Lymphedema of the leg

The Puzzle - An Inside Glimpse of Lymphedema - New Book

2011-09-01T08:53:00.001-07:00

Here's our new book on lymphedema. I also have a chapter with several articles.....

(including my own story). Pat

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The book is compiled so that people who have been touched by lymphedema can
share their stories; their trials and tribulations, their sadness and
disappointments, their strength and hopes. It is intended to encourage, educate
and inspire patients and loved ones, who can often feel isolated and uninformed.
We hope to increase awareness and general knowledge of a condition that is often
overlooked and misdiagnosed, yet which can have monumental physical and
emotional impact on the lives that it affects.

Not every story has a happy ending, yet there is hope. By sharing these stories
with one another, we can learn from the struggles and successes that others have
experienced, and can help each other to live well with lymphedema.

How do I get this book ???

This book will be available at:

14th State of Georgia Lymphedema Education & Awareness Program14th Program

OR FROM:

Beverly Thompson 770-476-2671
HILTON GARDEN INN — ATLANTA PERIMETER CENTER
1501 Lake Hearn Drive, Atlanta, GA 30319
Saturday, October 15, 2011
7:30 am - 5:00 pm

The book will be available at any sponsored Lighthouse Lymphedema Network
program or conference for a donation of $15.00
Lighthouse

Please mail your completed order form and donation to:

Lighthouse Lymphedema Network Book
10240 Crescent Ridge Drive
Roswell, GA 30076

Please send a donation of :
$19.95 per copy
Plus $5.00 per copy for Shipping Costs

Order Form

Name: Last First___________________________________________________

Mailing Address____________________________________________________

City State ZIP Code_________________________________________________

Home Telephone Number Cell Telephone Number________________________

Email Address_____________________________________________________

Number of Copies you would like to order______________________________

$_______________________________________________________________

Amount Enclosed__________________________________________________

2010 Georgia Lymphedema Education and Awareness Program

2010-06-05T03:56:00.000-07:00

2010 Georgia Lymphedema Education and Awareness Program

13th State of Georgia Lymphedema Education and Awareness Program, October 16,
2010, Decatur, GA.

View and Print out Brochure to Register (vertical menu item)

The LLN Brochure also includes much information about our not-for-profit
organization in Georgia and can be printed out (vertical menu item).

The program is entitled:

SHEDDING LIGHT ON LYMPHEDEMA

Sponsored by the Lighthouse Lymphedema Network

Don't Forget - Mark Your Calenders - See You There!!!

Baby Kayden in Oklahoma

2009-11-04T01:08:00.000-08:00

Baby Kayden in Oklahoma

Good Morning Everyone

I wanted to bring this to everyone’s attention and encourage anyone who can to help this little baby. Kayden has vascular Lymphedema and was just born on August 18, 2009…he’s got a long road ahead of him so let’s do anything we can for him and his family:

Baby Kayden

He’s a real little doll too!

Thanks Everyone!!!!!!!!!!!!!!!!!!!!

Pat

Understanding the Lymph System

2009-10-28T08:25:00.000-07:00

Understanding the Lymph System

I thought it would be helpful for readers to understand the lymph system, the anatomy, what it does, and how it helps with immunity.

Listed below are information pages that should be quite helpful and each page has many additional links for more a more in depth study.

Anatomy of the Lymph System

Lymphatic System Functions

Lymphatic System and Immunity

Pathology of the Lymph Nodes and Lymphoma

Lymph Nodes

Lymph Fluid

12th State of Georgia Lymphedema Awareness Programm

2009-10-17T03:48:00.000-07:00

12th State of Georgia Lymphedema Awareness Program

Lighthouse Lymphedema Network

THERE IS STILL TIME TO GET THOSE REGISTRATIONS IN

An educational and awareness conference for patients, caregivers and professionals!

Where?

Saint Joseph Hospital Auditorium 5665 Peachtree Dunwoody Road, NE Atlanta, GA 30342

When?

Saturday, October 24, 2009 7:30 am - 5:00 pm

Click here for Registration Form

Schedule

7:30-8:15am Registration – Continental Breakfast – Exhibits 8:15-8:30am Welcome .

Plenary Session:

8:30-10:00am Moderator: Elaine Gunter, MT (ASCP)

Nicole Stout, PT, MPT, CLT-LANA Will discuss her studies on early intervention for breast cancer including the anatomy, reconstruction, breast cancer surgeries, truncal and other upper extremity lymphedema

10:00-10:30am Break Exhibits

10:30-12:00 Charles McGarvey, PT, DPT, MS, FAPTA

Lymphedema Secondary to Pelvic Cancer Treatment: A Review of Literature and Clinical Practice

12:00 – 1:30pm Lunch Exhibits

1:00-2:15pm Teen (only) Networking -Parent Networking (parents of children with lymphedema)

Separate sessions

Plenary Session:

1:30-2:15pm Daniel Beless, MD, Director of Wound Care at Saint Joseph Hospital Wound Care and the lymphedema patient

2:15-3:00pm DeCourcy Squire, PT, CLT-LANA

Research updates from the International Society of Lymphology of Lymphedema Diagnosis and Treatment

3:00-3:30pm Break Exhibits

3:30-4:30pm Panel Discussion

All speakers will participate in this question and answer discussion

4:30-5:00pm Closing Remarks

New Lymphedema Treatment Clinic - Myrtle beach, Souther Carolina

2009-10-14T08:05:00.000-07:00

It gives me great pleasure to announce a new lymphedema treatment clinic in the Myrtle Beach, Souther Carolina area:

Tom Kincheloe, OTR/L, CLT
Founder/Clinical Director
RIVERTOWN LYMPHEDEMA CLINIC AND REHAB, LLC.
100 Prather Park Drive, Suite A
Myrtle Beach, SC 29588-7910
Bus. Phone: (843) 742-5701
Bus. Fax: (843) 742-5704
Cell: (843) 957-2422
Email: erivertownlymph@sc.rr.com

I know Tom personally and two things strike me about him.

First, is his real concern/compassion for his patients.

Secondly is his knowledge of lymphedema.

A winning combination! So if you live in his area and are looking for lymphedema help, give him a call.

Pat

The contralateral rectus abdominis musculocutaneous flap for treatment of lower extremity lymphedema.

2009-10-11T04:52:00.000-07:00

One of my desires is to bring all types of information relating to leg lymphedema to the readers. I must admit,

I really had to grit my teeth on this article.

The authors speak of a long term follow up time frame as 31 months. This is hardly adequate when you are

investigating long term possible complications. Indeed, I had the Thompson'sprocedure done in three surgeries

from 1971 through 1973. The first 31 months did see a reduction in leg size and a slight reduction in cellulitis

episodes.

However, long term should mean a 10, 20 or even longer time frame. After twenty years, I experienced horrific

complications from the surgery, not the least of all was mixed b-cell lymphoma.

Also, if the research proves to be correct about the possibilities that secondary lymphedema patients

are people who are already "at risk" for lymphedema, then the introduction of yet another area of surgery (abdomen)

could prove to be disasterous as well. Any type of surgery that would injury, damage or adversly effect the lymph

system in the abdomen can (as has been well documented) cause abdominal lymphedema.

Please do not consider the posting of this article as an endorsement of any kind and I would further discourage

lymphedema patients from having it.

Pat

The contralateral rectus abdominis musculocutaneous flap for treatment of lower extremity lymphedema.

