Chronic lower extremity lymphedema: A comparative study of high-resolution interstitial MR lymphangiography and heavily T2-weighted MRI.

Chronic lower extremity lymphedema: A comparative study of high-resolution interstitial MR lymphangiography and heavily T2-weighted MRI.
Eur J Radiol. 2008 Dec 22

Lu Q, Xu J, Liu N.
Department of Radiology, Shanghai Renji Hospital, Shanghai Jiao Tong University School of Medicine, 1630 Dong Fang Rd, Shanghai 200127, China.

PURPOSE: To assess the role of heavily T2-weighted image and interstitial MR lymphangiography (MRL) for the visualization of lymphatic vessels in patients with disorders of the lymphatic circulation.

METHODS: Forty lower extremities in 31 patients (9 bilateral and 22 unilateral) with primary lymphedema were examined by heavily T2-weighted image and indirect MRL. Maximum-intensity projection (MIP) was used to reconstruct the images of the lymphatic system. Two experienced radiologists analyzed the images with regard to the differences in image quality, number of lymphatic vessels, its maximum diameter and two other findings: accumulated lymph fluid in the tissue and honeycombing pattern.

RESULTS: The beaded appearance of the affected vessels in 73 leg segments of 40 lower extremities were present on both modalities 3D MIP. Larger amount of the dilated lymphatic vessels were visualized on heavily T2-weighted image than that on MRL (p=0.003) and the maximum diameter of it was 4.28+/-1.53mm on heavily T2-weighted image, whereas 3.41+/-1.05mm on MRL (p<0.01).>

CONCLUSION: The heavily T2-weighted imaging has greater sensitivity and the MRL image has higher legibility for detecting the pathologically modified lymphatic vessels and accompanying complications non-invasively. Combining these two MR techniques can accurately access the pathological changes in the lower extremity with lymphedema.

Elsevier/Science Direct

The role of operative management of varicose veins in patients with lymphedema and/or lipedema of the legs.

The role of operative management of varicose veins in patients with lymphedema and/or lipedema of the legs.
Lymphology. 2000 Dec

Földi M, Idiazabal G.
Földiclinic for Lymphology, Hinterzarten, Germany.

The role of operative management of "symptomatic" varicose veins in patients with lower extremity lymphedema or lipedema is controversial. We reviewed the clinical outcome of 261 patients between 1989-1997 at the Földiclinic with lower extremity lymphedema (68 patients), lipo-lymphedema or lympho-lipedema (103 patients) or lipedema (90 patients) who had undergone operation for varicose veins. In each group, the results were dismal as leg swelling worsened or was unchanged in greater than 90% whereas symptoms such as heaviness, fatigue, cramps (termed varicogenic symptomatology) were improved in less than 10%. These findings support that operations for varicose veins in the legs of patients with lymphedema, lipedema, or combinations of these disorders should be undertaken only if there is an absolute indication present (ascending phlebitis and/or bleeding). Otherwise, complete decongestive physiotherapy is still the best treatment approach for these groups of patients.

PMID: 11191657 [PubMed - indexed for MEDLINE]

Interventions for varicose veins and leg lymphedema in pregnancy.

Interventions for varicose veins and leg lymphedema in pregnancy.
Cochrane Database Syst Rev. 2007 Jan

Bamigboye AA, Smyth R.
Mediclinic Private Hospital and Department of Obstetrics and Gynaecology, University of Witwatersra, PO Box 15184, Nelspruit, Mpumalanga, South Africa, 1200. bami@medinet.co.za

BACKGROUND: Pregnancy is presumed to be a major contributory factor in the increased incidence of varicose veins in women, which can in turn lead to venous insufficiency and leg oedema. The most common symptom of varicose veins and oedema is the substantial pain experienced, as well as night cramps, numbness, tingling, the legs may feel heavy, achy, and possibly be unsightly. Treatment of varicose veins are usually divided into three main groups: surgery, pharmacological and non-pharmacological treatments. Treatments of leg oedema comprise mostly of symptom reduction rather than cure and use pharmacological and non-pharmacological approaches.

OBJECTIVES: To assess any form of intervention used to relieve the symptoms associated with varicose veins and leg oedema in pregnancy.

SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (October 2006).

SELECTION CRITERIA: Randomised trials of treatments for varicose veins or leg oedema, or both, in pregnancy.

DATA COLLECTION AND ANALYSIS: Both review authors independently assessed trials for eligibility, methodological quality and extracted all data.

MAIN RESULTS: Three trials, involving 159 women, were included.

VARICOSE VEINS: One trial, involving 69 women, reported that rutoside significantly reduced the symptoms associated with varicose veins (relative risk (RR) 1.89, 95% confidence interval (CI) 1.11 to 3.22). There were no significant differences in side-effects (RR 0.86, 95% CI 0.13 to 5.79) or incidence of deep vein thrombosis (RR 0.17, 95% CI 0.01 to 3.49).

EDEMA: One trial, involving 35 women, reported no significant difference in lower leg volume when compression stockings were compared against rest (weighted mean difference -258.80, 95% CI -566.91 to 49.31). Another trial, involving 55 women, compared reflexology with rest. Reflexology significantly reduced the symptoms associated with oedema (reduction in symptoms: RR 9.09, 95% CI 1.41 to 58.54). There was no evidence of significant difference in the women's satisfaction and acceptability with either intervention (RR 6.00, 95% CI 0.92 to 39.11).

AUTHORS' CONCLUSIONS: Rutosides appear to help relieve the symptoms of varicose veins in late pregnancy. However, this finding is based on one small study (69 women) and there are not enough data presented in the study to assess its safety in pregnancy. It therefore cannot be routinely recommended. Reflexology appears to help improve symptoms for women with leg oedema, but again this is based on one small study (43 women). External compression stockings do not appear to have any advantages in reducing oedema.

Plain language summary

Not enough evidence on treatments for varicose veins and leg oedema in pregnancyVaricose veins, sometimes called varicosity, occur when a valve in the blood vessel walls weakens and the blood stagnates. This in turn leads to problems with the circulation in the veins and to oedema or swelling. The vein then becomes distended, its walls stretch and sag, allowing the vein to swell into a tiny balloon near the surface of the skin. The veins in the legs are most commonly affected as they are working against gravity, but the vulva (vaginal opening) or rectum, resulting in haemorrhoids (piles), can be affected too. Pregnancy seems to increase the risk of varicose veins and they cause considerable pain, night cramps, numbness, tingling, the legs may feel heavy, achy, and they are rather ugly. Treatments for varicose veins are usually divided into three main groups: surgery, pharmacological treatments and non-pharmacological. The review identified three trials involving 159 women. Although the drug rutoside seemed to be effective in reducing symptoms, the study was too small to be able to say this with real confidence. Similarly, with compression stockings and reflexology, there were insufficient data to be able to assess benefits and harms, but they looked promising. More research is needed.

