About ACOLS The Academy of Lymphatic Studies is the leading school in the United States to provide comprehensive lymphedema certification training for health care professionals in this specialized treatment technique. |
September 9th, 2010
 Certain activities may trigger the onset of lymphedema, or may exacerbate the symptoms of existing lymphedema. Patients with lymphedema and those at risk for developing it – basically everyone who has undergone lymph node excision and/or radiation treatments – should observe the following precautions. The “Do’s” and “Don’ts” below are based on decades of experience and knowledge of clinical experts in the field of lymphedema management.
Skin Care
- Keep your skin meticulously clean and check frequently for any cracks, infections or rashes
- Moisturize your skin daily, especially after taking a shower or bath. Use appropriate ointments or lotions (see blog entry on June 11, 2010)
- Dry your skin thoroughly with a soft towel after taking a shower or bath; do not scrub
- If you undergo radiation therapy apply the ointments recommended by your physician to any radiation redness on your skin and avoid direct exposure to sunlight
- Avoid cosmetics that irritate the skin
Clothing – Jewelry – Compression Sleeve – Prosthesis
- Avoid clothing that is too tight (bras and sleeves that restrict); you should use a comfortable bra with wide and padded shoulder straps
- Do not wear tight jewelry and avoid elastic bands around your wrist
- Wear your compression sleeve all day and if necessary apply your bandages at night. Use rubber gloves when you put on your compression sleeve. See your therapist at least every six months (or sooner) to check the condition of the garment
- Discuss with your doctor and/or therapist, what kind of external breast prosthesis is appropriate in your case (heavier silicone or lighter foam)
Avoid any Injuries to the Skin
- Shaving: use an electric razor to remove hair from your armpit or chest; do not use razor blades
- Nail care: you should keep your fingernails cut short; avoid the use of scissors for cutting your fingernails; do not cut the cuticles. Avoid artificial nails
- Should you smoke, do not extinguish the cigarette with your affected hand
- Wear gloves when gardening and playing with your pets (scratches
- Mosquito bites: wear insect repellants, avoid mosquito infested areas
- Injections: do not allow injections in the swollen (or at risk) arm. Do not allow blood to be drawn from the affected (or at risk) arm. Have it drawn from the other arm, or if both arms are affected, from the lower extremity (certain contraindications may exist)
- Avoid blood pressure to be taken on the affected (or at risk) arm. Have the clinician use the other arm, or if both arms are affected, an oversize pressure cuff may be used on the thigh or calf. If you can’t avoid the blood pressure to be taken on the arm, make sure that the cuff is inflated only 10mm/Hg above the systolic pressure (this is the point at which the pulse stops) and that only manual equipment is used – automated equipment inflates generally to a very high pressure, which is held for a prolonged period
- To take care of minor injuries, always carry an alcohol swab, local antibiotic and a bandaid with you
- No piercing or tattoos on the arm, back or chest
Avoid Heat
- Avoid hot showers
- Avoid hot packs and/or ice packs on your arm, back and chest
- Avoid saunas or hot tubs and whirlpools. Do not sit too close to a fire place
- Avoid massage on the arm, chest and upper back area. Note: Manual lymph drainage is not considered to be a form of massage
- Avoid sunburn – while in the sun, use sunscreen, cover the arm with appropriate clothing or a dry towel
Exercises
- Discuss proper exercises and activities with your therapist
- Avoid movements that overstrain. Should you experience discomfort in your arm, reduce the exercise activity and elevate your arm
- Avoid heavy lifting
Nutrition
- Obesity may have a negative effect on your swelling; maintain your ideal body weight
- There is no special diet for lymphedema. Keep your diet well balanced. Today most nutritionists recommend a low-salt and low-fat diet, high in fiber
- Eating too little protein in the hope to have a positive effect on lymphedema (high-protein edema) is not recommended and may cause serious health problems. Reducing the protein intake will not reduce the protein component in lymphedema
Travel
- Avoid mosquito-infested regions
- Wear an additional bandage on top of your compression sleeve when traveling by car, train or air. Incorporate frequent stops, or get up from your seat frequently, elevate your arm(s) as often as possible
See your Doctor if you:
- Have any signs of an infection (fever, chills, red and hot skin)
- Notice any itching, rash, fungal infections, or any other unusual changes on the skin
- Experience pain, or an increase in swelling in your fingers, hand, arm or chest
August 13th, 2010
In this entry I would like to refer to an excellent article published December 2008 in the Clinical Journal of Oncology Nursing.