Ann Plast Surg. 2009 Jan

Parrett BM, Sepic J., Pribaz JJ

Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115

Lymphedema is common after inguinal lymphadenectomy or resection of groin tumors. Animal studies have shown success using the rectus abdominis musculocutaneous (RAM) flap as a treatment for lymphedema. Four patients with acquired lower extremity lymphedema were treated with a contralateral RAM flap with an inferior cutaneous pedicle left intact to facilitate lymphatic drainage into the unaffected groin. One patient also had lymphaticovenous anastomoses performed during flap transfer. All flaps survived with no postoperative complications. With a mean follow-up of 31 months, the mean reduction in limb circumference from the preoperative excess was 81% at the thigh, 70% at the calf, and 71% at the ankle. None of the patients with recurrent cellulitis had further incidences of groin cellulitis. Two patients required future flap debulking. Lymphoscintigraphy was performed in 1 patient and demonstrated reconstitution of lymphatic flow from the affected leg through the flap. According to this preliminary study, transfer of a contralateral RAM flap to the groin of a lymphedematous leg improves lymphedema and decreases the incidence of cellulitis.

PubMed

For further information on surgeries used for the treatment of lymphedema, please see:

Surgery for Lymphedema

and

The Thompson's Procedure

Lighthouse Lymphedema Network

2009-09-29T02:58:00.000-07:00

I wanted to make a special announcement that the Lighthouse Lymphedema Network
is now on Facebook.

You can join by going to: Lighthouse Facebook

There is also an area where you can post and participate.

AND - don't forget our upcoming program in October. We will be having both a
parenting network and a teen network this year....be there or be square!

see the details for that at:

Lighthouse Lymphedema Network

**yes, I'm on it too :-)

Pat

Risk factors for lower limb lymphedema after lymph node dissection in patients with ovarian and uterine carcinoma.

2009-09-28T03:09:00.000-07:00

Risk factors for lower limb lymphedema after lymph node dissection in patients with ovarian and uterine carcinoma.

BMC Cancer. 2009 Feb

Tada H, Teramukai S, Fukushima M, Sasaki H.

Department of Clinical Trial Design and Management, Translational Research Center, Kyoto University Hospital,

Corresponding author.

Harue Tada: haru.ta@kuhp.kyoto-u.ac.jp; Satoshi Teramukai: steramu@kuhp.kyoto-u.ac.jp; Masanori Fukushima:mfukushi@kuhp.kyoto-u.ac.jp; Hiroshi Sasaki: hrssasaki@jikei.ac.jp

BACKGROUND: Lymph node dissection has proven prognostic benefits for patients with ovarian or uterine carcinoma; however, one of the complications associated with this procedure is lymphedema. We aimed to identify the factors that are associated with the occurrence of lymphedema after lymph node dissection for the treatment of ovarian or uterine carcinoma.

METHODS: A total of 694 patients with histologically confirmed ovarian (135 patients) or uterine cancer (258 with cervical cancer, 301 with endometrial cancer) who underwent lymph node dissection were studied retrospectively. Logistic regression analyses were used to identify the risk factors associated with occurrence of lymphedema.

RESULTS: Among ovarian and uterine cancer patients who underwent pelvic lymph node dissection, post-operative radiotherapy (odds ratio: 1.79; 95% confidence interval: 1.20-2.67; p = 0.006) was statistically significantly associated with occurrence of lymphedema.

CONCLUSION: There was no relationship between any surgical procedure and occurrence of lymphedema among patients undergoing pelvic lymphadenectomy. Our findings are supported by a sound biological rationale because they suggest that limb lymphedema is caused by pelvic lymph node dissection.

PubMedCentral

*Editor's note: It is rare that I openly place a note of disagreement on an article, but in this case, I think one is called for. The incident ratio of lower limb lymphedema from gynecological cancer is skyrocketing with survival rates increasing as well. It is well document that the removal of lymph nodes damages the lymph system and that a damaged lymph system can lead to lymphedema. I would suggest that they doctors involved in this study go back to their research. Pat

Lymphoscintigraphy in angiomyomatous hamartomas and primary lower limb lymphedema

2009-09-28T02:55:00.000-07:00

Lymphoscintigraphy in angiomyomatous hamartomas and primary lower limb lymphedema

Clin Nucl Med. 2009 Jul

Bourgeois P, Dargent JL, Larsimont D, Munck D, Sales F, Boels M, De Valck C.

Department of Nuclear Medicine, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium. pierre.bourgeois@bordet.be

PURPOSE: Angiomyomatous hamartoma (AH) of the lymph node is a rare vascular benign disease of unknown etiology with a predisposition for the lymph nodes of the inguinal area. Only 18 cases have been described up to now in the literature and the disorder was reported to be associated with lymphedema or swelling of the ipsilateral limb in 4 patients. However, scintigraphic investigation of the lymphatic system in these patients was reported in only 2 cases.

MATERIAL AND METHODS: Five patients where the biopsy of inguinal nodes for suspected lymphadenitis led to the diagnosis of angiomyomatous hamartoma were investigated using lymphoscintigraphic techniques (1 girl aged 15; 1 boy aged 9 at the time of first biopsy and 11 at the time of the second one; and 3 men aged 30, 50, and 57). The operated limb was lymphedematous in 3 and 1 developed lymphedema after biopsy. The fifth patient developed a contralateral lymphedema after his second nodal biopsy.

RESULTS: In all cases, lymphoscintigraphic investigation of the limbs showed extensive lymph node abnormalities on the operated side and in 4 cases on the opposite side.

CONCLUSIONS: These observations support not only the hypothesis that lymphatic disturbance was involved in the pathogenesis of these tumors but also the proposition that lymphoscintigraphy should be performed in cases of inguinal lymphadenitis of unknown origin to diagnose the underlying situation of latent lymphedema.

Clinical Nuclear Medicine

Elective amputation of the toes in severe lymphedema of the lower leg: rationale and indications

2009-09-28T02:50:00.000-07:00

Elective amputation of the toes in severe lymphedema of the lower leg: rationale and indications

Ann Plast Surg. 2009 Aug

Chen HC, Gharb BB, Salgado CJ, Rampazzo A, Xu E, di Spilimbergo SS, Su S.

Department of Plastic Surgery, E-Da Hospital/I-Shou University, Taiwan.

Entry lesions at the toes interdigital spaces, in the setting of chronic lymphedema, are strongly associated with repetitive infective episodes which cause significant morbidity. A prospective study was designed to evaluate the outcome in 2 groups of patients affected by end stage III lymphedema of the lower extremity, treated with the Charles procedure with or without simultaneous amputation of the toes. At a mean 3 years of follow-up, 20% of the patients receiving elective toes amputation experienced recurrence of the infection and none required more proximal amputations. Among the patients not desiring elective toes amputation; 83% suffered multiples attacks of cellulitis and in 88% the toes were eventually amputated. The difference in the number of infective episodes between the 2 groups was highly significant. No cases of recurrent lymphedema were registered. Elective toes amputation in combination with the Charles procedure reduces recurrent cellulitis and long-term morbidity in stage III lymphedema of the lower leg.

Lippincott, Williams & Wilkins

The outcomes of program based on complex decongestive physiotherapy for a patient with secondary lymphedema caused by infection on the leg

2009-09-17T04:57:00.000-07:00

The outcomes of program based on complex decongestive physiotherapy for a patient with secondary lymphedema caused by infection on the leg
Fukuoka Igaku Zasshi. 2009 Jun

Nakao F, Furutani A, Yoshimura K, Hamano K, Kinoshita Y, Kawamoto R, Nakao H, Suzuki S.
Department of Health Sciences, Faculty of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.

