm and leg) volume have been the standard way of detecting lymphedema for years and have been shown to be accurate when properly done.156,157,161,170 Enlargement of the limb (increase in volume) is the end result of fluid building up in the tissues. Therefore, volume measurements are used to quantify the presence and severity of lymphedema and follow the response to treatment. Volume is measured by 3 main methods: tape measurements, perometry, and water displacement.170 Tape measurements are taken at defined intervals, using geometric formulas to calculate the total volume. This technique can be accurate if it is done in precisely the same way each time, and is most accurate when the same person takes the measurements each time. Perometry uses an infra‐red optical electronic scanner and computer to calculate the volume of the body part. Perometry is accurate if the body part is positioned exactly the same way each time and the machine has been calibrated for accuracy. Perometry has been used for a decade in research on lymphedema and has been accurate when compared to the long used ‘gold standard’ of water displacement.149 Perometry has been demonstrated to detect as little as a 3% change in limb volume in breast cancer survivors followed over time.207 Water displacement, the bench ‘gold standard’ for assessing volume, is rarely used these days due to its inconvenience. The body part to be measured is immersed in a large cylinder and the water that is pushed out (displaced) is measured. All of these volume methods are effective and accurate when done properly.170 They are most accurate on arms and legs. Measures of volume cannot differentiate lymphedema from other types of edema and do not determine when temporary post‐operative arm edema becomes chronic lymphedema. Although tape measurements have been developed for head and neck,78 they are not true volume measurements, nor have they been standardized. They are best used for following the effects of treatment rather than making a diagnosis.

Electrical Conductance Testing (BIS)

Bioimpedance Spectroscopy (BIS) is a method for measuring water content in tissues. It has been used for many years to assess the total water content of the body and body composition for fitness and weight loss purposes. BIS is now available to measure interstitial fluid as a component of assessment leading to the diagnosis of lymphedema.144,148,149 BIS has been shown to provide reliable data to be used in the diagnosis of breast cancer‐related lymphedema.150 BIS can detect early changes associated with lymphedema. 162,164 BIS is done by passing a small, painless, electrical

NLN Position Paper: The Diagnosis and Treatment of Lymphedema Page 5 of 31

current through the limb and measuring the resistance to current (impedance). The machine uses certain electrical current frequencies to determine if more fluid exists as compared to the contralateral limb. It does this by comparing the difference in resistance to electricity passed through interstitial fluid compared to intracellular fluid. BIS currently is done on the whole limb since the resistance to current flow for standard technique is calculated to the length of the body part. The higher the water content in the interstitial tissue, the lower the resistance (impedance). BIS may show promise for detecting smaller areas of localized lymphedema, but this application has not been subjected to adequate study to recommend it.206 BIS is not as accurate in advanced, fibrotic edema. As in measures of volume, BIS cannot differentiate lymphedema from other types of edema and does not determine when temporary post‐operative arm edema becomes chronic lymphedema.145,170,191.

Changes in Biomechanical Properties of Tissues

Lymphedema causes the affected skin and subcutaneous tissues to become inflamed and hardened (fibrotic).199 Lymphedema is graded clinically, not just by increased size or volume, but also by the progressive change in the skin texture as it becomes denser and harder.10,158 Currently, these skin changes are documented by physical examination of tissue texture, pitting, enlarged skin folds and other dermatologic conditions such as wounds or papillomas (benign growths on the skin in areas of lymphedema). Methods available for measuring skin texture and resistance quantitatively are: tissue dielectric constant151‐153 and tonometry.148,152,154,155 The tissue dielectric constant is a measure of tissue water content. The test is performed with a device that passes an electrical current of a specific frequency to one location of the skin and measures the reflected wave that returns. The reflected wave form indicates the amount of water present in the tissue. Tonometry uses a device that measures the amount of force required to indent a tissue which gives a specific measurement value to the degree of firmness or fibrosis. There are some technical difficulties to the use of these tools and a number of environmental factors and operator differences can give variable values. These measures of the biomechanical properties of tissues are important for research. Hopefully continued development will lead to better tools for clinical use so that diagnostic methods will include quantitative methods of skin and subcutaneous tissue changes associated with progressive lymphedema.

Genetic Testing

For patients who have been diagnosed with primary lymphedema, genetic counseling and genetic testing may be appropriate. 176‐178,184,202 All young children diagnosed with primary lymphedema should have a karyotype test performed. The karyotype determines the presence of chromosome abnormalities such as Turner’s syndrome that can be associated with lymphedema. Other types of primary lymphedema involve specific genes. For example, Milroy’s disease has a specific defect of the FLT4 gene that is responsible for producing a protein called vascular endothelial growth factor receptor 3 (VEGFR‐3). The FOXC2 and SOX18 genes are also associated with lymphedema. Most forms of inherited lymphedema are not detected on gene or chromosome tests.

NLN Position Paper: The Diagnosis and Treatment of Lymphedema Page 6 of 31

Children diagnosed with primary lymphedema should be referred to a Medical Geneticist or a Genetic Counselor to determine which tests are indicated for that child’s condition. With late onset of primary lymphedemas, genetic testing is of limited benefit, but Genetic Counseling may be offered on a case‐by‐case basis.