The article labeled “Demystifying Lymphedema: Development of the Lymphedema Putting Evidence into Practice Card” (E.Poage, M.Singer, J.Armer, M.Poundall, M.J.Shellabarger) offers a comprehensive and critical review of current literature in order to identify effective evidence-based treatment modalities for the treatment of secondary lymphedema.
According to the authors, the article was developed out of a need to have nurses take notice of complaints and to offer appropriate evidence-based interventions for the treatment of, and risk reduction for lymphedema.
The goal was to accurately describe lymphedema, to include its consequences, and evidence-based treatment modalities, so oncology nurses are able to comfortably identify patients who are at risk for, or who are experiencing early-stage lymphedema and recommend prompt and effective interventions.
Interventions covered in this article are:
Complete Decongestive Therapy (CDT)
Compression Bandaging (CB)
Manual Lymph Drainage (MLD)
Compression Garments
Exercises
Skin Care
Low-Level Laser Therapy (LLLT)
Hyperbaric Oxygen
Pneumatic Compression Pumps
Drug Therapy
Silver Dressings (for the treatment of ulcers associated with lymphedema)
Click here to access the article
July 22nd, 2010
Certain activities may trigger the onset of lymphedema, or may exacerbate the symptoms of existing lymphedema. Patients with lymphedema and those at risk for developing it – basically everyone who has undergone lymph node excision and/or radiation treatments – should observe the following precautions. The “Do’s” and “Don’ts” below are based on decades of experience and knowledge of clinical experts in the field of lymphedema management.
Skin Care
- Keep your skin meticulously clean and check frequently for any cracks, fungal infections or rashes
- Moisturize your skin daily, especially after taking a shower or bath. Use appropriate ointments or lotions (see blog entry on June 11, 2010)
- Dry your skin thoroughly with a soft towel after taking a shower or bath; do not scrub
- If you undergo radiation therapy apply the ointments recommended by your physician to any radiation redness on your skin and avoid direct exposure to sunlight
- Avoid cosmetics that irritate the skin
Clothing – Jewelry – Compression Stocking
- Avoid clothing that is too tight (underwear, socks or stockings that restrict)
- Do not wear tight jewelry and avoid elastic bands around your ankle
- Wear your compression stocking/pantyhose all day and if necessary apply your bandages at night. Use rubber gloves when you put on your compression garment. See your therapist at least every six months (or sooner) to check the condition of the garment
Avoid any Injuries to the Skin
- Shaving: use an electric razor to remove hair from the leg or lower body quadrant, do not use razor blades
- Nail care: you should keep your toenails short but be careful cutting your toenails, do not cut the cuticles
- Pets: be careful playing with your pets (scratches)
- Mosquito bites: wear insect repellants, avoid mosquito infested areas
- Injections: do not allow injections in the swollen (or at risk) leg, in the buttocks on the affected side, or the abdominal area. Do not allow blood to be drawn from the affected (or at risk) leg
- To take care of minor injuries, always carry an alcohol swab, local antibiotic and a bandaid with you
- Do not walk barefoot and wear solid shoes to avoid ankle injuries
- No piercing or tattoos on the leg, lower back or abdominal area
Avoid Heat
- Avoid hot showers
- Avoid hot packs and/or ice packs on your leg
- Avoid saunas or hot tubs and whirlpools. Do not sit too close to a fire place
- Avoid massage on the leg and the lumbar area. Note: Manual lymph drainage is not considered to be a form of massage
- Avoid sunburn – while in the sun, use sunscreen, cover the leg with appropriate clothing or a dry towel
Exercises
- Discuss proper exercises and activities with your therapist
- Avoid movements that overstrain. Should you experience discomfort in your leg, reduce the exercise activity and elevate your leg
- Elevate your leg as often as possible
Nutrition
- Obesity may have a negative effect on your swelling; maintain your ideal body weight
- There is no special diet for lymphedema. Keep your diet well balanced. Today most nutritionists recommend a low-salt and low-fat diet, high in fiber
- Eating too little protein in the hope to have a positive effect on lymphedema (high-protein edema) is not recommended and may cause serious health problems. Reducing the protein intake will not reduce the protein component in lymphedema
Travel