Lymphedema is a chronic problem causing distress and loss of functions throughout the lifespan. Complex decongestive physiotherapy (CDP) is in common use in developed countries but has only recently been used in Japan for people in outpatient settings. CDP is a representative conservative treatment for lymphedema, conducted by combining four kinds of physical therapies: skin care, manual lymph drainage (MLD), bandage and exercise. This research project lead by a nurse is underway using CDP in an outpatient department. We report a case of secondary lymphedema caused by infection successfully treated by CDP. A 22-year-old man suffered from cellulitis of unknown origin when he was a high school student. After this event, he had been repeatedly admitted to hospital with infections as a result of the lymphedema. He underwent MLD once or twice monthly and received health education for skin care, self-massage and exercise, and was advised to wear compression stockings. Within 7 months the leg swelling had significantly reduced and his feelings of malaise and pain disappeared. Fourteen months later the circumferences of his knee and ankle had kept the sizes, and he has not re-entered hospital for infections. For this man, CDP had a positive outcome, as it has for many others around the world. Our experience has found it very important to establish adequate support systems for such people in outpatient and community settings. However, more research and knowledge sharing are required to understand the usefulness and effectiveness about this program as a primary treatment combined with health education in community settings in Japan.

PubMed

Georgia Lymphedema Education and Awareness Program

2009-09-11T04:40:00.000-07:00

11th Annual Lymphedema Education & Awareness Program

An educational and awareness conference for patients, caregivers and professionals!

Where?

Piedmont Hospital

Richard H. Rich Auditorium

1968 Peachtree Road, NW, Building 77

Atlanta, Georgia

When?

Saturday, October 18, 20087:30 am - 5:30 pm

Program includes

What to expect of tissue after radiation?

What is the physiology response of radiation?

What does radiation do to the lymph nodes? - Peter Rossi, MD

How does vascular flow affect the lymphatics? - Ken Harper, MD

Expectations of surgery. - Christopher Hart, MD, FACSThe Lymphatic System, Wound Care,

Infections and Treatment - Paula Stewart, MDParent Networking

Aquatic Exercises

The Connection of obesity and increased swelling in people with lymphedema and lipedema.and more.

Additional information and registration form - Home website - Lighthouse Lymphedema Network

See you there - Pat

Combined edema reducing therapy in the treatment of advanced lower limb lymphedema

2009-06-11T07:42:00.000-07:00

Combined edema reducing therapy in the treatment of advanced lower limb lymphedema
Wiad Lek. 2008

Gabriel M, Sawlewicz P, Krüger A, Pawlaczyk K, Stanisić M, Majewski W.
Kliniki Chirurgii Ogólnej i Naczyń Uniwersytetu Medycznego w Poznaniu. mgabriel@pro.onet.pl

Combined edema reducing therapy is a recognized method of lymphedema treatment. However such therapy can be difficult to implement from methodological and logistic point of view in cases of advanced forms of lymphedema. The aim of the study was the presentation and discussion of intensive phase of combined treatment in patient with advanced primary lymphedema.

MATERIAL AND METHODS: Therapy was conducted on 19 patients (27 limbs) with edema reducing therapy program. Procedures were conducted daily for 4-6 weeks in out-patient and in-wards conditions.

RESULTS: Intensive phase of treatment succeeded in 3870-15 330 ml edema reduction, consisting of 48-65% of initial status. Chronic leg ulcers were healed completely in 2 patients. Ten patients underwent minor adverse events (AE), such as superficial skin ulceration (n = 2), popliteal fossa skin maceration (n = 2), neuropathic foot pain (n = 3) and skin scratches (n = 3). Modification of the treatment allowed the complete healing of AEs within 2-7 days, but it produced significant delay in achievement of desired therapeutic result, In 2 cases it prolonged hospital stay for 7 days.

CONCLUSIONS: 1. Combined edema reducing therapy is very efficient form of treatment in advanced primary lymphedema. 2. Intensive, 4-6 week, phase of the treatment allows 3.8 to 15.3 1 edema reduction. 3. In our opinion this phase should be conducted only in specialized centers for proper final results achievement with adverse events minimization. 4. The main point of the therapy is a combination of appropriate forms of available treatment.

PubMed

Humanitarian rescue medical action for patient with advanced lower extremity lymphedema.

2009-06-11T07:39:00.000-07:00

Humanitarian rescue medical action for patient with advanced lower extremity lymphedema.

Lymphology. 2008 Jun

Chen HC, Salgado CJ, Mardini S, Feng GM, Li TS.
E-Da Hospital/I-Shou University, Department of Plastic Surgery, Yan-Chau Shiang, Kaohsiung County, Taiwan. salgado_plastics@hotmail.com

No clear data exists regarding the initiating process of medial care delivery in cases of humanitarian rescue for advanced and debilitating patient conditions. We report on the delivery of care from a hospital located in a rural area in Southern Taiwan to a desperate patient from a country across the world in Lima, Peru. The patient is a 45-year old woman with unilateral severe, progressive primary lymphedema of 26 years who was scheduled to undergo a high femoral amputation for infections, lymphatic leak, inability to ambulate, and symptomatic cardiomegaly. All arrangements for care, including dental restoration, were made by our hospital in collaboration with the government of Peru. Upon multi-departmental consultation, an 8-hour Charles procedure was performed removing 47 kg of lymphedematous thigh and leg tissue. Eleven months postoperatively the patient is healed and ambulating without assistance. Her weight dropped from 120 to 73 kg. This case of humanitarian action demonstrates intense collaboration and coordination between two governments with dialogue, diplomatic success, a lymphedema surgical feat, and ultimately a successful outcome for the patient.

PubMed

Anatomy of the subcutaneous lymph vascular network of the human leg in relation to the great saphenous vein.

2009-06-11T07:35:00.000-07:00

Anatomy of the subcutaneous lymph vascular network of the human leg in relation to the great saphenous vein.

Anat Rec (Hoboken). 2009

Schacht V, Luedemann W, Abels C, Berens von Rautenfeld D.
Department of Dermatology, University Medical Center Freiburg, Freiburg, Germany. vivien.schacht@uniklinik-freiburg.de

The anatomical relationship between lymphatic collectors and veins is of clinical importance for preventing lymphedema secondary to lymphatic collector injury during surgical procedures. To identify areas at risk during surgical interventions, we performed an anatomical study of human legs. The lymphatic collectors of 42 legs of human cadavers were injected with Berlin Blue solution or contrast medium. After fixation, the collectors were dissected and their distances from the great saphenous vein were determined. We found that the lymphatic collectors on the dorsum of the foot ran in close parallel with the corium, whereas in the groin a greater number of lymphatic collectors clustered around the great saphenous vein. The ventromedial bundle that drains into the superficial inguinal nodes included 5-20 lymphatic collectors. The average width of the ventromedial bundle varied between 116 mm at the middle of the lower leg and 32 mm at the groin. Our study cannot confirm the previous observation of a bottleneck of the ventromedial bundle occurring at the knee, but does support the finding of an elongated bottleneck at the thigh and groin draining into the superficial inguinal lymph nodes. In addition, the idea of one sentinel lymph node for a specific region of the leg is not supported by these data. These observations will help surgeons to plan incisions and dissections with respect to lymphatic collectors, thereby minimizing damage to them and reducing complications resulting from unnecessary lymphatic excisions. Anat Rec, 2009.