Cochran Library

Short Stretch Bandages are for Leg Lymphedema

Short Stretch Bandages are for Leg Lymphedema
The short stretch bandage is a wrap used in the treatment of lymphedema. It is called “short strech” because of it rating on elasticity. These bandages are rated at approximately 70%, which means they can stretch up to 70% beyond their actual non extended length. Because of this, they are able to provide continual compression on the lymphedema limb. They work inconjunction with your muscles to help not only prevent additional swelling, but to help lymph flow.

Short strech bandages are used extensively for both the treatment phase and management phase of lymphedema.

Pat

Wear And Care For Short Stretch Bandages

Your doctor or lymphedema therapist assistant will be able to provide you with the correct bandages. He/she will also walk you through proper fitting and caring practices for your garments. Bandages should be firm. Wash them everyday in a mild detergent (Ivory or Dreft– NOT Woolite) in a laundry bag if lymph fluid leaks through the skin. Never put them in a dryer as this will destroy the elasticity. I always hang them in a “z” on a hanger.

Short stretch bandages are usually not covered by your insurance company. Once you know the specific types of bandages you use, you may purchase them online. Many companies provide a wide selection of brand name bandages. They offer fast delivery and low prices, with all orders being safe and secure.

Short Stretch Compression Bandages

Minimally elastic. They compensate for the diminished skin pressure associated with lymphedema, and prevent the reaccumulation of evacuated, stagnating lymph fluid. The more inelastic the bandage is, the greater the potential working pressure (pressure produced when the muscle pump works against the resistance of the bandage, as when exercising). Inelastic and short stretch bandages have advantages over elastic garments because they force a higher working pressure and greater muscle pump efficiency. Conversely, because of the low resting pressure (pressure exerted when the muscle is inactive and relaxed), compression bandages may be worn day and night with good patient compliance.

Compression bandaging is applied in layers. The digits (fingers and toes) are individually wrapped with gauze bandages. A tubular bandage, made of primarily cotton, is worn underneath the compression padding and bandages to protect the skin and absorb excess perspiration. Padding bandages are applied just prior to the actual compression bandages to cushion the limb (especially over skin creases or bony prominences) and to prevent sharp indentations and irritations to the skin. In addition, they serve to distribute the pressure evenly over the limb. The last stage is the actual short stretch compression bandages used to apply the final compression. They are wrapped with mild to moderate tension in an overlapping pattern in a distal to proximal direction.

Short Stretch Bandages FACTS

by Paige-Leigh Zazzali

Compression sleeves and stockings may not be comfortable for some patients with lymphedema. Short stretch bandages provide relief and alleviate swelling in the affected limb or area. Bandages also allow more flexibility for the patient.

Short Stretch Bandages can remain on the affected area all day and night as long as you still feel comfortable. Patients may use soft cotton padding underneath the bandage if they have sensitive skin. Bandages over 6 months old should not be used. It is ideal to have two sets of short stretch bandages, and replace them every 2-3 months.

Why Not Use Ace Wraps?

One should not use ace wraps as an alternative for several reasons. Ace wraps are very elastic, able to stretch to several times their original length. As a result, they are not able to provide the needed compression rating on the limb.

Another problem associated with ace wraps is that they can cause irregularities in the shape of the affected limb. Due to the elasticity, it is almost impossible to have an equal and consistent pressure grade on the limb. This “bunching” or irregularity further hinders lymph flow.

Short Stretch Bandage versus Ace Wraps

Q I am having difficulty wrapping my leg with the compression bandages. I have a friend who has wrapped his ankle for years with ace wraps and he is willing to help me with my bandages. These techniques are basically the same, right?

A: I am glad you are seeking assistance if you are having difficulty with self-bandaging. I applaud your friend for his willingness to assist you. However, I would encourage you to make an appointment for you and your friend with your Certified Lymphedema Therapist.

The compression bandages used for treatment of Lymphedema are not the same as Ace wraps.

There are two types of pressure at work with compression bandages. The first is “Working Pressure.” This is the resistance the bandage places against the muscles when you are active, up walking, doing exercises, etc. It is important for the compression bandages to have a High Working Pressure in order to keep fluid from recollecting in the extremity during activity. The lower the elasticity of the bandage, the higher the Working Pressure. The second pressure is called “Resting Pressure.” This pressure depends on the amount of tension (Stretch) used with the bandage. The Resting Pressure is a permanent pressure exerted on the venous and lymphatic vasculature and may cause a tourniquet effect on the extremity. The higher the tension, or stretch, equates to a higher resting pressure.The Short-Stretch Bandages used for LE have lower elasticity than Ace wraps which are considered a Long-Stretch Bandage. Short-Stretch Bandages have a LOW Resting Pressure, and a HIGH Working Pressure. The High Working Pressure is to support removal of fluid from the affected extremity and further evacuation of fluid from the extremity during the active time. LOW Resting Pressure of Short-Stretch Bandages reduces the changes of the tourniquet effect.

It is important that only trained therapists, or caregivers/friends provided education by a trained therapist, apply Short-Stretch Compression Bandages or assist in the bandaging process. Compression bandages are essential to the successful reduction of fluid and protein from the affected extremity. It is vital that the bandages be applied correctly, with proper tension and padding.

Also, inform your therapist of any specific difficulties you are having with self bandaging. Your therapist may have some tips/techniques that will solve your bandaging difficulties. Notify your therapist that your friend will accompany you to your next appointment to receive education regarding bandaging techniques. This also will allow your therapist to allot the time necessary for the education.

NLN LymphLink Question Corner

Examples of short-stretch bandages

Examples of short-stretch bandages are Unna's paste bandage and Comprilan® (Beiersdorf Medical, Charlotte, NC). Ace® bandages are inappropriate as a treatment of venous ulceration. Prescription compression stockings can be used in the maintenance phase of treatment. Prescription compression stockings can be used in the maintenance phase of treatment.