Other Vascular Imaging

Some forms of edema are caused by diseases or abnormalities in the cardiovascular system (heart, arteries veins). For children, and some adults, diagnosed with primary lymphedema, it is important to evaluate for other vascular abnormalities.179,180 Conditions such as congestive heart failure, vein clots known as deep venous thrombosis (DVT), damaged vein valves known as venous insufficiency, and some arterial conditions can lead to swelling or exist concurrent with lymphedema. With secondary lymphedema from cancer, obstruction of a vein can contribute to the severity of edema.196 Imaging studies of the heart, veins or arteries may be needed to get a complete and accurate diagnosis of the cause and proper treatment for edema.190 The most common cardiovascular studies ordered for the evaluation of complex edemas are: echocardiogram, venous ultrasound and arterial ultrasound with ankle brachial index (ABI). Ultrasound studies of veins looking for a clot can be done lying down. To accurately diagnose venous insufficiency (incompetent valves) the ultrasound must be done standing or on a tilt table that can be tipped into a standing position (for patients who cannot stand for the test). If there is a concern for abnormalities of blood vessels in the chest, abdomen or pelvis, more advanced imaging, such as computed tomography venograms or arteriograms, may be recommended.

Other Diagnostic Tests

There is no blood test for lymphedema. Other medical conditions such as hypothyroidism (myxedema) or low protein (hypoproteinemia) can cause edema and need to be done in a complete evaluation of swelling. Standard plain x‐rays may be ordered for some inherited lymphedemas to evaluate for orthopedic conditions.182,183

Treatment of Lymphedema: Complete Decongestive Therapy (CDT)

Complete Decongestive therapy is also called Combined, Complex or Comprehensive Decongestive Therapy. All refer to the same method known as CDT. CDT is the main treatment for lymphedema. Experts who treat lymphedema consider CDT the “gold standard” of treatment.11,12 CDT has been shown to be safe and effective. 13‐19,197 CDT consists of an initial reductive phase (Phase I) followed by a maintenance phase (Phase II). 11, 20‐23 In Phase I, the main goals are reducing the size of the affected part and improving the skin. After Phase I, the person with lymphedema needs to continue into Phase II, an ongoing, individualized self‐ management phase to make sure the gains of Phase I are maintained long term.24

NLN Position Paper: The Diagnosis and Treatment of Lymphedema Page 7 of 31

Effects

of CDT are to:

1. decrease swelling25,26 2. increase lymph drainage from the congested areas27,28 3. reduce skin fibrosis and improve the skin condition1 4. enhance patient’s functional status29 5. relieve discomfort and improve quality of life8,25,26,30‐34 6. reduce the risk of cellulitis and Stewart‐Treves‐Syndrome, a rare form of

angiosarcoma35‐45,197

Components of CDT

1. manual lymph drainage (MLD) 2. multi‐layer, short‐stretch compression bandaging 3. lymphatic exercise 4. skin care 5. education in lymphedema self‐management, and elastic compression

garments22,46

Frequency and Duration of Phase I (Reductive) CDT

Optimally, CDT is performed daily (5 days/week) until the reduction of fluid volume has reached a plateau, which can take 3 to 8 weeks. 22,47 Some patients may have good results from CDT with modifications of the frequency and duration of treatment.49 CDT frequency and duration should be individualized to produce the greatest reduction of swelling and improvement of skin condition in the shortest period of time.

Maintenance (Phase II) CDT

At the completion of Phase I CDT, the person with lymphedema is set up on a self‐ management program that includes self‐lymph drainage (sometimes called Simple Lymphatic Drainage), home lymphatic exercises, a skin care regimen, and compression garments or bandages that the individual learns to apply. Some individuals may require additional measures at home to maintain the gains achieved in Phase I. These measures may include garments with Velcro, specialized foam construction garments, and pneumatic compression devices.136 Phase II maintenance must be monitored and changed periodically, just as treatment for any other chronic medical condition. Compression garments must be replaced every 4‐6 months to be effective. Specialized equipment requires maintenance and replacement according to manufacturers’ guidelines. Phase II CDT and periodic medical monitoring are essential to the long‐term success of lymphedema treatment.16,22‐24

Therapist Training

Therapists providing CDT should have completed at least 135 hours of training as recommended by the Lymphology Association of North America® (LANA®). (See NLN Position Paper: Training of Lymphedema Therapists.205) Additional specialty training

NLN Position Paper: The Diagnosis and Treatment of Lymphedema Page 8 of 31

may be required for therapists treating facial, truncal, and genital lymphedema, or lymphedema in people with complex illnesses or disabilities.

Manual Lymph Drainage (MLD)

Manual lymph drainage is an essential part of CDT. It is a specialized manual (hands‐on) technique that appears to work by two mechanisms. It stimulates superficial lymphatic vessels to remove excess interstitial fluid and it moves it through subepidermal (under the skin) fluid channels that form when lymphatics are damaged. 47,201 Some people refer to MLD as massage, but it is different from the usual types of muscle or myofascial massage commonly known to the public. MLD is a light, skin technique learned by certified lymphedema therapists designed to improve fluid removal from congested areas where the lymphatics are not working properly and into lymph vessels and lymph nodes that are functioning.48

Compression Bandaging

Compression bandaging refers to a specific technique54 utilizing multiple layers of several materials to create safe and effective gradient compression. The necessary components of compression bandaging are:

1. Tubular bandage lining 2. Digit bandages 3. Polyester, cotton, or foam under‐cast padding 4. Multiple layers of short‐stretch bandages with 50% overlap and 50% stretch to

cover the entire limb

In some patients, it is also necessary to utilize polyurethane foam in various densities and configurations within the bandaging system. These materials are applied according to standard technique to body parts with lymphedema. Short‐stretch bandages have limited stretchability when pulled. They can stretch 40‐60% from resting length, compared to long‐stretch bandages such as Ace® bandages that stretch to greater than 140% of resting length. To achieve an effective compression gradient, short‐stretch bandages must be strategically applied with low‐to‐moderate tension using more layers at the ends of the extremities than higher up.50‐55 Pressure within the short‐stretch bandages is low when the patient is not moving (“resting pressure”). Muscle contractions increase interstitial fluid pressure to assist the fluid to move out of congested areas (“working pressure”), as muscles expand within the limited space of the short‐stretch bandages.56 The cycling between low‐resting and high‐working pressures in the interstitial fluid areas under the bandages creates an internal pump‐like action. This action encourages movement of congested interstitial fluid into the vascular circulation. The short‐stretch bandages also prevent refilling of the fluid into the tissues. Another property of short‐stretch bandages is to reduce the tissue hardening (fibrosis).1 Compression Bandaging is always a part of Phase I CDT. Some individuals with more severe forms of lymphedema may need to use home compression bandaging longer term as part of Phase II. Some locations of the body, such as the head and neck, are not