PubMed

A 62-year-old woman with non-pitting leg oedema

2009-06-11T07:30:00.000-07:00

A 62-year-old woman with non-pitting leg oedema

Tidsskr Nor Laegeforen. 2009 Apr

Bergersen TK, Mørk C.
kristin.bergersen@rikshospitalet.no

A patient presented with non-pitting lymphoedema of the legs and finger clubbing. A skin biopsy showed epidermal hyperkeratosis and abundant mucinous material (Alcian blue positive) in reticular dermis. Treatment (radioactive iodine) for Grave's disease (with exophthalmus) 20 years ago, raised suspicion of thyroid dermopathy. Together, these three extrathyroidal manifestations of Graves' disease are typical of the EMO syndrome. In addition, the patient had elevated serum concentrations of thyroid-stimulating hormone receptor autoantibodies. Autoimmune mechanisms are involved in the stimulation of fibroblasts and the production of large amounts of mucin. Pretibial myxoedema relates to scars, mechanical factors, and dependent position. Lack of steroid treatment during radioactive iodine therapy and smoking, may have exacerbated the thyroid dermopathy in this case. Awareness of pretibial myxoedema as a late autoimmune manifestation of Graves' disease, may contribute to earlier diagnosis and correct treatment.

Full Text Article

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

2009-06-08T08:05:00.000-07:00

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

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

Lymphedema of the lower limbs: management problems in a developing country

2009-05-19T07:49:00.000-07:00

Lymphedema of the lower limbs: management problems in a developing country

Nig Q J Hosp Med. 2008 Apr-Jun

Adigun AI, Ogundipe OK.
Department of Surgery, Univerity of Ilorin Teaching Hospital, Ilorin, Nigeria.

BACKGROUND: Lymphoedema is a clinical condition involving the extremities that is characterized by accumulation of protein rich fluid within the intercellular space of the skin and the subcutaneous tissue. It most frequently occurs in the extremities. Developing countries are mostly faced with cases of secondary lymphoedema where patients present lately. In addition to swollen limbs, there are lot of skin changes on the affected limb, these create a lot of problems to the managing clinician. We hereby present five cases out of several patients managed to highlight the challenges.

METHODS: We review the case notes of three patients managed by our unit and present the summary of each patient.

RESULT: Majority of our patients present late to the hospital, mainly because of the socio-cultural and spiritual beliefs concerning the aetiology of the condition. Most of them have visited the spiritualist, herbalist and the clergymen for solution. Clinicians in the developing countries are seriously handicapped by lack of modern equipment for both diagnostic and therapeutic management of these clinical conditions.

CONCLUSION: Chronic lymphoedema is a major cause of permanent disability. Excisional surgery such as Charles procedure even though old is still very much relevant in our environment. Patients need to be enlightened on the need for early presentation, adequate post-operative care and prolonged follow-up.

PMID: 19068559 [PubMed - indexed for MEDLINE]

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

2008-12-30T06:03:00.000-08:00

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.

2008-11-25T06:24:00.000-08:00

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.

2008-11-25T06:15:00.000-08:00

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

2008-11-23T07:51:00.000-08:00

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

2008-11-23T07:37:00.000-08:00

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

2008-11-23T07:32:00.000-08:00

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

2008-11-23T07:15:00.000-08:00

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.

Link no longer available

Images Leg Lymph System Leg Lymphatics

2008-11-18T05:02:00.001-08:00

Images Lymph System Lymphatic System

2008-11-18T04:56:00.000-08:00

Images Male Pelvic Lymph Nodes

2008-11-18T04:53:00.001-08:00

Diagnostic image Foot Swelling Foot Lymphedema

2008-11-18T04:48:00.001-08:00

Diagnostic Images Leg Swelling and Leg Lymphedema

2008-11-18T04:26:00.000-08:00

How to Bandage Wrap the Lymphedema Leg

2008-11-14T08:24:00.000-08:00

How to Bandage Wrap the Lymphedema Leg

One of the best posts on how to wrap a leg…from one of my online members:

Since you have the swelling in the feet (and toes), it is probably lymphedema, perhaps compounded with lipedema. The traditional bandaging technique is with a stockinet, then some artiflex (cotton padding), and lastly, the bandages. I bandage directly over the skin. The padding is supposed to even out if you should constrict some part of the bandaging, causing the lymph not to flow, but the bandages are really not like rubber bands – properly spaced and overlapped, they will not cause constriction – and the artiflex is a pain. The stockinet is just another thing to wash and dry. I went to a bandage supplier (now out of business) and found that they have new bandages that are thick enough to be used without layering (e.g. the stockinet and padding).

Perhaps this is the way to go, or perhaps you want to bother with stockinets and padding. If you were seeing a therapist, they would also use foam instead of artiflex (just cotton padding). Some pictures of bandaging look absolutely monstrous. My so called therapist used some foam, etc., but I soon discovered that the leg went down more without it. The pad is supposed to “spread” the compression so there is no binding – but what really happens is all the elasticity of the bandages goes to compressing the FOAM – not compressing your leg. A little compression trickles down to the actual leg, but my experience was that the swelling went down better without the extra stuff. However, since this is against tradition, you should at least be aware if any part of your leg feels too tight, and, if so redo the bandages (which is at least an hour for two legs – and bandages that were OK while you were up and around can suddenly become too tight in the middle of the night – which means you have to get up and do it again.) Anyway, with or without stockinet and padding, here is one technique for bandaging:

materials (1 large leg not grossly larger than normal (I am 5'9” and the calf measure is 21” and I have wide, swollen feet - if you are substantially larger, you may need more)

optional: stockinet, artiflex, foam

required:

1 roll 1” professional strength masking tape. 1 ea 3” strip of heavy padding around the ankles 1 ea 1” x 5m medi-rip 2 ea 8 cm. x 5 m short stretch bandages 1 ea 10 cm x 10 m short stretch bandages 1 ea 6 cm x 5 m short stretch bandages.

Double for 2 legs, if you are very much larger than me, add another 1 ea 10 cm. x 5 m short stretch bandage for each leg.

I sit on my bed and have a low table I can rest my foot on, but two chairs will work also (one to sit on and one to put your foot on).

Wrap the 3” strip of heavy padding (or chock pads) around the ankles. The figure 8's you are making around your foot and from the foot onto the leg will tend to bind right at the intersection of the foot and leg (where the 90” turn is made. This is the only place padding is essential.

Secure it with masking tape. Secure all the bandages after they have been wrapped with masking tape. Cut a lot of 5” strips of masking tape and have them ready. Stick them on the edge of the table, or a windowsill, or something.

First hold all the bandages so that you are drawing from the bottom of the bandage cylinder (the bandages rolled up are a cylinder), not the top. A little experimentation will show you that this is much easier.

Start with the 1” medi-rip (it is a self cohesive bandage, but looses some of the self cohesion with laundering). Use this tiny bandage to bandage along the toe line. That is, make the same arc that the joints of the toes to the feet make. Do not bind the toes. If you can, wrap each toe with it, but I find that this binds the toes and hurts, so I leave my toes unwrapped, even though they swell, but if you start with the larger short stretch bandages, there will be a half moon that swells even more (Since if you make a straight circle from just below the little toe to just below the big toe, this will leave some area of foot not bandaged and the lymph will be pushed into this area, and it will be worse than before. The little 1” medirip can be wrapped in a curved path that covers all of the foot. Overlap this 1” medirep by 1/2 and continue winding it around your foot until you get to the end of the arch, then take it up diagonally over the top of the foot, and you will still have enough bandage to wrap again just under the toe line again for a few wraps. The medi wrap has strands of elastic in an otherwise cotton strip, so pull the medirip tight (that is the elastic is extended, but not to the point of discomfort).

When you wrap the bandages, pull a bit at the end of each circle, but do not stretch them too hard, or with constant tension as far as they will stretch. You want them to exert a little spring, but don't strangle your legs. If you get them too tight, it will hurt, and you must undo your wrapping and redo it (a big pain). If you don't stretch them a little, they won't have much compression. Of course, it's always the bottom bandages on the feet that hurt, so you have to unwrap the whole deal to get to them.