- Avoid mosquito-infested regions
- Wear an additional bandage or stocking on top of your compression garment when traveling by car, train or air. Incorporate frequent stops, or get up from your seat frequently, elevate your leg(s) as often as possible
See your Doctor if you:
- Have any signs of an infection (fever, chills, red and hot skin)
- Notice any itching, rash, fungal infections, or any other unusual changes on the skin
- Experience pain, or an increase in swelling in your toes, foot, leg, lower back or abdominal area
July 2nd, 2010
Compression therapy, like manual lymph drainage, exercises and skin care, is a main element of complete decongestive therapy (CDT). In most cases,
 Elastic fibers in the skin are damaged in lymphedema the elastic fibers in skin tissues affected by lymphedema are damaged and unable to provide an adequate resistant force against the musculature working underneath, and the blood and lymph vessels within these tissues. This is the reason why the affected extremity/body part is always at risk for reaccumulation of fluid during and following successful CDT treatments. External compression compensates for the elastic insufficiency of the affected tissue, providing the resistance necessary to maintain the reduction of the swelling.
During the decongestive (intensive) phase of CDT the affected extremity/body part is gradually decongested by a lymphedema therapist. In this phase of the treatment the volume of the affected limb changes almost on a daily basis, and it is necessary that external compression adapts to these constant changes. Bandages are much better suited for this task than compression garments (sleeves, stockings), which would have to be re-fitted constantly. Garments are used in the second phase of CDT, when the limb is decongested and volume changes are minimal.
So what exactly are short-stretch bandages?
There are two main qualities of pressure in compression therapy – the working pressure and the resting pressure. The working pressure is determined by the resistance the bandage provides against the working musculature underneath, and is active only during muscle activity, and therefore temporary. The pressure the bandage exerts on the tissues at rest, i.e. without muscle contraction, is known as the resting pressure, which is permanent. Relevant to these pressure qualities are the number of bandage layers, the tension with which these layers are applied, and most importantly the type of bandage used.
There are two distinct types of compression bandages – short-stretch and long-stretch bandages. The difference refers to the extent the bandages can be stretched from their original length. Short-stretch bandages are made from cotton fibers, which are interwoven in a way that allows for about 60% extensibility of its original length, whereas long-stretch bandages, commonly known as “Ace” bandages contain polyurethane, which allows for an extensibility of more than 140% of the bandages’ original length.
 Short-stretch bandages applied on lower extremity lymphedema Crucial in lymphedema management is to provide the skin tissues with a solid counterforce against the muscles working underneath, particularly while standing, sitting, walking, or performing therapeutic exercises. The subsequent increase in the tissue pressure during muscle activity in a bandaged extremity promotes lymphatic and venous return, and prevents reaccumulation of evacuated fluid in the skin. It is equally important to prevent the bandages from exerting too much pressure on the tissues during rest, which could cause a tourniquet effect and effectively prevent adequate return of these fluids.
Short-stretch cotton bandages provide the high working pressure needed to achieve these crucial goals and make them the preferred compression bandage in the management of lymphedema. Due to the low resting pressure of short-stretch bandages, tourniquet effects are prevented – provided these bandages are applied correctly.
Long-stretch (“Ace”) bandages have the exact opposite effect and are not suitable for lymphedema management. The low working pressure these bandages provide does not offer adequate resistance, and fluid would inevitably reaccumulate. In addition, the high resting pressure of long-stretch bandages could constrict veins and lymph vessels during rest.
June 11th, 2010
It is summer, and some of you affected by lymphedema might be planning an extended road, or airplane trip. Getting to your destination may require hours of sitting, which causes a considerable slow in the venous and lymphatic circulation and fluid to pool in the extremities.