NLN Position Paper: The Diagnosis and Treatment of Lymphedema Page 9 of 31

amenable to standard short‐stretch bandaging so other compression techniques have to be used.204

Exercise (including lymphatic “Remedial Exercise”)

With lymphedema, specific exercise is beneficial for all patients.203 Although heavy activity may temporarily increase fluid load, appropriate exercise enables the person with lymphedema to resume activity while minimizing the risk of exacerbation of swelling.29,57‐60,139 For people who have lymphedema, compression garments or compression bandages must be worn during exercise (except in aqua therapy) to counterbalance the build up of interstitial fluid.58,61 (See NLN Position Paper: Exercise for Lymphedema Patients.205) Since exercise has been shown to have major positive effects during and after cancer treatment, safe exercise must be a goal for all cancer‐ related lymphedema.60,62 For other forms of lymphedema, exercise also has positive effects. People with or at‐risk for lymphedema are encouraged to work with a lymphedema specialist to incorporate an individualized exercise program into lymphedema management.

Skin and Nail Care

Meticulous hygiene is recommended to decrease the amount of fungus and bacteria on the skin. Low pH moisturizers should be applied to keep skin from drying and cracking.63 Cracks and dry areas of the skin are entry points for bacteria and fungus, which can result in infections and wounds.64,65 Skin infections are known as cellulitis (or erysipelas). Cellulitis is a serious infection of the skin that requires antibiotic treatment in people with lymphedema.36‐38 (See NLN Position Paper: Lymphedema Risk Reduction Practices.205)

Compression Garments

Following achievement of maximal volume reduction with Phase I CDT, patients should be fitted with a compression garment. The patient should receive two garments at a time for each affected body part: one to wear and one to wash and dry. Having two garments insures that the patient does not wear a dirty or wet garment which promotes bacterial or fungal infection. Garments may be sleeves, stockings, bras, compression shorts, face or neck compression wear, etc. The type of garment depends upon the body part with lymphedema. Properly‐fitted garments are essential for long‐term control of lymphedema.4,66 Garment style and compression strength should be prescribed according to the patient’s ability to manage the garment and maintain the best volume control and skin health. 67 Ready‐made garments come in a variety of sizes and can be fitted to many individuals. Custom garments are made specifically for the individual who cannot fit a ready‐made garment. They are more expensive than ready‐made garments. Custom garments may be required for patients with irregularly‐shaped limb(s) or body parts, wounds, lack of sensation or difficulty with hand dexterity. Custom garments are often a necessity for growing children. Custom garments allow for options such as special linings to reduce the risk of skin breakdown and fastening devices which can help the patient put on and remove the garment. Garments should be washed daily so the

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garment lasts as long as possible and does not lose its compression strength. Manufacturer instructions must be followed for washing and drying to prolong the life of the garment. Most daily garments must be replaced every 4‐6 months to maintain compression strength. Compression garments for children must be replaced when growth necessitates, which is usually multiple times per year for babies and younger children.

In addition to the day garments used in Phase II, some patients with more severe forms of lymphedema will need night garments or advanced day garments to maintain the reductions obtained in Phase I. There are a variety of options for advanced and night garments that may be required for control of lymphedema, such as Velcro closure garments and specialized foam compression garments.68,136,137

Patient Education

Since lymphedema is a life‐long condition, patient education in self‐management is very important.69 To reduce the risk of developing lymphedema or having lymphedema worsen, all patients with lymphedema or at‐risk for lymphedema should be instructed in essential self care. The important areas of education include risk‐reduction practices, self‐lymph drainage, skin care, signs and symptoms of infection, proper fit and care of garments, and the importance of good nutrition, exercise and weight control.

Weight Loss

Lymphedema risk increases with obesity, so weight loss should be a part of lymphedema treatment in overweight individuals, as well as maintenance of optimal weight in normal‐weight individuals. 45,70‐74 In one study, weight loss alone was shown to reduce arm volume in the lymphedema arm more than the uninvolved arm of obese women with post‐mastectomy lymphedema.75

Modifications and Individualization of CDT

CDT programs should be individualized based on the presence of other medical conditions or patient abilities. Patients with wounds, scars, or musculoskeletal conditions; palliative care patients; or patients with post‐radiation fibrosis may require adaptations of CDT. If there is limited mobility of the body part with or near the swelling, the patient may require other therapies, such as scar massage or myofascial therapy, in addition to CDT, to have a benefit from CDT.49,64,65,68

Decongestive Therapy for Head and Neck Lymphedema.

Lymphedema can be a complication of treatment for head and neck cancer. Manifestations of lymphedema in patients with head and neck cancer are both internal (difficulty swallowing, vocal cord swelling) and external (swelling of the face, jaw and neck). Modifications of CDT have been shown to be beneficial, especially manual lymphatic drainage and modified garments. 76‐78

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Intermittent Pneumatic Compression Therapy (IPC)

IPC, also known as compression pump therapy, can be useful in some patients as an adjunct to Phase I CDT79‐ 88 or a necessary component of a successful home program (Phase II CDT).89‐91

Single‐chamber pumps, used in the past, are not used for lymphedema now. Single chamber pumps can cause fluid to move in both directions, meaning fluid can build up in the already‐swollen area. Also, the pressure in single‐chamber pumps does not stimulate lymphatic flow as sequential pumps do.92 Acceptable pumps should have appliances (pump garments) with multiple chambers and have a sequential pressure delivery with the chambers compressing in a specific pattern determined individually for the patient’s diagnosis and pattern of lymphedema.93 Since lymphedema is a condition involving a quadrant of the body (upper or lower trunk, chest, abdomen), and not just the limb with the swelling, many patients who require IPC will need a pump that treats the trunk of the body and not just the limb with the swelling.