Next,step 2 take a 8 cm. x 5 m short stretch bandage, and start at the tip of the foot, but do not bind any toes, and since you already have the medi-rip, allow a little breathing space to make sure you don't bind toes. Then wind around your foot overlapping the bandages by about 1/2 to 2/3 (I probably overlap 2/3) until you have gotten almost to the leg (your foot should be at a 90 degree angle to the leg, and for me this is 2 or 3 wraps), then go around the heel itself, and, as you come off the other side of the heel, take the bandage diagonally up on the top of the foot to just below the top of the first wrap (just under the bottom of the big toe), go around the bottom of the foot, and then bring the bandage back around the ankle just above the heel, then around the ankle, and back up diagonally across the top of the foot just like before, overlapping 1/2 to 2/3 of the previous path. This will make large figure 8s.

Continue with the figure 8's each layer a little higher around the ankle, until you again are wrapping just in front of the leg (no more space to do another figure 8) and use the rest of the bandages going in straight circles (not figure 8's) around the ankles.

Next,step 3 take the second 8 cm x 5 meter short stretch bandage, and start at the base of the leg (around the ankles), go around once or twice, to anchor the bandage, then on the next turn go down around the bottom of the foot close to the heel, and then around the bottom of the foot and then over and up around the leg, then continue making figure 8's up the leg overlapping by about 2/3.

To make a figure 8 around the leg, on one side of the front of the leg, the bandage is going uphill (or towards your knee), then it goes more or less straight around the back of the leg at the high end of the 8, then goes downhill (or towards the foot), as you come across the front of the leg again, then more or less straight across the back of the leg at the low end of the 8 and then up again for the next figure 8. On me, this bandage is finished just about at the beginning of the calf (a little above the bottom of the muscle – it would be ideal if this bandage ended just before the muscle begins, but it will be a bit different for everyone depending of how much they overlap and how large their leg is.

Next,step 4 do figure 8's with the 10 cm x 10 m bandage. Begin at the bottom of the leg with the beginning of the bandage facing upward, so the first direction is in a downward direction, (the end pointing up) coming around and then going up again. The 10 cm x 10 m bandage should take you up to just below the knee, but if the legs are very large, you may need another 10 cm. bandage. Each course of the figure 8 should overlap a little less or evenly, but not more than the previous course. The more you overlap the greater the compression, and you must always have less compression proximally (towards your heart) than distally (towards your toes).

Finally,step 5 take the last 6 cm. x 5 meter short stretch bandage and start at about mid calf or a little higher, and wind in straight circles until just below and as close as possible to the knee. This last bandage gives compression over the tops of the top 8's where there is not as much overlap, and sort of holds it all up, as the circumference of the leg is actually smaller at the knee than at the mid calf (doesn't slide down because a smaller circle would have to slide over a larger circumference of the leg).

I have been complemented on my ability to wrap, but It is hard to know if a novice can make much sense of my directions – but I tried. You don't see to many photographs of the figure 8's, but they give more compression and stay up better, and bind less. You will get the general idea of winding up the leg, and overlap by looking at the photographs, however. It may seem complicated to follow my directions (I tried to be clear), but the real technique is not very hard at all.

The new thick bandages that do not need padding (padding is included) are : KomprimED. They are located on the bandagesplus web site under bandages, then under two way stretch bandages. I think you should start with these, as the padding may be more important for someone who is just beginning bandages. This is much simpler than all those stupid layers.

*Soft and comfortable directly on patient's skin *Thicker texture avoids application of foam and padding in many cases *Suitable for lymphedema and venous ulcers *Patient-friendly application requires less layers *All bandages are short-stretch/low stretch KomprimED 4cmx5m

Other wise, the standard short stretch bandages are rosidal or comprilan. I use rosidal. The medi-rip is under the section cohesive bandages on page 2 under the more general category bandages.

Suppliers of Bandages, Wrapping materials and Supplies:

Lymphedema Products

Bandages Plus

Academy of Lymphatic Studies - Academy Store

Drapers Fitness - Lymphedema Bandages

Allegro Medical

Discount Surgical Stockings

Suppliers of leg compression garments and sleeves:

Telesto Medtech - Compression Garments

Lympha Press "Lymphedema" Garments

Self Manual Lymph Drainage for the Lower Extremity

2008-11-14T08:17:00.000-08:00

Self Manual Lymph Drainage for the Lower Extremity

Rules for MLD:

The strokes should be made with arcing motions or half circle motions.

Do not slide over your skin, but rather, keep your fingers in contact with your skin and stretch it gently over the underlying tissues.

You should have NO PAIN.

Each stroke should be done 10-15 times SLOWLY, taking about 2 seconds for each stroke.

If redness occurs, you are pressing too hard.

For lymphedema of BOTH legs, perform all moves on both sides.
The best position to be in for this is seated reclined, or lying down and propped up slightly.

Make sure you can make skin-to-skin contact for all of these strokes. They won't work when done over clothing.

1. Neck: Place the flats of your fingers on your opposite shoulder, in the triangular part just above the collarbone and next to your neck. Move your hand in an arcing motion stretching the skin forward and down towards your chest. Repeat this on the other side.

2. Armpit: Raise your arm (on the same side as the leg in which you have lymphedema), bend you elbow, and place the hand behind your head. Place the flat of your opposite hand in your armpit. Stretch the skin in an arcing motion up towards the neck.

3. Above the waist: Place the flat of your opposite hand on the side of your body (on the side on which you have lymphedema) below the breast, but above the waist. Move your hand upwards in an arcing motion in the direction of your armpit, stretching your skin.

4. Below the waist: Place the flat of your opposite hand on the side of your body (on the side on which you have lymphedema) on or just below the waist, but above your hip. Move your hand upwards in an arcing motion in the direction of your armpit, stretching your skin.

5. Deep (diaphragmatic) breathing: Place both open palms on top of each other below the belly button. Take a slow breath in and feel your belly rise up into your hands as it expands to take in the air. Then breath out and feel your belly sink in as the breath leaves you. As you get better at this you can use your hands to resist your stomach slightly as you breath in, and press in slightly with your hands as you breath out. Don’t get dizzy. Start with only 2 or 3 breaths and work up to 10 as you get stronger.

6. Groin: Place the flat of your hand on the front of your groin, right where your underwear falls. Make a scooping motion in the groin, rolling your hand from the thumb to the little finger. Imagine that your hands are the bottom of a water wheel.

7. Back of knee: Place the flat fingers of both hands behind your knee. Perform a scooping motion up towards the body.

8. Repeat steps 3, 4 and 6 (waist and groin areas)

A very special Thanks to Katy from

LymphedemaTherapists · Lymphedema Therapists

Self Massage Treatment for Leg Lymphedema

2008-11-14T08:11:00.000-08:00

Self Massage Treatment for Leg Lymphedema
All the Lymphatic Drainage strokes are based on one principle motion.

Research has found that the initial lymphatics open up and the lymph angions are stimulated by a straight stretch, but even more so with a little lateral motion. After these 2 motions, we need to release completely to allow the initial lymphatics to close and the lymph to be sucked down the channels. In this zero pressure phase don’t completely disconnect from the skin, just return your pressure to nothing. Also don’t pull the skin back with you as you return, let it spring back by itself.

This basic motion may resemble a circle, and is called stationary circles. All motions are based on this principle.

In orienting this motion, we always want to push the lymph towards the correct nodes, so the last, lateral stretch motion should be going towards the nodes.

Think about moving water. Visualize those initial lymphatics just in the skin, stretch, opening them up, then release and wait for the lymph angions to pump the lymph down the vessel. Remember how superficial this is. If you are feeling muscle, or other tissue under the skin, you are pushing too hard.