Air travel may be especially challenging for individuals with lymphedema and those at risk for developing lymphedema. The cabin pressure during flights is lower than the atmospheric pressure on the ground, which causes a change in pressure in the connective tissues. These pressure changes, combined with the pooling of fluid in the tissues may cause swelling even in normal tissues. It just makes sense that these travel related issues may have even more serious consequences in individuals with a compromised lymphatic system.
 To avoid the onset of swelling and to prevent the worsening of pre-existing lymphedema, it is recommended to wear a compression garment during air travel. Compression increases tissue pressure and considerably aids in the prevention of fluid accumulation in the tissues.
While traveling with lymphedema does have some drawbacks and requires more planning, it should not stop you from taking a well deserved trip.
The following recommendations are intended to help your planning and make your trip more enjoyable:
Plan Ahead
- Seek the advise of your physician and your lymphedema therapist if there are any questions
- If you are an individual at risk for developing lymphedema, you should discuss with your physician and/or lymphedema therapist if it may be beneficial to wear a well-fitted compression garment, or short-stretch bandage(s) during the flight
- Check the quality of your compression garment. If you have more than one garment, take the extra one with you as a back up. If your destination is located at high altitudes, you need to take the same precautions as for your flight
- Ensure that you can manage your luggage. If you travel with another person or a group, ask someone else to carry the luggage for you. Should you travel on your own, use a suitcase with wheels and don’t lift your luggage from the baggage carousel with your swollen arm
- Carry your prescription medication with you; if necessary get your prescriptions filled before you leave to make sure they last you through your vacation. If your destination is located in hot or mosquito-infested areas, take precaution (sun screen, insect repellants, and antibiotics). Should you travel to a tropical country in which filariasis is endemic (especially during the wet season), talk to your doctor about special medication to take with you. Take some antifungal powder with you – the bathrooms and showers in hotel rooms may be a source for infection
 Endemic countries for filariasis
- Bring skin lotion – the air in pressurized cabins is very dry
- If possible, request an exit seat, which gives you more legroom. Definitely request an aisle seat so you can get up periodically without disturbing the person sitting next to you
- Wear loose, comfortable clothing and comfortable shoes that have been worn previously. If you have lymphedema of the leg avoid taking off your shoes during the flight
- Allow ample time to check in and reach your departure gate
During the Flight
Arrival
- Do not remove your garment and any additional bandage materials before you reach your final destination
- Upon arrival at your destination, a shower and a nap should be your top priority. Make sure you moisturize your skin thoroughly after the shower. A few more exercises with your garments in place would be beneficial
- Should you spend a lot of time on the beach, make sure you wear sunscreen and cover your affected limb as often as possible. Wear rubber sandals in the water if you have lymphedema affecting your leg(s). See also “precautions for lymphedema” in the next blog post.
Another good source for information is the National Lymphedema Networks position paper on air travel with lymphedema
May 21st, 2010
The external support provided by compression garments for extremities such as sleeves, gauntlets, stockings and pantyhose, or those manufactured for other parts of the body (vests, brassieres) are an essential component of lymphedema management.
Without the benefits of compression therapy, the lymphedemateous fluid removed by successful treatments would reaccumulate, and long-term management of lymphedema would be impossible.
As outlined in the last blog entry on April 30, compression garments are available in several sizes, variations and compression classes. In this entry I would like to shed some light on the different compression classes suitable for patients affected by lymphedema.
What are 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 most distant part of an extremity (ankle, wrist) to the nearest part (shoulder, hip). This gradient is necessary to avoid tourniquet effects and subsequent obstruction of lymph flow.
Most manufacturers in the United States use the following pressure values within the compression classes:
- Compression class 1: 20-30 mmHg
- Compression class 2: 30-40 mmHg
- Compression class 3: 40-50 mmHg
- Compression class 4: over 60 mmHg
 Compression classes (with permission from JUZO)
In general, compression levels provided by class 2 garments will be sufficient to prevent swelling in most patients affected by lymphedema of the upper extremity; patients with involvement of the leg will usually require a garment of compression class 3.