Recommended pump pressures generally range from 30‐60 mmHg, although lower or higher pressures may be indicated.200 The pressure displayed on the pump may not accurately reflect what is delivered to the skin surface. One study demonstrated considerable differences in skin/device interface pressure patterns and magnitude which may have an impact on therapeutic outcomes.94 This is a significant concern because superficial structures may be harmed if the pressures applied in therapy are too high.95 In general, lower pressures are considered to be safer, but the pressure has to be individualized to the patient’s diagnosis and skin condition.95,200 The length of each treatment is usually one hour. IPC is not a “stand‐alone” treatment. It is utilized along with standard CDT to maintain control of lymphedema at home.90,91 (Phase II). To maintain edema control, a compression garment, or short‐stretch bandages, should be worn between pump treatments and also when IPC therapy is discontinued.136

Patients being considered for IPC therapy must be evaluated by a physician or health‐ care provider with expertise in lymphedema. It is important to insure safe selection of the proper device and appropriateness of IPC. The prescription must include the intensity of pressure and pattern of pressure needed, taking into consideration several aspects of the patient’s situation including determination of need for programmable pressure to treat fibrotic areas,200,201 address treatment of ulcers, and adjust for patient’s level of pain and skin sensitivity. If trunk, chest or genital swelling is present, the physician must determine whether a pump that provides appliances to treat those areas is necessary or if the patient can manage the trunk swelling through self‐MLD or garments. If a pump with only extremity attachments is used, close monitoring should be instituted to detect an increase in edema or fibrotic (hard) tissue above the device sleeve, called a fibroscelerotic ring.96 If this occurs, consideration should be given to using a device that treats the trunk in addition to the extremities. Additionally, the physician or health‐care provider must evaluate the impact of various other medical conditions that are usually considered contraindications for pneumatic compression

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therapy, including acute infection, severe arterial vascular disease, acute superficial or deep vein phlebitis (inflammation or clot), recurrent cancer in the affected area, or uncompensated congestive heart failure.

Surgical Treatment of LE

Surgery for lymphedema is not curative, but it has been used in specific circumstances for control of a severe condition. Circumstances where surgery may be considered are: reducing the weight of the affected limb, minimizing the frequency of inflammatory attacks, improving cosmetic appearance, or fitting the limb into garments. As with all surgical procedures, the risks and benefits must be weighed against the individual needs of the patient, and the expertise of the surgical team. Surgery is usually only considered when adequate trials of all usual methods of treatment have failed.97,98 There are several types of surgical procedures available that have been used for lymphedema: (a) excisional operations, including debulking and liposuction, (b) tissue transfers, and (c) microsurgical lymphatic reconstruction. There are very few surgeons who perform these procedures. It is extremely important that patients with lymphedema are treated by surgeons experienced in the care of lymphedema and who work with certified lymphedema providers for the patient’s on‐going care after surgery. Surgery for lymphedema must be done in conjunction with CDT.147

Debulking

Debulking surgery removes the hard connective tissue and any large folds of fatty tissue associated with the lymphedema‐affected body part.99‐101 The potential risks of this surgery include prolonged hospitalization, poor wound healing, nerve damage or loss, significant scarring, destruction of the remaining lymphatic vessels in that body part, loss of limb function, return of swelling, poor cosmetic results, and decrease in quality of life. Post‐operatively, compression garments are still necessary for the maintenance of the limb and must be worn life‐long due to the lymphatic scarring from these surgeries and lymphatic insufficiency.

Liposuction

Liposuction involves the circumferential removal of fatty tissue deposits in the body part affected by long‐standing lymphedema. It is generally performed under general anesthesia and involves the creation of many small incisions. Tubular suction devices are inserted into the incisions by the surgeon to break up, liquefy, and suction out the fat.102‐104 Liposuction for lymphedema is similar, but not exactly the same, as cosmetic liposuction. Tight bandaging is necessary to stop the bleeding after liposuction for lymphedema. Life‐long compression garments are generally needed to prevent lymphedema from coming back due to the scarring of lymph vessels that can occur from the procedure. The risks of liposuction include bleeding, infection, skin loss, abnormal sensation (such as numbness, tingling, “pins and needles” feeling), and lymphedema returning.

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Tissue Transfers

Tissue transfers (grafts) have been attempted to bring lymph vessels into a congested area to remove excess interstitial fluid. There are few studies of the long‐term effectiveness of tissue transfers for lymphedema. Published articles are either outdated, done on animals, or describe lymph vessel function in breast reconstruction flaps.104,105

Microsurgical Lymphatic Reconstruction

Microsurgical and supramicrosurgical (much smaller vessels) techniques have been developed to move lymph vessels to congested areas to try to improve lymphatic drainage. Surgeries involve connecting lymph vessels and veins, lymph nodes and veins, or lymph vessels to lymph vessels. Reductions in limb volume have been reported and a number of preliminary studies have been done, but there are no long‐term studies of the effectiveness of these techniques.106‐115

Summary on Surgical Treatments

In general, surgical treatment is associated with significant risks, may result in reduced swelling for an unknown time, and is done by very few surgeons with experience in lymphedema. Surgical management of lymphedema should always be done in conjunction with CDT and does not stop the need for compression garments and Phase II maintenance. Since CDT, and other adjunctive therapies such as advanced garments and IPC, can usually produce good management in compliant patients, surgery is rarely a necessary consideration.138

Pharmaceutical Approaches

Lymphedema should not be exclusively treated with drugs or dietary supplements. Diuretics are ineffective for removal of interstitial fluid from the tissues. Excess diuretic use can lead to dehydration, electrolyte imbalance, and tissue damage. However, diuretics may be medically indicated in patients with lymphedema who have other medical conditions such as high blood pressure and heart disease. Therefore, diuretic use must be assessed on a case‐by‐case basis. Individuals with lymphedema should not stop diuretics before checking with their physician or health care provider.