Here are four points remember when performing Lymphatic Massage-

1. Correct pressure is deep enough so that you do not slide over the skin, but light enough so that you don’t feel anything below the skin. This is about 1-4 ounces. It is very common for massage therapists trained in Swedish or deep tissue to apply too much pressure with lymphatic drainage massage. Sometimes it is hard to believe that something so light could be effective. Always remember- you are working on skin. How much pressure does it take to deform the skin? Almost nothing. Remember- if you push too hard you collapse the initial lymphatic.

2. Direction of your stroke is of great importance, because we always want to push the lymph towards the correct nodes. If you push the lymph the wrong way, your work will not be effective.

3. Rhythm is very important because with the correct rhythm and speed, the initial lymphatics are opened, and then allowed to shut and then there is a little time that is given for that lymph to get sucked down along the vessel. An appropriate rhythm will also stimulate the parasympathetic nervous system, causing the client to relax.

4. Sequence means the order of the strokes. When we want to drain an area, we always start near the node that we are draining to. Always push the lymph toward the node. Then as we work, we move further and further away from the node, but always pushing the fluid back in the direction of the node. In this way we clear a path for the lymph to move, as well as create a suctioning effect that draws the lymph to the node.

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Leg Swelling (Lymphedema) in a Patient With Gynecologic Cancer

2008-11-12T04:46:00.000-08:00

Leg Swelling (Lymphedema) in a Patient With Gynecologic Cancer
Lower-Extremity Lymphedema in a Patient With Gynecologic Cancer
Kathleen Appollo, RN, BSN, OCN
Oncology Nursing Forum – Vol 34, No. 5, 2006

Case Study

H.F. is a 56-year-old woman who presented to the gynecologic oncology department at a major comprehensive cancer center after an endometrial biopsy revealed an International Federation of Gynecology and Obstetrics grade III serous carcinoma of the endometri- um. In addition to relevant endometrial cancer statistics, she received information about choices for treatment. The standard surgical treatment at the cancer center consists of a total abdominal hysterectomy with bilateral salpingo-oophorectomy, pelvic lymph node dissection, and para-aortic lymph node sampling. The acute and chronic side effects of surgery were discussed, including develop- ment of lower-extremity lymphedema. H.F. was informed that the lymphedema could occur anytime after surgery and she would need to monitor for lymphedema development for the rest of her life.

After preoperative testing, H.F. had an uneventful surgical procedure and routine postoperative course. The ﬁnal pathology showed high-grade stage IIIC papillary serous carcinoma deeply invading the endometrium, with spread to a left para-aortic lymph node. As result, her oncologist recommended both radiation and chemotherapy.

H.F. completed all therapy and was scheduled to return every three months for evaluation. She was cautioned to maintain skin integrity by applying moisturizers and sunscreen as needed and to avoid sources of trauma, injury, infection, and constriction to the lower extremities. In addition, she was encouraged to maintain her weight with a healthy diet and she was advised to return to the lymphedema specialist for lymphedema control.

She understands that she must be diligent in her care to maintain control. H.F. knows that she should be joyous that she is free from cancer but often wonders about the sacriﬁces that she has made in the quality of her per- sonal life. She did not feel the need to seek professional psychiatric help but did join a support group. Although the members of the group all have cancer, none has lymphedema.

Even so, H.F. has found that sharing difﬁculties with others has helped her to cope, and she feels good when she has helped another deal with a difﬁcult issue. Although she has not returned to her former music activities, she has found that helping others in the support group has given her the same satisfaction that she felt when her music brought happiness to others.

Lymphatic System and Lymphedema

Lymph is extracellular fluid composed of water, fats, proteins, bacteria, and waste products. The lymphatic system is an inter connected network of organs, lymph vessels, and lymph nodes that transports lymph from body tissues to the bloodstream, helping to maintain body ﬂuid balance. It also is a major component of the body’s immune system.

The superficial lymphatic capillaries are made up of endothelial cells that overlap but do not form a continuous connection. Each cell is anchored to surrounding tissue by ﬁlaments that pull on the cells in response to changes in tissue pressure. As the cell is pulled by the ﬁlament, ﬂuid drains into the vessel. Pressure changes occur during muscle contraction, respiration, and arterial pulsation and when the skin is stretched. Lymph ﬂows into progressively larger deep vessels that have one-way valves to ensure that the ﬂuid moves away from tissues in a slow, steady, low-pressure system. Afferent vessels carry lymph into lymph nodes, where the lymph is ﬁltered of cellular waste products, pathogens, and cancer cells and where lymphocytes are added.

Efferent vessels carry lymph out of the lymph nodes to return to circulation. Lymph drains from the lower limbs into the lumbar lymphatic trunk, joining the intestinal lymphatic trunk and cisterna chyli to form the thoracic duct that empties lymph into the left subclavian vein (Casely-Smith & Casely-Smith, 1997; Mortimer, 1998).

Lymphedema occurs when lymph remains in the tissues because the lymphatic system is unable to transport interstitial ﬁltrate (Foldi, 1998; International Society of Lymphology, 2003). Primary lymphedema is a result of an absence of or abnormalities in lymphatic tissue. Secondary lymphedema, which is the focus of this discussion, results when the ﬂow of lymph is interrupted because of malignancies, surgery, infection, trauma, or postradiation ﬁbrosis and the lymph remains in the tissue.

Incidence and Risk Factors

Although much has been written about upper-extremity lymphedema after breast surgery, information about lower-extremity lymphedema is lacking. The literature varies widely about the number of patients affected. In one study, the incidence of lymphedema in patients after a hysterectomy with lymph node removal was 20% (Ryan, Stainton, Slaytor, et al., 2003). Another study reported a 3.4% incidence rate in patients following endometrial staging surgery, including hysterectomy, bilateral salpingo-oophorectomy, and lymph node dissection (Abu-Rustum et al., 2006). A retrospective series of staging surgery for endometrial cancer followed by radiation therapy reported an incidence of 4.6% (Nunns, Williamson, Swaney, & Davy 2000).

H.F. was at risk to develop lymphedema after her surgery for endometrial cancer because of the disruption of lymphatics and lymph nodes during staging surgery. She was at additional risk because of the postoperative radiation. Other risk factors are believed to include injury, trauma, heat changes, infection to the extremity, and weight gain and decreased mobility (Brewer, Hahn, Rohrbach, Bell, & Baddour, 2000; Mortimer, 1998).

Treatment

Although research is lacking to support many recommendations for the prevention of lymphedema (Ridner, 2002), education regarding measures that are believed to reduce risk include protecting the skin from trauma and infection. Those measures were discussed with H.F. postoperatively and at each ofﬁce visit. The plan is based on the concept that any action or condition that predisposes a patient to or increases swelling may disrupt the ﬁne balance of drainage after surgery (Mortimer, 1998). In addition, open skin may lead to infection, which can occur more easily in stagnant, protein-rich lymph ﬂuid, a perfect medium for bacteria growth (Brewer et al., 2000). Because deep vein thrombosis and cancer recurrence can cause swelling, they were ruled out before H.F. was referred for complex decongestive therapy. Her treatment began with manual lymphatic drainage, a gentle massage that starts proximally to encourage the flow of lymph from the distal extremity. More lymph is encouraged to move into the normally functioning lymphatics (Cheville et al., 2003; Foldi, 1998; Lerner, 1998).