Generally calf length stockings are used with 30-40 mmHg or 40-50 mmHg. It is easier for some patients to apply a zippered stocking over a cotton liner (Jobst Ulcercare®; Jobst-A Beiersdorf Company, Charlotte, NC) or to superimpose two 20-30 mmHg stockings (yielding 40 mmHg). Consider intermittent pneumatic compression in patients who don't respond to standard compression measures and in patients who are not ambulatory.

Compression leads to increased venous flow, decreased pathological reflux while walking, and increased ejection volume with activation of the calf pump. Tissue pressure is increased which favors resorption of edema fluid. In order to achieve maximum benefit from compression the patient needs to ambulate.

Phlebology.org

A prospective randomised trial of four-layer versus short stretch compression bandages for the treatment of venous leg ulcers.

Scriven JM, Taylor LE, Wood AJ, Bell PR, Naylor AR, London NJ.
Department of Surgery, University of Leicester.

This trial was undertaken to examine the safety and efficacy of four-layer compared with short stretch compression bandages for the treatment of venous leg ulcers within the confines of a prospective, randomised, ethically approved trial. Fifty-three patients were recruited from a dedicated venous ulcer assessment clinic and their individual ulcerated limbs were randomised to receive either a four-layer bandage (FLB)(n = 32) or a short stretch bandage (SSB)(n = 32). The endpoint was a completely healed ulcer. However, if after 12 weeks of compression therapy no healing had been achieved, that limb was withdrawn from the study and deemed to have failed to heal with the prescribed bandage. Leg volume was measured using the multiple disc model at the first bandaging visit, 4 weeks later, and on ulcer healing. Complications arising during the study were recorded. Data from all limbs were analysed on an intention to treat basis; thus the three limbs not completing the protocol were included in the analysis. Of the 53 patients, 50 completed the protocol. At 1 year the healing rate was FLB 55% and SSB 57% (chi 2 = 0.0, df = 1, P = 1.0). Limbs in the FLB arm of the study sustained one minor complication, whereas SSB limbs sustained four significant complications. Leg volumes reduced significantly after 4 weeks of compression, but subsequent volume changes were insignificant. Ulcer healing rates were not influenced by the presence of deep venous reflux, post-thrombotic deep vein changes nor by ulcer duration. Although larger ulcers took longer to heal, the overall healing rates for large (> 10 cm2) and small (10 cm2 or less) ulcers were comparable. Four-layer and short stretch bandages were equally efficacious in healing venous ulcers independent of pattern of venous reflux, ulcer area or duration. FLB limbs sustained fewer complications than SSB.

PubMed

Physical properties of short-stretch compression bandages used to treat lymphedema.
King TI, Droessler JL.

Occupational Therapy Department, University of Wisconsin-Milwaukee, PO Box 413, Milwaukee, Wisconsin 53201, USA.

This study examined the physical properties of six common brands of short-stretch compression bandages used to treat lymphedema. The physical properties examined were (a) maintenance of pressure over a 12-hr period, (b) variability of pressure across the width of the bandages, and © variability of pressure when the bandages were wrapped with a 50% overlap. The results of the study indicate that all six brands of bandages tested maintain pressure well over a 12-hr period. Each has a variance of pressure between the middle and edge of the bandage, with the edges measuring (in mmHg) between 6% and 28% lower than the middle. When the bandages were wrapped with an 50% overlap, all six brands measured fairly consistently in pressure readings (in mmHg) across the width. These results indicate that the six brands of short-stretch compression bandages tested have similar physical characteristics.

PMID: 14601819 [PubMed - indexed for MEDLINE]

A comparison of multilayer bandage systems during rest, exercise, and over 2 days of wear time.

Department of Dermatology, University Hospital of Zurich, Gloriastrasse 31, CH8091 Zurich, Switzerland.

Hafner J, Botonakis I, Burg G.

jhafner@derm.unizh.ch

OBJECTIVE: To study the interface pressure between the leg and 8 different multilayer bandage systems during postural changes, exercise (walking), and over 2 days of wear time.

DESIGN: Comparison of 8 different compression bandages under standardized conditions.

SETTING: Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland.

PARTICIPANTS: A series of 10 healthy volunteers, 5 females and 5 males, aged 26 to 65 years.

INTERVENTION: An electropneumatic device was used to measure interface pressure at 12 points of the leg.

MAIN OUTCOME MEASURES:

(1) Pressure changes from the standing to the sitting and supine position at rest,

(2) pressure amplitude during exercise (200-m treadmill walk at 3.2 m/s, 0 degrees incline), and

(3) pressure decrease over 2 days of wear time.

RESULTS: Results are given as median with the 10% to 90% confidence intervals. Multilayer bandages of short and medium stretch showed a larger pressure decrease when the patient was supine (eg, 3 short stretch bandages: 18.0 mm Hg [reference range, 15.5-19.5 mm Hg]) than systems of medium and long stretch bandages (eg, 4-layer bandage, 6.0 mm Hg [reference range, 4.5-7.0 mm Hg]) (P=.005). The amplitude of pressure waves during exercise was comparable among most multilayer bandage systems. The pressure loss over time was the smallest in elastic bandages (eg, 4-layer bandage, 6.0 mm Hg [reference range, 0.0-10.5 mm Hg]), compared with short stretch bandages (eg, 3 short stretch bandages, 18.0 mm Hg [reference range, 16.5-20.5 mm Hg]) (P=.005).

CONCLUSIONS: Highly elastic multilayer bandage systems showed the smallest pressure loss over several days, but the small pressure decrease when the patient was supine makes them potentially hazardous to patients with arterial occlusive disease. Short stretch bandages and the Unna boot with an inelastic zinc plaster bandage generate large pressure waves while walking and showed a marked pressure decrease when the patient was supine, but they lose a lot of their pressure within the first hours of wear. Multilayer systems composed of short stretch and cohesive medium stretch bandages represent a good compromise between elastic and inelastic bandage systems (moderate pressure loss over time, large pressure decrease on lying down). The clinical effectiveness of the different types of compression still remains to be studied.