Some drugs such as Coumarin (not coumadin) and Diosmin have been tried for

lymphedema. They have not been found to be effective and have adverse side effects.116‐123

Natural Supplements

There is limited evidence from rigorously‐designed studies on the use of natural supplements for lymphedema. Studies have indicated American horse chestnut may help venous edema but not lymphedema.124 Selenium has been reported to improve lymphedema in head and neck cancer.125,126 Bromelain, a substance found in pineapple, has anti‐inflammatory, anticoagulant, enzymatic, and diuretic effects. Some have wondered if there might be a benefit for bromelain use with lymphedema, but it has not been studied for use specifically for lymphedema.127‐132

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Due to potential interactions with prescription drugs and other negative side effects, patients should check with their physician or health‐care provider before taking any natural supplement.

Complementary, Integrative and Alternative Treatments

A number of promising treatments have been reported, but they have not yet been subjected to sufficient rigorous research to recommend as the standard of care. These treatments include cold laser, electrical stimulation, vibratory therapy, oscillation therapy, endermologie and aqualymphatic therapy.133‐142,146 All of these techniques are done in combination with components of CDT. Acupuncture has shown benefit for some symptoms of cancer and cancer treatment, including fatigue, hot flashes, muscular or joint pain, neuropathy and nausea. There are no rigorous studies on using acupuncture for treating lymphedema or using acupuncture on lymphedema extremities (see NLN Position Paper on Risk Reduction. 205). Rebounder trampolines have been advocated by some for treating lymphedema, but there are no published studies on this treatment. Rebounding is good exercise, it but is not known to be superior to other forms of aerobic exercise in individuals with lymphedema.

Summary on Treatment and Diagnosis of Lymphedema

Treatment of lymphedema should be undertaken only after a thorough diagnostic evaluation has been done according to accepted guidelines by qualified practitioners. CDT is the current international standard of care for managing lymphedema. CDT has been shown to be effective in large numbers of case studies demonstrating limb volume reductions of 50‐70% or more, improved appearance of the limb, reduced symptoms, improved quality of life, and fewer infections after treatment. Even people with progressive lymphedema for 30 years or more before starting CDT have been shown to respond. Patient adherence during Phase II CDT is critical for preserving volume reduction. It is recommended that CDT adaptations or other lymphedema treatments be used on a case‐by‐case basis under the supervision of a health‐care provider (physician, nurse, physician assistant, therapist) with demonstrated expertise in lymphedema management. IPC is a demonstrated effective adjunct to CDT. All interventions for lymphedema must have the goals of inducing and maintaining volume reduction, preventing medical complications, improving skin condition, reducing infection, enhancing patient adherence, and improving comfort and quality of life.

This document has been written and reviewed by members of the 2010‐2011 NLN Medical Advisory Committee (MAC). MAC members have disclosed no relevant financial arrangements or affiliations.

Lymphedema Risk Reduction Practices- National Lymphedema Network

2011-02-16T18:21:00.001-08:00

POSITION STATEMENT OF THE NATIONAL LYMPHEDEMA NETWORK

By NLN Medical Advisory Committee; Next Revision Date Spring 2011

TOPIC: LYMPHEDEMA RISK REDUCTION PRACTICES

I. Skin Care - Avoid trauma / injury to reduce infection risk1,2 • Keep extremity clean and dry • Apply moisturizer daily to prevent chapping/chafing of skin2 • Attention to nail care; do not cut cuticles

• Protect exposed skin with sunscreen and insect repellent • Use care with razors to avoid nicks and skin irritation • If possible, avoid punctures such as injections and blood draws • Wear gloves while doing activities that may cause skin injury (i.e., washing

dishes, gardening, working with tools, using chemicals such as detergent) • If scratches/punctures to skin occur, wash with soap and water, apply antibiotics,

and observe for signs of infection (i.e. redness) • If a rash, itching, redness, pain, increased skin temperature, fever or flu-like

symptoms occur, contact your physician immediately for early treatment of possible infection3

II. Activity / Lifestyle

• Gradually build up the duration and intensity of any activity or exercise4-8 • Take frequent rest periods during activity to allow for limb recovery • Monitor the extremity during and after activity for any change in size, shape,

tissue, texture, soreness, heaviness or firmness9 • Maintain optimal weight10-13

III. Avoid Limb Constriction9 • If possible, avoid having blood pressure taken on the at-risk extremity • Wear loose fitting jewelry and clothing

IV. Compression Garments2,9,14 • Should be well-fitting • Support the at-risk limb with a compression garment for strenuous activity (i.e.

weight lifting, prolonged standing, running) except in patients with open wounds

or with poor circulation in the at-risk limb15 • Consider wearing a well-fitting compression garment for air travel16,17

V. Extremes of Temperature1 • Avoid exposure to extreme cold, which can be associated with rebound swelling,

or chapping of skin • Avoid prolonged (greater than 15 minutes) exposure to heat, particularly hot tubs

and saunas • Avoid placing limb in water temperatures above 102°Fahrenheit (38.9°Celsius)

VI. Additional Practices Specific to Lower Extremity Lymphedema

• • •

Avoid prolonged standing, sitting18 or crossing legs Wear proper, well-fitting footwear and hosiery19,20 Support the at-risk limb with a compression garment for strenuous activity except in patients with open wounds or with poor circulation in the at-risk limb15

NOTE: Given that there is little evidence-based literature regarding many of these practices, the majority of the recommendations must at this time be based on the knowledge of pathophysiology and decades of clinical experience by experts in the field.