Massage was followed by padding of the extremity and application of short stretch compression bandages with gradual pressure changes distally to proximally. That type of bandaging helps the ﬂow of lymph to the nodal basins (Cheville et al.; International Society of Lymphology, 2003).
H.F. was taught the techniques so that she could continue maintenance therapy at home. She was encouraged to practice manual lymphatic drainage, use compression bandages at night, wear a ﬁtted compression garment, follow meticulous skin care guidelines, protect the leg from trauma and injury, and perform muscle-building exercises. H.F. also was taught to wear the compression garment especially during air travel because changes in atmospheric pressure may increase the pressure balance in the leg (National Lymphedema Network, 2005).

Quality of Life

Lymphedema may have a profound effect on the lives of cancer survivors (Kwan et al., 2002; Ryan, Stainton, Jaconelli, et al., 2003). H.F. described a heavy, achy feeling in her leg, which has been reported in patients with breast cancer before swelling occurred (Armer, Radina, Porock, & Culbertson, 2003). Pain assessment is crucial in helping patients to cope. An over-the-counter medication may sufﬁce, but some patients may need prescription-strength pain medication, making individual assessment critical.

H.F. stated that her pace was slower in her walks. In patients with breast cancer, fatigue often is a troublesome symptom affecting quality of life (Armer & Porock, 2002). Pacing activities or decreasing distances may help to maintain stamina. Pacing also may deter swelling that is associated with strenuous or long-distance exercise. The need for sleep medication should be evaluated because insomnia caused by leg discomfort or worry may contribute to fatigue.
Changes in wardrobe often are necessary when swelling occurs (Ryan, Stainton, Jaconelli, et al., 2003). Alteration in body image may result in changes to regular social activities and may lead to social isolation (Tobin, Lacey, Meyer, & Mortimer, 1993). Referrals to support groups or individual therapy sessions may be indicated depending on patient preference. H.F. found that she gained much by participating in a support group and thereby moved from one type of social interaction to another. Healthcare professionals must be sensitive to lifestyle changes as well as the ﬁnancial burden that may result from a forced change in wardrobe.

With increased survival after cancer treatment, the long-term sequelae caused by cancer treatment should be recognized and treated. Patients must be informed about the potential lifelong side effects of treatment. Although H.F. was informed about the possibility of lymphedema development, many patients have reported that they were not informed about this life-alterating condition until they developed symptoms (Beesley, Janda, Eakin, Obermair, & Battistutta, 2007; Ryan, Stainton, Jaconelli, et al., 2003). Continued research is needed to determine the best interventions to decrease the side effects of treatment and maximize quality of life.

Author Contact

Kathleen Appollo, RN, BSN, OCN can be reached at appollok @mskcc.org, with copy to editor at ONF Editor@ons.org.

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Preventative Steps for Leg Lymphedema

2008-11-04T06:57:00.000-08:00

Preventative Steps for Leg Lymphedema

For the patient who is at risk of developing Lymphedema, and for the patient who has developed Lymphedema.

Who is at risk?

At risk is anyone who has had gynecological, melanoma, prostate or kidney cancer in combination with inguinal node dissection and/or radiation therapy. Lymphedema can occur immediately postoperatively, within a few months, a couple of years, or 20 years or more after cancer therapy. With proper education and care, Lymphedema can be avoided or, if it develops, kept under control. (For information regarding other causes of lower extremity Lymphedema, see What is Lymphedema?) The following instructions should be reviewed carefully pre-operatively and discussed with your physician or therapist.

1. Absolutely do not ignore any slight increase of swelling in the toes, foot, ankle, leg, abdomen, genitals (consult with your doctor immediately).

2. Never allow an injection or a blood drawing in the affected leg(s). Wear a LYMPHEDEMA ALERT Necklace.

3. Keep the edemic or at-risk leg spotlessly clean. Use lotion (Eucerin, Lymphoderm, Curel, whatever works best for you) after bathing. When drying it, be gentle, but thorough. Make sure it is dry in any creases and between the toes.

4. Avoid vigorous, repetitive movements against resistance with the affected legs.

5. Do not wear socks, stockings or undergarments with tight elastic bands.

6. Avoid extreme temperature changes when bathing or sunbathing (no saunas or hottubs). Keep the leg(s) protected from the sun.

7. Try to avoid any type of trauma, such as bruising, cuts, sunburn or other burns, sports injuries, insect bites, cat scratches. (Watch for subsequent signs of infection.)

8. When manicuring your toenails, avoid cutting your cuticles (inform your pedicurist).

9. Exercise is important, but consult with your therapist. Do not overtire a leg at risk; if it starts to ache, lie down and elevate it. Recommended exercises: walking, swimming, light aerobics, bike riding, and yoga.

10. When travelling by air, patients with Lymphedema and those at-risk should wear a well-fitted compression stocking. For those with Lymphedema, additional bandages may be required to maintain compression on a long flight. Increase fluid intake while in the air.

11. Use an electric razor to remove hair from legs. Maintain electric razor, properly replacing heads as needed.

12. Patients who have Lymphedema should wear a well-fitted compression stocking during all waking hours. At least every 4-6 months, see your therapist for follow-up. If the stocking is too loose, most likely the leg circumference has reduced or the stocking is worn.

13. Warning: If you notice a rash, itching, redness, pain, increase of temperature or fever, see your physician immediately. An inflammation or infection in the affected leg could be the beginning or a worsening of Lymphedema.

14. Maintain your ideal weight through a well-balanced, low sodium, high-fiber diet. Avoid smoking and alcohol. Lymphedema is a high protein edema, but eating too little protein will not reduce the protein element in the lymph fluid; rather, this may weaken the connective tissue and worsen the condition. The diet should contain easily-digested protein such as chicken, fish or tofu.

15. Always wear closed shoes (high tops or well-fitted boots are highly recommended). No sandals, slippers or going barefoot. Dry feet carefully after swimming.

16. See a podiatrist once a year as prophylaxis (to check for and treat fungi, ingrown toenails, calluses, pressure areas, athelete's foot).

17. Wear clean socks & hosiery at all times.

18. Use talcum powder on feet, especially if you perspire a great deal; talcum will make it easier to pull on compression stockings. Be sure to wear rubber gloves, as well, when pulling on stockings. Powder behind the knee often helps, preventing rubbing and irritation.

Unfortunately, prevention is not a cure. But, as a cancer and/or Lymphedema patient, you are in control of your ongoing cancer checkups and the continued maintenance of your Lymphedema.

Revised © January 2001 National Lymphedema Network. Permission to print out and duplicate this page in its entirety for educational purposes only, not for sale. All other rights reserved. For more information, contact the NLN: 1-800-541-3259.

Complications of Leg Lymphedema

2008-10-26T11:14:00.000-07:00

Complications of Leg Lymphedema
1. Infections such as cellulitis, lymphangitis, erysipelas. This is due not only to the large accumulation of fluid, but it is well documented that lymphodemous limbs are localized immunodeficient and the proein rich fluid provides an excellent nurturing invironment for bacteria.

2. Draining wounds that leak lymphorrea which is very caustic to surrounding skin tissue and acts as a port of entry for infections.

3. Increased pain as a result of the compression of nerves usually caused by the development of fibrosis and increased build up of fluids.

4. Loss of Function due to the swelling and limb changes.

5. Depression - Psychological coping as a result of the disfigurement and debilitating effect of lymphedema.

6. Deep venous thrombosis again as a result of the pressure of the swelling and fibrosis against the vascular system. Also, can happen as a result of cellulitis, lymphangitis and infections. See also Thrombophlebitis

7. Sepsis, Gangrene are possibilities as a result of the infections.

8. Possible amputation of the limb.

9. Pleural effusions may result if the lymphatics in the abdomen or chest are to overwhelmed to clear the lung cavity of fluids.