PMID: 10890987 [PubMed - indexed for MEDLINE]

Lymphedema Short Stretch Bandage - Suppliers and Vendors

Lymphedema Products

Bandages Plus

Academy of Lymphatic Studies - Academy Store

Drapers Fitness - Lymphedema Bandages

Allegro Medical

Discount Surgical Stockings

Juzo Stockings

Bio Concepts Inc

Support Hose Store

eWellness

First Aid Direct

Farrow Medical Innovations

About Leg Lymphedema Sleeves and Garments

About Leg Lymphedema Sleeves and Garments

Most people do not know what lymphedema is until they have it. Once diagnosed they are shocked and concerned about what to do. There are several different options for the treatment of lymphedema including various kinds of compression garments. They often are recommended to prevent swelling when flying on an airplane. The Ted Mann Family Resource Center at UCLA has pamphlets on this topic. There are a few people around the country that specialize in this treatment.

Many patients will be prescribed garments that will provide compression for the affected limb. The garments help to keep fluid from accumulating in the limb. These garments have specific amounts of pressure and can be worn on the legs, hands, feet, or arms. The garments are made of a tight stretchy fabric. An expert fitter must fit lymphedema garments (sleeves).

Measurements are taken, and a patient must try on the sleeves to make certain that they have a comfortable fit.

Sometimes custom sleeves must be made, but most people are able to find a pre-made sleeve in a suitable size. The sleeves prevent the accumulation of more fluid in the limb; they do not pump fluid out of the limb. The garments are usually used in combination with therapy or as a preventive or maintenance measure. Lymphedema sleeves and treatment can change the size of the affected limb as can various activities. Sometimes patients need more than one sleeve during this process because of the changing size of the limb. There is a tendency for patients to think that their sleeve has been fit improperly. Sometimes it has been, but more often than not, the limb has changed in size.

Note these sleeves wear out with continued daily use and must be refit and replaced on a regular basis (approximately every 3-6 months). Over time with washing and wearing they lose their compression. Different levels of compression are used for prevention versus maintenance.

For individuals with more severe or chronic lymphedema, Reflections carries two products that help to move fluid from the extremity, therefore, having a therapeutic effect. These two products are called CircAid and the Reid Sleeve. They are both custom made for the patient.

Do I need a prescription for a lymphedema garment?

Yes, a prescription is needed even for a prevention sleeve. Your doctor or nurse practitioner may write your prescription. A typical prescription for a lymphedema sleeve reads as follows:

“Compression garment for (leg, arm, hand, foot) (right, left, bilateral), for (diagnosis - type of cancer or other condition). Compression of (amount of pressure to be specified by doctor).”

Even if your insurance company does not reimburse for the cost of these products, a prescription from your doctor will allow you to purchase the item without paying sales tax. Your doctor may fax the prescription directly to Reflections (310-794-9088) and we will hold it until you come for your fitting.

Will lymphedema garments be covered by insurance?

Medicare does not cover the price of lymphedema garments; however, many other insurance plans do. It is important to talk to your insurance company to determine whether these are covered items and what kind of authorization may be needed. Your doctor may be required to provide a medical justification for your compression garment in order for your insurance company to reimburse for the product. Many doctors do not fully understand these sleeves, how they work or what may be required by your insurance company. Talk to your doctor about these issues at the time your referral is made. Inform them that you may need a letter justifying the need and that they may need to provide this on an ongoing basis as your garment needs to be changed or renewed.

What are the prices of these products?

The products vary in price. Those that are custom made are more expensive than those which are stocked as part of our regular inventory. The following listing will provide an approximate idea of the range of prices for these products. The most important concern is to obtain the best product for your particular condition, which should be assessed by the physician/treatment team who is involved with the care of your lymphedemagarment.

Cancer Resources

Compression Garments for the Treatment of Lymphoedema

by: Judith R. Casley-Smith & J.R. Casley-Smith (L.A.A., University of Adelaide)

Compression garments and compression bandages, are probably the most difficult problem we have had in the maintenance and control of lymphoedema before, during and after treatment. These are not yet completely solved. However the situation is a great deal better than it was in 1987 in Australia , when we introduced Complex Physical Therapy (C.P.T., Complex Lymphatic or Lymphedema Therapy - C.L.T.). They are absolutely essential for maintaining the great reductions achieved by this combination of treatments.

Compression garments are necessary

1. to prevent lymphoedema occurring or increasing,
2. to try to maintain the size of the limb when treatment is unavailable or unaffordable,
3. to maintain the reduction achieved after treatment, and to continue the remodelling of the limb.

1. Prophylaxis - Prevention of Lymphoedema

If a limb is a risk (e.g. after a mastectomy, operation for melanoma, etc.) then a correctly fitting garment should be kept on hand for immediate wearing, e.g., after an injury, during an aircraft flight (even for just one hour!), or excessive work causing aching and leading to swelling, etc. Prevention is of the utmost priority, because it is much easier to prevent lymphoedema than to treat it! However the garments in this situation should be no more than 30 mm Hg for arms and 40 mm Hg for legs (much higher pressures can, and should be used after a course of C.P.T.

2. Garments used as the only Treatment

If no other treatment is used, good compression garments will limit the amount of swelling and thereby slow the advancement of lymphoedema. Some patients even get reductions in their limbs using just such garments and the L.A.A. exercises. However, this is far from the ideal. Again, the pressure must be less than if the limb had been reduced with (C.P.T.).

3. After Therapy

For reasons already mentioned, these are essential after C.P.T. If patients do not wear and maintain garments correctly they just throw time, effort and money away!

The Choice of a Garment

Availability is almost as important as efficacy. There is no point in treating a patient by C.P.T., and then having to wait weeks for a suitable garment to arrive. A patient, alone, is often not able to bandage themselves as is done in the clinic (especially post-mastectomy patients). In fact it is hard enough for some to put on a pressure garment. This means that the choice of appropriate bandages and sleeves/stockings depends very greatly on good suppliers. If the garment has to be custom made, it is helpful to have a local seamstress who can do any fine alterations necessary. (However if this is done the garment guarantee is often invalidated.)

Once a therapist is experienced, they find that almost all of the reduction occurs in the first 7-10 days. When they are confident of this, a suitably-fitting garment may possibly be ordered at this point if a made-to-measure one is required. In this regard, it is essential that measurement of the patient in the clinic or by a supplier is done absolutely correctly. Mistakes can be made, but it should not be the patient who has to bear that cost.

Choice is also limited by whether a patient can actually be fitted with a ready-made garment, or whether they need a custom-made one. Children and many patients with primary lymphoedema can only be fitted with custom-made ones. Use of a regular (standard) garment is advised if the patient correctly fits the measurement parameters. This overcomes the possibility of mistakes in the size or fit of a made-to-measure garment; it is also cheaper. We stress that the regular garment must fit correctly and comfortably. However a made-to-measure garment may be still more comfortable to wear.