However, there are a number of exceptions to this general rule. Some patients with lower extremity lymphedema may require garments of lower compression levels than those provided in class 3, or maybe a garment of a higher compression. Alternatively, patients with lymphedema of the arm may use a sleeve of compression class 1, or even class 3 in some cases.
Many factors must be considered by the physician and/or lymphedema therapist in order to determine the correct compression class for each individual patient. Tolerance to external compression, age, activity level, skin integrity and possible additional conditions, such as arterial insufficiencies or heart problems may influence the level of compression.
May 7th, 2010
Please Note: The author of this blog, Joe Zuther, is currently on a cross country bicycle ride from San Diego, CA to St. Augustine, FL to raise awareness for lymphedema. Visit his Facebook page “Joe’s Cross Country Bike Ride” for daily updates and pictures. His blog about the ride is on http://joebikes.wordpress.com/
Compression Therapy and it’s Role in the Treatment of Lymphedema
Compression therapy applied by either padded short-stretch bandages, compression garments, or a combination of both, is an integral part of lymphedema management.
The goal of compression therapy is to maintain (and improve) the reduction of the swelling achieved during lymphedema treatments.
 Lymphatic Elephantiasis It is important to understand that although the swelling in lymphedema may be reduced to a normal or near normal size during treatments, the damage to the lymphatic system which caused the onset of lymphedema is permanent. In addition to the underlying damage to the lymphatic system, the elastic fibers in the tissues that were affected by lymphedema are damaged as well. These fibers loose their elasticity and tend to harden, especially in extreme cases (lymphostatic elephantiasis) and untreated lymphedema present over a long period of time. Without proper long-term management the evacuated fluid, in most cases, will reaccumulate in the affected body part.
Compression garments by themselves will not reduce existing swelling and must therefore not be worn on an untreated, swollen extremity. Patients with lymphedema graduate from padded short-stretch bandages, which are applied by the lymphedema therapist in the intensive phase of complete decongestive therapy (see blog entry on March 29, 2010) to elastic compression garments only when the affected extremity is decongested.
Compression garments, much like hearing aids or eyeglasses, become part of the patient’s life and have to be worn on a daily basis in order to preserve the treatment success achieved during the decongestion of the edematous limb.
 Compression Pantyhose Manufacturers of compression garments provide a wide variety of styles and variations, such as sleeves, gauntlets, stockings, pantyhose, vests, etc. They can be ordered in a large selection of standard sizes and different compression classes, which are determined either by the physician or the lymphedema therapist. While most patients’ measurements will fit within the parameters of the manufacturer’s standard sizes, some compression garments have to be ordered custom made. The correct size of the garment needs to be determined by the lymphedema therapist, or a certified fitter.
April 23rd, 2010
Manual Lymph Drainage (MLD) and it’s Role in the Treatment of Lymphedema
Please Note: The author of this blog, Joe Zuther, is currently on a cross country bicycle ride from San Diego, CA to St. Augustine, FL to raise awareness for lymphedema. Visit his Facebook page “Joe’s Cross Country Bike Ride” for daily updates and pictures. His blog about the ride is on http://joebikes.wordpress.com/
MLD is a gentle manual treatment technique, which is applied in combination with compression therapy, skin care and decongestive exercises primarily for the treatment of lymphedema. This technique is based on four basic strokes, which were first described by Vodder (1896-1986), a massage therapist and doctor of philosophy from Denmark.
It is unfortunate that MLD is often confused with the term “massage”. The only commonality between massage and MLD is that both are manual techniques – however, massage is applied with considerably more pressure in order to achieve the desired effects on musculature, tendons or ligaments. The goal of MLD for the most part is to have an effect on the lymphatic structures in the skin and subcutaneous tissues, which are located above muscles, tendons and ligaments. The pressure necessary to achieve the desired results in MLD is very light and sometimes described as the pressure applied while stroking a newborn’s head. In fact, too much pressure could damage the delicate lymphatic structures in the superficial tissues.
How does MLD work?
In addition to its important function in immune defense, the lymphatic system functions like a “sweeper” to clear the tissues of excess fluids, protein molecules and cell debris. If portions of this system are not functioning, as is the case in lymphedema, these substances will accumulate in the tissues and swelling will be present in the affected body part.