Exercise in the patient with lymphedema-NLN

2011-02-16T18:20:00.003-08:00

POSTION STATEMENT OF THE NATIONAL LYMPHEDEMA NETWORK

TOPIC: EXERCISE

Exercise presents several considerations for individuals with lymphedema and for those at risk for developing lymphedema.

It is the position of the NLN that:

␣ Exercise is an integral part of a healthy lifestyle ␣ “Lymphedema” exercises (remedial exercises) are standard components of Phase I and

Phase II complex decongestive therapy (CDT) (Refer to NLN Lymphedema Treatment

Position Paper) ␣ The majority of individuals with lymphedema can safely perform aerobic and resistive

exercise using the affected body part(s) when: ␣ Compression garments are worn ␣ The affected body part is not exercised to fatigue ␣ Appropriate modifications are adopted to prevent trauma and overuse

␣ The majority of individuals who are at risk for developing lymphedema can safely perform aerobic and resistive exercise using the “at risk” body part when exercises are:

␣ initiated at a low intensity

␣ increased gradually ␣ It is not clear in individuals at risk for lymphedema whether a garment is necessary, but it

may be helpful. ␣ Concern regarding the adverse effects of exercise should be determined by lymphedema

severity or risk.*

Types of Exercise: Lymphedema-related Benefits and Risks

“Lymphedema,” Remedial Exercise

Lymphedema exercise involves active, repetitive, non-resistive, motion of the involved body part. Exercise in Phase I and II CDT is performed with compression on the involved extremity. Lymphedema exercise enhances the efficacy of the muscle pump and promotes venous and lymphatic return.

Studies: Lymphedema exercises have been formally studied and shown to significantly reduce limb swelling.1-3 Potential Benefits: Lymphedema exercises promote lymph flow which can reduce limb swelling. Potential Risks: If performed improperly or without appropriate compression lymphedema exercises may worsen limb swelling.

Flexibility/Stretching Exercise

Flexibility exercises include a wide range of activities that stretch muscles and connective tissue to preserve range of motion. Flexibility exercises can minimize scarring and joint contractures which may lessen lymph flow. Flexibility exercises should be performed slowly and progressed gradually.

Studies: Flexibility exercises have not been formally studied in individuals with or at risk for lymphedema. Potential Benefits: When performed appropriately, flexibility exercises can preserve range of motion, prevent joint contractures, and enhance lymph flow. Potential Risks: Overly vigorous stretching may cause tissue injury and inflammation producing lymphatic overload and lymphedema. Aggressive stretching is contraindicated except for very limited circumstances.

Resistive exercises are performed repetitively against an opposing load to enhance muscle power, stamina and tone. Resistive exercise may reduce limb volume when used as an adjunct to compression therapy.4 Resistance, generally in the form of weights, should be introduced at a low level and increased gradually with close monitoring for injury, overuse and swelling. Modifications to minimize the potential harmful effects of exercise and improve safety include: 1. adequate rest intervals between sets; 2. avoidance of constant gripping of hand weights, equipment, or bands; 3. application of compression in the form of garments or bandages. The amount of compression may need to be adjusted to prevent increased swelling.

Studies: Resistive exercise has been formally studied in “at risk” individuals, and when begun at a low level and increased gradually, has not been found to trigger or worsen lymphedema.4-9 An isolated study in lymphedema patients suggests that resistive exercise, in the absence of compression, may lead to increased lymph accumulation and eventually worsen limb swelling.10 Potential Benefits: Resistive exercise may enhance lymph flow and prevent limb swelling from muscle overuse. Potential Risks: Strength training increases local blood flow and metabolic waste production. These effects increase the demand on the lymphatic system, potentially triggering or worsening limb swelling.

Aerobic Conditioning

Aerobic conditioning (“cardio” exercise) is typically performed continuously using large muscle groups in a repetitive fashion at 60% - 75% of an individual’s maximum heart rate.11 Walking, jogging, cycling, and swimming are examples of aerobic conditioning.

Studies: Aerobic conditioning has been formally studied on a limited basis and has not been associated with lymphedema in “at risk” individuals during short-term follow up of 1 year.7, 12 Potential Benefits: Aerobic conditioning enhances cardiovascular fitness, effective weight management and overall health and may specifically benefit lymphedema patients by improving venous and lymph flow.3 Potential Risks: Increased blood flow and deposition of metabolic waste in areas at risk for, or with established, lymphedema which may increase lymph swelling.

For Individuals with Lymphedema

Exercise as lymphedema treatment (“Remedial exercise”):

Remedial exercise is an integral part of CDT, the current standard of care for lymphedema reduction and long-term management.13, 14 Exercise enhances lymphatic function through increased lymph and flow. Exercise in Phase I CDT is performed with short-stretch compression bandages on the involved body part to reduce lymph production and maximize the influence of muscle contractions. During Phase II CDT, remedial exercises should be performed on a regular basis with garments or bandages in place.

Considerations for designing an exercise program:

Exercise causes both positive and negative physiological effects in the lymphatic system and surrounding tissues. The balance between positive and negative effects must be considered on an individual basis when designing an exercise program. Positive effects include increased lymph flow. This increase will vary depending on the condition of each individual’s lymphatic system. Negative effects of exercise may include accumulation of waste products and lymph fluid in the body tissues, as well as the potential for tissue trauma and inflammation.