The quality of the fabric is also important. These garments must last at least 4 months. They need to be changed and washed daily, especially in a hot climate. Patients must follow the manufacturer's washing instructions and should never allow them to dry in the sun or in a drier. Jobst-Beiersdorf supplies Jobst 'Jolastic' a special washing solution for elastic garments, but there are other suitable mild detergents.

Patients must be shown how to put on the sleeve/stocking so as to cause minimum stress on it. Rubber gloves with a raised pattern on the finger tips should be used. (Sigvaris supply these, or certain washing-up gloves are suitable.) Such gloves will:

protect the garment from fingernails, rings, etc., make them easier to get on, allow the garment to be adjusted evenly over the limb and fit it correctly.

Care must be taken in the use of skin preparations when wearing a garment. Although some have been recommended for use under garments (Com-pat Body Lotion - Jobst), the manufacturers do not guarantee that they will not affect the life of the garments. Of course wearing a bandage at night allows suitable skin care products to be used easily.

We also stress the importance of skin care. Be aware of the list of products from Hamilton Laboratories and from certain other manufacturers. Particularly recommended are: Hamilton's Body Wash, plus Shower Oil as a moisturiser. These are much preferable to soap for lymphoedema. Other useful products are: Dimethicream or Skin Repair for general moisturising, Urederm for the treatment of chronic dry skin and Dermex 7A as a protection and moisturiser while swimming or during hydrotherapy in pools. Castellani's Solution can be used on any moist 'folds' (ask your pharmacist for it); 'Minidine' also works well. Remember protective sunscreens. Lodema (coumarin) powder is very good under a garment. Lodema (coumarin) ointment can however only be used under bandages or if a garment is not used at night; it is also good for bites, stings cuts, burns or bruises.

The comfort, and therefore the patient's compliance, is of great importance for maintaining the gains made during therapy. Hence much depends on the fit of the garment and the material used.

Some patients have allergy problems to synthetic materials and a cotton coating of the elastic fibres is then very important. Some garments 'breathe' more than others, giving greater comfort and compliance. A new garment may cause pressure or irritation at a joint or under the arm; a lining in the garment at this point or powder or a smooth adhesive dressing (e.g. 'Fixomull', Jobst) may alleviate this.

It is useful for the patient to wear the garment for the last few days of treatment so that all the above problems can be checked. It will also give a good indication as to whether the compression is adequate. If not, a second, lower grade, over-garment will be needed also.

A number of patients need gloves or mittens. The gauntlet variety (i.e. attached to, and part of the sleeve) are preferable in that they reduce the risk of a pressure band at the overlap. This is difficult with a stocking. Separate bandaging of the toes and distal part of the foot may be needed.

Garments should be able to be worn easily and stay in place without slipping. A woman with a prosthesis often cannot maintain an arm sleeve in place with a support strap attached to her bra strap on that side. It may be more comfortable to wear a chest garment incorporating a bra and sleeve, joined with a slit under the arm to allow for breathing and perspiration. A wide strap around the chest below the other breast may work.

Many bands used on garments are too narrow to be comfortable and need to be replaced by something wider. Similarly, a waist band to support a leg stocking may slip - allowing the stocking to slip down. In this case a pantyhose arrangement, with one leg cut off (if only one is lymphoedematous) and a slit at the crutch, feels more secure and a lot more comfortable.
After a mastectomy a well fitted bra should always be worn. The straps should not cut into the shoulders, nor should wire under a cup cause red lines or indentations. These will both restrict lymphatic drainage. Realize that the opposite breast is also 'at risk' of swelling due to overloading of the natural collateral drainage. Similarly with a lumpectomy plus radiotherapy, the breast on which this was performed is also 'at risk' and should be properly supported.

There are solutions available which have been specially made to stick the garment to the limb (e.g. 'It Sticks!' from Jobst and 'It Sticks' from Sigvaris). These must be used with care and applied as a number of vertical stripes. If they are applied horizontally in a ring around the limb, they can shrink as they dry. They pull the garment with them and so cause a band of excess pressure at the top of the limb, which will restrict lymphatic drainage. So be careful!

One needs to be wary of a stocking or sleeve that stops too short of the top end of the limb, or that causes a pressure band at that (or any other) point. This will reduce lymphatic drainage as well as causing a band of fibrous tissue to form which also later reduces this.

Patients also need to be aware of the amount of exercise that they should do. If too much is attempted, the limb will swell further; then the garment becomes uncomfortable. The patient then feels it is too tight and so takes it off, then the limb swells still further and a new garment is required of a larger size! Some patients also like to remove their garments for long periods of time (e.g. at night). Then the limb again swells and the patient feels that the garment was the wrong size and may wrongly blame the clinic or the supplier!

These principles also apply to the treatment of acute injury and to oedemas (usually lymphoedemas) caused by paralysis or confinement to wheel chairs.

Similarly, venous oedemas (including chronic venous insufficiency and during pregnancy) should be treated with compression stockings, but of a lower grade (18 - 48 mm Hg is usually recommended by the manufacturers and therapists).

Patients with a lympho-venous shunt, diabetes or arterial insufficiency can only tolerate a garment with a lower pressure than usual. This also applies to untreated patients.

If a patient finds it too difficult to put on a high compression garment, then two lower compression ones - on top of each other - may be preferable. But a 40 mmHg plus a 30 mm Hg one do NOT give 70 mm Hg, but approximately 55 mm Hg.

For lymphoedema of the leg, unlike for chronic venous insufficiency or varicose veins, a full thigh-high stocking is essential to prevent just pushing the lymphoedema above the knee. In venous oedema, a calf stocking of lower pressure is sufficient unless lymphoedema is also present.

When choosing a garment or sock, it is very important that it does not cause constriction just below the knee - thus preventing drainage and leading to swelling. Some socks are not long enough for taller people and slip when walking; if so, get one that comes to mid-thigh (which will also alleviate the problem of a 'tourniquet' effect below the knee.

Good communications and suggestions between the patient and therapist, and between the therapist and the supplier are essential to provide the best possible service for the patient. Pressure sometimes needs to be applied to the manufacturer to actually supply the patient's need and thereby to give an efficient service. A patient with problems should always return to their therapist. Analgesics should never be taken just to overcome constant pain from an ill-fitting bandage or garment. Manufacturers try hard to accommodate customer requirements, but need feed-back to understand.