 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 reroute the lymph flow around these blocked areas into more centrally located healthy lymph vessels and nodes (see figure). 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.
In order to maintain the decongestive effect achieved during MLD and to avoid reaccumulation of fluid into the tissues, it is absolutely essential to follow up the MLD treatment with external support, i.e. compression to the affected body part/extremity.
April 16th, 2010
As we all know, knowledge is power and the more you are informed on all things related to lymphedema, the better you empower yourself to effectively take control over your health and choose the treatment options most appropriate for you. One of the positive things about the Internet is that almost all information you need is just a mouse click away, but sometimes it may be challenging to separate the useful from the non-relevant information.
One of my colleagues made me aware of an interesting resource for lymphedema related topics she came across the other day on a web site called Medifocus. I took a good look and found that their contributions on lymphedema related topics are well researched and informative, and I would like to share this information with you.
According to their web site, Medifocus has been a provider of health information for patients and families confronting serious medical issues since 1996. The information on medical information published on their web site is gathered by their staff of experienced medical research professionals and reviewed by Medifocus’ own medical advisory board.
They have medical information guides for over 120 medical conditions, including cancer, heart ailments and women’s health issues, which are updated regularly using peer-reviewed medical information sources.
In their June 2009 newsletter they summarize their research on articles related to lymphedema, and I found some of the contributions very informative.
Here is the link:
http://www.lymphedema-guidebook.com/mda/viewdigest.php?gid=OC030&uniqueid=-2
April 2nd, 2010
Complete Decongestive Therapy (CDT) and it’s Role in the Treatment of Lymphedema
Over the past decades it became very clear that the therapy of choice for the vast majority of patients suffering from lymphedema is complete decongestive therapy (CDT), sometimes referred to as complex decongestive therapy, or combined physical therapy. CDT as the standard therapy for lymphedema is listed on the web sites of the American Cancer Society (ACS), the National Cancer Institute (NCI) and the International Society of Lymphology (ISL) – just to name a few.
CDT, if applied correctly by a skilled and certified lymphedema therapist, shows excellent long-term results in both primary and secondary lymphedema. Numerous studies have proven the effectiveness of this non-invasive, safe and reliable treatment approach, which has been well established in European countries since the 1970s. Although CDT has been practiced in the United States in one form or another since the 1980s, it only became accepted in the 1990s after definite guidelines and all components of CDT were included in the teaching syllabi of U.S. schools providing training in lymphedema management.
 Secondary Lymphedema before CDT  Secondary Lymphedema after CDT How does CDT work?
The swelling in lymphedema is caused by an abnormal accumulation of protein and water molecules in the tissue. In order to achieve reduction of this swelling it is necessary to re-route the lymph flow – to include these excess protein and water molecules – around the blocked area(s) into more centrally located healthy lymph vessels. This goal is achieved by a combination of different treatment modalities, all of which are integral components of CDT and include
Manual Lymph Drainage (MLD),
Compression therapy,
Decongestive exercises and
Skin care
(I will discuss each of these components in future postings in this series, so stay tuned.)
It is important to understand that CDT is performed in two phases. In phase 1, also known as the intensive or decongestive phase, treatments are given by trained lymphedema therapists on a daily basis until the limb is decongested.
The duration of the intensive phase varies with the severity of the condition and averages 2-3 weeks for patients with lymphedema affecting the arm, and 2-4 weeks for patients with lymphedema of the leg. In extreme cases the decongestive phase may last up to six to eight weeks and may have to be repeated several times.
The end of the first phase of treatment is determined by the results of measurements on the affected body part, which are taken by the therapist. Once measurements approach a plateau, the end of phase 1 is reached and the patient progresses seamlessly into phase 2 of CDT, also known as the self-management phase, which for the most part is continued by the patient alone.
Depending on the stage of lymphedema, the involved extremity or body part may have reached a normal size at the end of the intensive phase, or there may still be a circumferential difference between the involved and the uninvolved limb.
Phase 2 is a lifelong process during which patients not only can maintain, but also improve the reduction achieved during phase 1. Regular check ups with the physician and the lymphedema therapist are necessary.
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Joe Zuther