Exercise programs should be strategically designed to maximize the positive effects and minimize the negative effects. Potential considerations include lymphedema location, areas of reduced lymph flow, other medical conditions, prior level of physical activity, overall health of the individual and environmental conditions (e.g. hot weather, high altitude).

NLN ♦ 116 New Montgomery Street, Suite 235 ♦ San Francisco, CA 94105 Tel: 415-908-3681 ♦ Fax: 415-908-3813 Infoline: 1-800-541-3259 ♦ Email: nln@lymphnet.org ♦ Online: www.lymphnet.org

NLN Position Paper: Exercise Page 2 of 4

For Individuals at Risk for Lymphedema

Definition of Individuals at Risk for Lymphedema

Individuals at risk for lymphedema have not displayed signs and symptoms of lymphedema but may have sustained damage to their lymphatic systems through surgical lymph node removal or irradiation.15 Additionally, “at risk” individuals may have surgical incisions in the vicinity of lymph transport vessels. Individuals who have family members with hereditary lymphedema may also be at risk. An individual’s risk of lymphedema may change over time depending on weight gain, degree of radiation-induced scarring, and other factors.

Exercise Guidelines for Individuals at Risk for Lymphedema

Although lymphedema may not be evident, in “at risk” individuals the lymphatic system may function well below the normal range.16 Exercise may trigger lymphedema by increasing lymph production to the point that it exceeds the lymphatic system’s ability to remove fluid. Local inflammation from overuse or trauma may contribute as well. Temporary overload may not produce immediate swelling. However repeated episodes may add up and lead to chronic lymphedema.

Sub-clinical lymphatic impairment cannot be reliably measured. Thus, an individual’s exact lymphedema risk cannot be estimated and controversy persists as to which individuals should use compression garments during exercise. Current understanding of the underlying physiology provides strong support for use of compression garments. However, these issues have yet to be tested in clinical trials. “At risk” individuals may reduce their risk of developing lymphedema during exercise by wearing a well-fitted compression garment.

Key Points to Remember Regarding Exercise

␣ Before starting any exercise program individuals should be medically cleared ␣ For individuals with lymphedema, adequate compression should be utilized in the form of

compression bandages or garments ␣ Individuals at risk for developing lymphedema may consider obtaining a compression garment ␣ Compression garments should be:

o measured by an individual trained and experienced in fitting compression garments

o at least Class I for upper extremity support ␣ A hand piece, either a glove or gauntlet, is necessary when wearing a compression sleeve. ␣ Exercise adjustments may be indicated for individual medical needs or frequent lymphedema flare

ups. ␣ Performing exercise beyond an individual’s usual duration or intensity may trigger or worsen

lymphedema. ␣ Exercise should be started gradually, increased cautiously and stopped for pain, increased swelling

or discomfort.

NLN ♦ 116 New Montgomery Street, Suite 235 ♦ San Francisco, CA 94105 Tel: 415-908-3681 ♦ Fax: 415-908-3813 Infoline: 1-800-541-3259 ♦ Email: nln@lymphnet.org ♦ Online: www.lymphnet.org

NLN Position Paper: Exercise Page 3 of 4

NLN Position Paper: Exercise Page 4 of 4

REFERENCES 1. Boris M, Weindorf S, Lasinski B, Boris G. Lymphedema reduction by noninvasive complex

lymphedema therapy. Oncology (Williston Park). Sep 1994;8(9):95-106; discussion 109-110. 2. Foldi E, Foldi M, Weissleder H. Conservative treatment of lymphoedema of the limbs. Angiology.

Mar 1985;36(3):171-180. 3. Foldi M FE. Textbook of Lymphology. Munchen: Urban & Fisher; 2003. 4. Johansson K, Tibe K, Weibull A, Newton RC. Low intensity resistance exercise for breast cancer

patients with arm lymphedema with or without compression sleeve. Lymphology. Dec

2005;38(4):167-180. 5. Ahmed RL, Thomas W, Yee D, Schmitz KH. Randomized controlled trial of weight training and

lymphedema in breast cancer survivors. J Clin Oncol. Jun 20 2006;24(18):2765-2772. 6. Cheema B, Gaul CA, Lane K, Fiatarone Singh MA. Progressive resistance training in breast

cancer: a systematic review of clinical trials. Breast Cancer Res Treat. Jul 12 2007. 7. Courneya KS, Segal RJ, Mackey JR, et al. Effects of aerobic and resistance exercise in breast

cancer patients receiving adjuvant chemotherapy: a multicenter randomized controlled trial. J Clin

Oncol. Oct 1 2007;25(28):4396-4404. 8. McKenzie DC, Kalda AL. Effect of upper extremity exercise on secondary lymphedema in breast

cancer patients: a pilot study. J Clin Oncol. Feb 1 2003;21(3):463-466. 9. Turner J, Hayes S, Reul-Hirche H. Improving the physical status and quality of life of women

treated for breast cancer: a pilot study of a structured exercise intervention. J Surg Oncol. Jun 1

2004;86(3):141-146. 10. Lane KN, Dolan LB, Worsley D, McKenzie DC. Upper extremity lymphatic function at rest and

during exercise in breast cancer survivors with and without lymphedema compared with healthy

controls. J Appl Physiol. Sep 2007;103(3):917-925. 11. Fletcher GF, Balady G, Blair SN, et al. Statement on exercise: benefits and recommendations for

physical activity programs for all Americans. A statement for health professionals by the Committee on Exercise and Cardiac Rehabilitation of the Council on Clinical Cardiology, American Heart Association. Circulation. Aug 15 1996;94(4):857-862.