An excellent book for for doctors and therapists who wish further more detailed information is: Hohlbaum GG. The Medical Compression Stocking. Stuttgart & New York, Schattauer, 1989.

Vital Points on Compression Bandages and Garments

Treatment for lymphoedema is a continual process. It is not cured by one course of treatment. While a therapist can reduce the swelling initially, the patient is responsible for maintaining that reduction. What follows are a few simple rules, all are vital!:

1. The bandages or garments must be worn all day and all night.

2. Each set of bandages, or a garment, must be changed and washed at least every couple of days.

3. Care must be exercised when putting on bandages or garments.

4. Bandages or garments must be replaced if they lose elasticity or are damaged.

5. At least two sets of bandages or garments must be owned.

6. Order a new garment well before an old one has worn out.

7. The manufacturer's washing instructions must be followed and they must not be dried in the sun or in a drier.

8. The therapist must be consulted if a limb becomes painful or discoloured (e.g. blue toes), or if a garment chafes or is too loose or too tight.

9. Nights are more restful if the patient changes bandages or garments before sleeping.

10. Wash the limb thoroughly when changing bandages.

Lymphoedema Association of Australia

HELPFUL POINTS WHEN APPLYING YOUR LYMHPEDEMA LEG GARMENT

HELPFUL POINTS WHEN APPLYING YOUR LYMHPEDEMA LEG GARMENT
The use of rubber gloves

Using common household rubber gloves simplifies the procedure of applying your garment. Rubber gloves allow you to smooth out the fabric with a minimum effort and grip the material. Rubber gloves also protect the fabric from runs/snags caused by fingernails.

The use of slip on aids

Sometimes garments slide down the arm or leg. Sliding or rolling of the fabric can reduce the effectiveness of the compression garment and be bothersome to you. This problem can be eliminated with the use of adhesive lotion. If this is a problem with you, talk to your therapist.

To use adhesive lotion, put the garment on and turn the top of the border over and apply the adhesive lotion to the area where the garment ends. Allow 3-4 minutes for the lotion to become tacky. Then turn the garment border back over.

Proper fit and garment distribution

It is important to notice that the fabric is woven in straight lines, after application of the garment, make sure seams and stitches run vertically. If this is not the case, use your rubber gloves to straighten the fabric. It is a common mistake to over-stretch the garment while applying it. This leads to a loss of support (compression) in your garment. If the garment is constantly bunching up behind the knee, it is most likely over-stretched. To correct this, simply work the fabric downward towards the calf.

The use of adhesive lotion

Sometimes garments slide down the arm or leg. Sliding or rolling of the fabric can reduce the effectiveness of the compression garment and be bothersome to you. This problem can be eliminated with the use of adhesive lotion. If this is a problem with you, talk to your therapist. To use adhesive lotion, put the garment on and turn the top of the border over and apply the adhesive lotion to the area where the garment ends. Allow 3-4 minutes for the lotion to become tacky. Then turn the garment border back over.

ProRehab, PC has certified fitters for Juzo, Jobst & CircAid.

Compression Garments and Stockings for Leg Lymphedema

Compression Garments and Stockings for Leg Lymphedema

There are three broad groups of compression appliances we use in the treatment and mangement of lymphedema.

First are the compression bandages that are generally used during the treatment phase and that we wrap our legs or arms with each day.

Secondly are the compression garments referred to generally as compression stockings. After our treatments are complete and the limb is reduced as far as we can get it through MLD or CDT the next step is in wearing these compression stockings.

You can buy them “off the self” or have them custom made for your exact measurements. I personally believe the custom made type is the superior ones to use, even though they do cost a great deal more.

Below is a compilation of articles that go indepth on what these stockings are, why we use them, how to use them, the benefits and finally how to care for them.

Pat

Compression Garments - Off the shelf versus Custom Made

We had a question in our Lipedema Yahoo group regarding which variety of compression garment works best, our always wonderful and brillant member Helen, a therapist from the UK posted this response. Thought I would share it here as well.

(Thanks Helen what ever would we do without you!)

You just know that Helen's got to stick her oar in with post! (see below). Red rag to a bull!

What a lot of confusing, contradictory information there is out there that is being given to those with lipoedema! I find it hard to believe.

I go back to my request for us all to be “singing from the same hymn sheet” as much as possible.

“Off the shelf” garments are just that - they are picked for you off the shelf. That means they haven't been made specially for you but will fit people whose measurements are within the range that that particular garment fits.

The problem with these garments is that for some people they might have, for example, a very small ankle, maybe a small knee, but a disproportionately larger calf. But if the calf size still fits within the range of the off-the-shelf garment (but at the top end of the measurement) and the ankle and knee are on the lowest end of the scale of the garment measurements, it will mean that that garment will have a looser fit at the ankle and knee, compared with the calf. And that has the squeezed-in-the-middle-effect of the long balloon that I wrote about last week.

The custom-mades however, are made specially for you, using your measurements. That means that if you have typical lipoedema (tiny ankle, bigger above in slight or large bulges) the garments can be made to fit your body. It won't fit anybody else's.

In terms of time, it depends if the therapist or pharmacy has these garments in stock if you are prescribed 'off-the-shelf' hosiery - if not then they still have to be ordered and I have no idea how long it takes for them to arrive (others on the site will answer that for you). I never order 'off the shelfs' - I only clear up the mess of those who do order them incorrectly for my clients… a long, frustrating story!!! Certainly I have had clients whose 'off-the- shelf' garments take 3 weeks to arrive. Not much of a 'service', if you ask me, and fairly useless, especially if the client has some lymphoedema present.

If you have custom-mades, they take 5 days from Germany, generally (Haddenham Healthcare garments). Your garment needs to be with you for when the intensive treatment (MLD and bandaging for 10 days +) finishes. I measure my clients on treatment day 5. The timing of the arrival of the garment is crucial for lymphoedema but I find it's not too serious with straightforward lipoedema, if it's late.

In terms of the fabric and ease of getting on…. it annoys me that people in need of good advice are not being given it. You should have been told that you need the appropriate compression fabirc for you. So the fact that an 'off-the-shelf- garment' might be easier to get on will relate to it being cheaper and of poorer quality. Yes, custom-mades might be a stronger fabric but - the same manufacturer will also sell a range of 'off-the-shelf' hosiery…and those garments will be in the same fabric as their custom-mades.

It's just that money rules. Therefore there are manufacturers around who supply to hospitals and surgeries where the NHS (in Britain) or insurance companies are obviously after a cheap option. And that affects the quality of the garment. But those same institutions are aware that as far as the population goes, as a whole, for 'the greater good', some compression is better than no compression.

But that doesn't mean that 'some compression' is enough for you! You are an indvidual with individual needs. You are not just a series of measurements - there is much to be considered. Your properly trained MLD (Manual Lymphatic Drainage) therapist should be able to advise you correctly.

However, there will always be some individuals who do happen to fit off-the-shelf garments (good quality ones - always check) and that is fortunate for those people.

I would always consider custom-mades first - as there is usually much better choice of fabric and colour. I would rather have a high proportion of cotton and the choice of 'without crotch' than a sweaty pair of tights that squeeze in the wrong places. But that's just me - I don't fit standard off-the-shelf compression.

Hope that is clearer than mud. I think a table woud be a good thing to put on here with examples of the off-the-shelf measurements for a typical manuafacturer. However, Yahoo doesn't seem to display them properly - I have tried in the past.

Have a good day Helen MLD therapist, UK

It's All in the Stocking

By Joy C. Cohn, PT, CLT-LANA, and Anne Lowry, MS, PT, CLT-LANA

Lymphedema management has changed dramatically in the United States over the past decade as health care professionals have trained in the European techniques known as complete decongestive therapy or complex decongestive therapy. The treatment of this chronic condition occurs in two phases. Phase one is generally intensive (1–5 days per week for 1–6 weeks) including manual lymphatic drainage, skin care, compressive bandaging, and remedial exercises. At the end of this intensive phase of treatment, when the limb has been “decongested” or reduced in volume, the patient is usually fitted with a compression garment to maintain the reduction. This commences the second (or maintenance) phase during which patients use self-treatment techniques as well as compression garments to maintain the reduction achieved in the first phase. Success in selecting and fitting the compression garment is essential to effective long-term control of edema.

External compression reduces ultrafiltration from the vasculature, enhances the musculoskeletal pump, increases the resorption of fluid into the venous and lymphatic system, reduces the local volume in the veins, and helps maintain the limb shape.1 During phase one, compression bandaging with low stretch bandages allows for a precise fit, readily adapting to the changing shape of the limb. However, bandaging is bulky, time consuming to apply, and unattractive. Garments offer considerably more freedom of movement in a more attractive form.

CHOOSING THE RIGHT GARMENT

Selecting an appropriate compression garment is probably the most challenging task in lymphedema treatment. It is important to begin the discussion of garments early in the course of treatment. It often takes time for patients to adjust to the fact that they will need a garment. In many instances, patients must pay all or part of the cost of the garment, and they will need to plan in advance for the expenditure.

Important factors to consider when choosing a compression garment are: coverage, compression class, appearance, custom-made versus ready-made, material, construction, suspension, skin condition/sensitivity, donning/doffing, and cost and source of payment.

When considering coverage, preventing edema distally or proximally to the garment is important. During the decongestive phase of lymphedema treatment, the therapist will have learned whether, for instance, a bandage to the knee has caused an increase in knee or thigh volume. In that case, the patient will need a garment to the thigh or perhaps to the waist. Usually an arm sleeve will be accompanied by a separate glove or gauntlet to prevent trapping fluid in the hand. Some individuals never experience significant edema in the hand. If therapists back off on bandaging the hand during treatment and the patient does not experience any additional edema, this guides the decision as to whether to order a gauntlet, which just covers the back of the hand, or a full glove with edema control for all of the fingers. Some patients find they can even do without any hand garment, but in our practice, we always order at least a gauntlet since it is very difficult to predict exactly how every patient will respond.
Medical grade garments are available in various compression classes measured in millimeters of mercury (mmHg). These are standardized as:

Class I: 20-30 mmHg
Class II: 30-40 mmHg
Class III: 40-50 mmHg
Class IV: 50-60 mmHg

In a stocking, these numbers are the compression at the ankle with a gradually decreasing compression gradient to the top of the garment. Many ready-made stockings have a higher stretch fabric over the upper thigh called a mantissa. Even garments with the same fabric throughout will give lower compression over a larger diameter body part. Arm sleeves are generally Class I or II, and gloves and gauntlets are typically Class I. Lower extremity garments are generally Class II or III. Additional compression for the leg can be gained by using a higher compression class of garment or by layering a knee-high stocking under or over a longer stocking.

READY-MADE VS CUSTOM

Often the question of a custom-made versus a ready-made garment answers itself. Ready-made garments come in various girths, lengths, fabrics, and compression classes. They are made for a limb of average proportions, although some ready-made stockings do allow for an extra-wide calf and/or thigh. A patient with a disproportionate limb or who needs a higher compression class will require a custom garment.

Ready-made garments are less expensive, quicker to obtain, and easier to replace. They are usually made of relatively thin fabrics with few or no seams, making them cosmetically more acceptable to many patients. Their disadvantages are that they are less precise in fit, are more likely to roll at the top, and may not provide enough support.

Patients are always concerned about the appearance of the garment, particularly when the arm and hand are involved. Some garments are made only in beige, which has a medical connotation to some people, and which does not match the skin tone of darker-complected individuals. A garment may be ideal from a therapeutic point of view, but if the patient will not wear it for cosmetic reasons, it is useless. Sometimes the therapist has to choose a less effective garment that is acceptable to the patient. Some patients prefer a cosmetically desirable garment for public times, and a “workhorse” garment for sport or heavy activity.

FABRIC CONSIDERATIONS

Garments can be made of elastic or nonelastic fabrics. In general, the elastic fabrics are for daytime wear, while nonelastic ones can be worn day or night. Nonelastic garments provide compression by means of a series of hook and loop straps along the length of the garment. The wearer tightens the straps to the appropriate tension. Nonelastic arm sleeves and thigh-high leg garments are well padded with foam. They are comfortable, but too bulky for most daytime activities. Some lower leg garments are thin enough to be worn for walking. Nonelastic garments can be used in place of bandaging by patients who cannot bandage themselves.

The fibers used in elastic compression garments are generally latex rubber, synthetic rubbers, nylon, polyester, cotton, or a blend of these. Some are lined with cotton or silk for comfort. Fabrics can be thick or thin, depending on the fibers used and the amount of compression provided. In general, higher compressions mean heavier fabrics.