12. Basen-Engquist K, Taylor CL, Rosenblum C, et al. Randomized pilot test of a lifestyle physical activity intervention for breast cancer survivors. Patient Educ Couns. Dec 2006;64(1-3):225-234.

13. Bernas MJ, Witte CL, Witte MH. The diagnosis and treatment of peripheral lymphedema: draft revision of the 1995 Consensus Document of the International Society of Lymphology Executive Committee for discussion at the September 3-7, 2001, XVIII International Congress of Lymphology in Genoa, Italy. Lymphology. Jun 2001;34(2):84-91.

14. Best Practice for The Management of Lymphoedema, International Consensus. London: MEP Ltd; 2006.

15. Meek AG. Breast radiotherapy and Lymphedema. Cancer. Dec 15 1998;83(12 Supple American):2788-2797.

16. Goltner E, Gass P, Haas JP, Schneider P. The importance of volumetry, lymphscintigraphy and computer tomography in the diagnosis of brachial edema after mastectomy. Lymphology. Sep 1988;21(3):134-143.

Training of Lymphedema Therapists, from the NLN

2011-02-16T18:20:00.001-08:00

POSITION STATEMENT OF THE NATIONAL LYMPHEDEMA NETWORK

NLN Medical Advisory Committee; Approved by the NLN Board of Directors: 8/1/10; Expires: 8/1/13

TOPIC: TRAINING OF LYMPHEDEMA THERAPISTS

The growth of lymphedema awareness has resulted in a proliferation of treatment approaches throughout the health care continuum (1-4). As lymphedema therapy techniques have been established in the United States, variation among the treatment approaches and training methods have evolved. There are continuing broad scale efforts to oversee and address optimal treatment approaches and training methods (5-8).

In order to have an adequate knowledge base in the pathophysiology of lymphatic function and disorders, and sufficient training in manual techniques and compression bandaging principles, along with other components of Complete Decongestive Therapy (CDT), it is the position of the National Lymphedema Network that the minimum requirements for specialist training in lymphedema management are as follows:

␣ Practitioners treating patients with lymphedema will successfully have completed a minimum of 135 hours of Complete Decongestive Therapy coursework. The CDT entry level curriculum should be presented in no more than four integrated courses from a single training program. Unrelated review, advanced or supplemental courses do not satisfy the entry level requirement of intentional course linkage.

␣ It is required that one-third (1/3) of the training hours, a minimum of 45 hours, should be theoretical instruction. Two-thirds (2/3) of the training hours, a minimum of 90 hours, should be practical, hands-on, face-to-face laboratory instruction. It is expected that the course work would include ongoing measures of student competency such as exams after completion of independent study unit and evaluation of skills competency.

␣ Didactic instruction can be delivered in the classroom or by distributed education, which is defined as the teacher and the student being separated by time and or space. Typically, distributed education involves technology such as the internet, interactive television, or videotape. Review time (independent study) and homework are not recognized as interactive instruction and will not be counted as contact hours.

␣ Proof of satisfactory completion of 12 credit hours of college level human anatomy, physiology, and/or pathophysiology from an accredited college or university.␣ Have current unrestricted licensure in a related medical field (PT, PTA, OT, COTA, MT, SLP, RN, MD, DO, DC, PA, ATC).

These criteria are consistent with the Lymphology Association of North America (LANA) standards that have been put forth in an effort to establish basic minimum standards to certify adequate competency in the treatment of lymphedema. Advanced education in Complete Decongestive Therapy is necessary to achieve these basic criteria. Patients and health care providers are advocating for advanced training to adequately meet the needs of this specialized population (9,10).

It is the position of the NLN that therapists treating patients with lymphedema meet the above criteria as a basic minimum standard to ensure that an appropriate level of care is being provided to this population.

REFERENCES

1. Foldi M, Foldi E, Kubik S. Textbook of Lymphology. Urban and Fischer, 2006.

2. Rockson SG, Miller LT, Senie R, Brennan MJ, Casley-Smith JR, Foldi E, et al. American Cancer Society Lymphedema Workshop. Workgroup III: Diagnosis and management of lymphedema. Cancer 1998; 83(12 Suppl American):2882-2885.

3. Szuba A, Achalu R, Rockson SG. Decongestive lymphatic therapy for patients with breast carcinoma-associated lymphedema. A randomized, prospective study of a role for adjunctive intermittent pneumatic compression. Cancer 2002; 95(11):2260-2267.

4. The Diagnosis and Treatment of Peripheral Lymphedema, 2009 Consensus Document of the International Society of Lymphology. Lymphology, 2009, 42(2): 51-60.

5. Casley-Smith JR, Boris M, Weindorf S, Lasinski B. Treatment for lymphedema of the arm--the Casley-Smith method: a noninvasive method produces continued reduction. Cancer 1998; 83(12 Suppl American):2843-2860.

6. Armer J, Feldman J, Fu M, Stout N, Lasinski B, Tuppo C, et al. ALFP: Identifying issues in lymphoedema in the United States. Journal of Lymphology, 2009, 4(2):85- 91.

7. Walley DR, Augustine E, et.al. American Cancer Society Lymphedema Workshop. Workgroup IV: Lymphedema Treatment Resources - Professional Education and Availability of Patient Services. Cancer 1998, 83(2):2886-2287.

8. Foldi E. Treatment of lymphedema and patient rehabilitation. Anticancer Res 1998; 18(3c):2211-2212.

9. Augustine E. Oncology Section of the American Physical Therapy Association Position Statement--Physical Therapy: Management of Lymphedema in Patients with a History of Cancer. Rehabilitation Oncology 2000, 18(1):9-12.

10. Lymphedema. Understanding and managing lymphedema after cancer treatment. American Cancer Society, 2006, Chapter 7, 102-106.

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