In selecting the fabric of an elastic garment, skin sensitivities are a paramount consideration. The compressive force in these garments comes from latex or synthetic rubber, so the therapist must know if the patient is allergic to latex. Most garments containing latex are knitted from a thread consisting of a latex core wrapped with nylon or cotton. A patient or helper at home who is severely sensitive to latex (eg, has a respiratory response to it) may not be able to use garments containing latex. Patients who have only a local allergic response may be able to wear them if an underliner is used.

There are three basic styles of garment construction: circular knit, flat knit, and cut and sew. Circular knit fabrics are seamless, but have a tendency to roll down at the top, especially if the area it covers is very fleshy. This creates a tourniquet effect, obstructing flow of fluid from the limb. In a flat knit garment, a flat piece of fabric is knitted to the patient’s measurements, and seamed up the back. These garments may roll less at the top. In addition, some flat knit garments are made of a coarse-textured fabric, which can provide a mini-massage to the skin, promoting improved fluid uptake and transport. A cut and sew garment is made of several pieces seamed together. More porous fabrics are cooler to wear, an important consideration for patient comfort.

To be effective and comfortable, the garment has to stay in place. Some will stay up by themselves. Some options are a silicone band inside the top edge or a few longitudinal (not circular) stripes of a clear body adhesive. For stockings, a garter belt, suspenders, or an extension of the garment to the waist are available. Arm sleeves can have extensions over the shoulder, which attach to a bra strap or a diagonal strap across the chest.

SKIN SENSITIVITIES

The condition of the patient’s skin will affect the choice of garment. Patients may have wounds or very fragile or sensitive skin. Pulling a tight garment over the skin can cause damage from shearing. In those cases, an understocking (even an ordinary thin nylon) will protect the skin, hold any wound dressings in place, and help the compression stocking slip on more easily. To decrease the friction of donning and doffing, custom garments and some ready-made garments can have zippers. Many patients ask for zippers in the garment. Zippers work well if patients have very narrow ankles or a paralyzed limb. We rarely recommend zippers because they do not eliminate the need to get the garment over the heel, they make the garment bulkier and less attractive, and many patients have difficulty closing the zipper once the garment is fitted on the limb.

For patients who need edema control for both legs, compressive panty hose can be difficult to don. An alternative can be a pair of thigh-high compression stockings with a compression bike pant over them. This arrangement is easier for most patients to manage, and is often more acceptable to men than a panty-hose style garment.
Compression garments are quite expensive, ranging in our area from about $50 for a pair of ready-made knee-high stockings to more than $500 for a custom-made waist-high garment. Some insurers will pay the supplier directly for the garments, some will reimburse the patient for all or part of the cost after the patient pays and submits a claim, but some insurers will not pay anything toward a compression garment. The only garments Medicare covers at present are stockings for patients who have been hospitalized with recurrent ulcers. Insurance plans differ widely and change frequently—another reason to open a discussion with the patient on reimbursment early in the treatment course.

USAGE

Garments are ordered when the patient experiences a plateau in volume reduction, when the limb is not edematous, and in certain instances, for reducing the risk of developing lymphedema. Compression garments are very uncomfortable when applied to an edematous extremity, and they rarely produce significant reduction when used alone.2 Measurement for garments should be done as early in the day as possible, when the limb is at its smallest. Treating therapists usually do the measuring themselves, although nontherapist fitters can be used.

Contraindications to the use of compressive garments are:1,3 acute

Important

infections/inflammation, cardiac edema, malignant lymphedema (relative), arterial disease, and acute vascular blockages (superior vena cava syndrome, acute deep venous thrombosis).

Extra precautions should be used in the case of: uncontrolled hypertension; paralysis; insensate limb; diabetes due to the high incidence of small vessel disease; and latex allergy (do not forget that the gloves used to don garments may have latex).

It is very important to educate patients in the proper use of their garments. We have seen many patients who have rejected garments in the past due to difficulty in donning or wearing them throughout the day but who successfully wear them with education. The education should include written and verbal instruction in don/doff procedures (including alternatives), care of the garments, and wearing and replacement schedules.

Donning and doffing are one of the major obstacles faced by many patients due to other conditions that limit their ability to reach their feet or to pull on a garment due to limited hand strength or pain. Rubber gloves and patience in applying the garment in stages are the hallmarks of success. There are several devices available from garment manufacturers that can help the patient get the garment onto the foot and over the heel or hand. These include frames to hold the garment open, slippery covers for the limb, and silicone-based products that make the skin more slippery. Cornstarch has also worked well for us. We avoid powders with talc due to the risk of skin irritation. Most garment manufacturers warn against the use of petroleum-based ointments because the fibers (especially latex rubber) can be weakened by exposure to these products. When patients require a higher compression class than they are able to don easily, we will try layering the garments to achieve effec-tive control.

All garment manufacturers recommend replacement of the garments every 4 to 6 months. The actual interval is based on considerations such as wear due to use, severity of the edema, and type of fabric. Many patients buy two garments to have one to wash while the other is worn. Garment manufacturers include care instructions with their garments. In all cases, we recommend daily washing by hand with mild liquid detergents (for example, Ivory or Dreft) and squeezing gently in a rolled-up towel and hanging to dry.

Finally, patients are encouraged to don their garments as soon as is practical in the morning, when the limb is at its smallest. Many patients alter their lifestyle to shower in the evening so they can don their garments over dry skin first thing in the morning.

Given the long-term use of garments by most lymphedema patients, it is imperative that the treating therapist give a great deal of thought to choosing the appropriate garment and educating the patient in its use. This is crucial to successful treatment of patients with a chronic condition.

REFERENCES

1. Casley–Smith JR, Casley–Smith JR. Modern Treatment for Lymphoedema. 5th ed. Adelaide, Australia: Lymphoedema Association of Australia; 1997:174-175, 178. 2. Johansson K, Lie E, Ekdahl J, Lindfeldt J. A randomized study comparing manual lymph drainage with sequential pneumatic compression for treatment of postoperative arm lymphedema. Lymphology. 1998;31:56-64. 3. Hohlbaum GG, ed. The Medical Compression Stocking. New York: Schauttauer; 1989:56. Joy C. Cohn, PT, CLT-LANA, and Anne Lowry, MS, PT, CLT-LANA, are certified lymphedema therapists in the lymphedema treatment program at Chestnut Hill Rehabilitation Hospital in Wyndmoor, Pa.

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Images Leg Lymph System Leg Lymphatics

Images Lymph System Lymphatic System