10. Skin complications such as dry skin, splitting, plaques and nodules, susceptibility to fungus and bacterial infections.

11. Chronic localized inflammations.

12. Pain ranging from mild in early lymphedema to severe in late stage lymphedema.

13. Lymphatic cancers which can include angiosarcoma, lymphoma; Kaposi's Sarcoma; lymphangiosarcoma (Stewart_treves Syndrome); Cutaneous T-Cell lymphoma; Cutaneous B-Cell lymphoma; Pseudolymphomatous Cutaneous Angiosarcoma. See also: Primary Lymphedema and Cancer for a discussion and Lymphatic Cancers Secondary to Lymphedema.
Note: These cancers are rare and are usually associated with long term, untreated or improperply treated lymphedema. Typically occuring in stage three or four; quite rare in stage two.

14. Skin complications possible in stages 3 and 4 include papillomatosis; placques including “cobblestone” appearing placque; dermatofibroma; Skin Tags; Warts and Verrucas; Mycetoma skin fungus; dermatitis and many lymphedema patients report increased problems with psoriasis; eczema and shingles. I would suspect this may be due to again, the immunocompromised condition of the arm or leg afflicted with lymphedema.

15. Documented but rare complications in late stage also can include Lymphomatoid Papulosis; Cutis Marmorata; Acroangiodermatitis; Dermatolymphangioadenitis (DLA); Papillomatosis cutis carcinoides

16. Debilitating joint problems. This is caused by a combination of the excess fluid weight and the constant inflammatory process that accompanies lymphedema. As we have gotten older, many lymphedema patients are having total knee replacement, total hip replacement, or total shoulder replacement while others are experiencing carpal tunnel syndrome and are having carpal tunnel surgery or experiencing shoulder problems associated with lymphedema and must haverotator cuff surgery.

Risk Factors for Lymphedema

2008-10-26T11:07:00.000-07:00

Risk Factors for Lymphedema

There are certain factors that can create a significant risk for the development of what is referred to as secondary leg lymphedema.

These risk factors include:

1.) Lymph node removal for biopsies

2.) Serious infections that include lymphangitis, cellulitis or erysipelas.

3.) Deep invasive wounds that might tear, cut or damage the lymphatics.

4.) Radiation treatments, especially ones that are focused in areas that might contain “clusters” of lymph nodes

5.) Morbid obesity can cause secondary lymphedema by “crushing” the lymphatics

6.) Serious burns, even intense sunburn

7.) Infection of the microscopic parasite filarial larvae, though this is more common in tropical countries

8.) For primary lymphedema any person who has a family history of unknown swelling of a limb

9.) Radiation and chemotherapy for cancer

10.) Insect bites

11.) Bone fractures and breaks

Symptoms of Leg Lymphedema

2008-10-26T10:54:00.000-07:00

Symptoms of Leg Lymphedema

These symptoms may include:

1.) Unexplained swelling of either part of or the entire leg. In early stage lymphedema, this swelling will actually do down during the night and/or periods of rest, causing the patient to think it is just a passing thing and ignore it.

2.) A feeling of heaviness or tightness in the leg

3.) Increasing restriction on the range of motion for the leg.

4.) Unsual or unexplained aching or discomfort in the leg.

5.) Any change involving hardening and/or thicking of the skin or areas of skin on the leg.

6.) Tingling or "Needles and pins" discomfort.

7.) "Compressible" swelling where when mashed there will be an endentation - called pitting edema

8.) Hardening and thickening of the skin on your leg

What are the symptoms of Lymphedema?

Lymphedema usually manifests as severe swelling of an arm or leg. For patients who have developed lymphedema as a complication of cancer treatment, the swelling is almost always on the same side as the treatment. In some cases, lymphedema may involve both of the limbs, typically the legs. The swelling commonly extends from the arm or leg into the fingers or the toes. In the early stages of lymphedema, the swelling is soft, and pressing on the limb may result in movement of the fluid. This is called “pitting edema”. In the later stages of lymphedema, scar tissue and fibrous tissue may develop in the swollen limb causing a more dense texture of the swelling and a cobblestoned or orange-peel like appearance of the skin. Patients with lymphedema may experience heaviness of the effected arm or leg and have difficulty with exercise or participation in other activities. In the most severe cases of lymphedema, swelling may be disfiguring and may lead to embarrassment and emotional distress and even difficulty in wearing clothes or shoes.

In addition to swelling, patients with lymphedema are at risk for developing certain types of skin infection in the swollen arm or leg known as cellulitis and lymphangitis. In mild to moderate infection, the skin will become warm, red, tender, and the patient may feel flu-like symptoms. Oral antibiotics and careful skin care should be started as soon as symptoms develop. In severe cases, high fevers and even shock may develop and require immediate hospitalization for intravenous antibiotics and close observation. Patients with severe, long-standing lymphedema are at increased risk for developing certain types of cancer, including certain skins cancers and lymphoma, although this is very rare.

Causes of Leg Lymphedema

2008-10-26T10:44:00.000-07:00

Causes of Leg Lymphedema
Primary Leg Lymphedema:

Congenital (from birth) malformation of the lymph system or in the development of the lymph system; hereditary lymphedema in which lymph nodes may be missing

Secondary Leg Lymphedema:

Secondary leg lymphedema (also referred to as acquired lymphedema) is caused by or can develop as a results of:

1.) Surgeries involving the abdomen or legs where the lymph system has been damaged. This includes any intrusive surgery.

Examples are

vein stripping surgery for peripheral vascular disease hip replacement knee replacement insertion of bolts, screws and other devices in orthopaedic repair lipectomy

2.) Removal of lymph nodes for cancer biopsy. These cancers include, but are not limited to prostate cancer testicular cancer ovarian cancer uteran cancer vulva cancer bladder lymphoma - both hodgkins and non hodgkins melanoma colon Kaposi Sarcoma

3.) Radiation treatment of these cancers that scars the lymph system and lymph nodes

4. Some types of chemo therapy. For example, tamoxifen has been linked to secondary lymphedema and blood clots.

5.) Severe infections/sepsis. Generally referred to as lymphangitis, this is a serious life-threatening infection of the lymph system/nodes.

6.) Trauma injuries such as those experienced in an automobile accident that severly injures the leg and the lymph system.

7.) Burns - this even includes severe sunburn. We have a member that acquired secondary leg lymphedema from this.

8.) Bone breaks and fractures.

9.) Morbid obesity - the lymphatics are eventually crushed by the excessive weight. When that occurs, the damage is permanent and chronic secondary leg lymphedema begins.

10.)Insect bites

11.)Parasitic infections

Basics of Leg Lymphedema

2008-10-26T10:39:00.000-07:00

Lymphedema of the Legs and Ankles

By Linda Fisher

The obstruction of the flow of lymph from a given area results in the accumulation of abnormally large amounts of tissue fluid in that area. Such an accumulation is called lymphedema.

Lymphadema is not only uncomfortable, it may cause such problems as pain, infection and recurrent infection, difficulty in movement, clothing restrictions, and air travel restrictions.
Remembering that the lymph moves upward in the body toward the heart, from the finger tips in toward the heart, and from the top of the head down toward the heart, we can see that the fluid moving furthest in the body is from the lower extremities. Some causes of lymphedema of the lower extremities is congestive heart failure, trauma to the back or lower abdominal area, blockage in the groin (inguinal nodes), or blockage behind the knee (popliteal nodes).

I often use the analogy of a traffic accident on the freeway to explain movement of lymph. At the point of the accident, all traffic either stops or slows to a near halt, until the accident is cleared away, thus allowing the traffic to again flow naturally. Anatomically, at the point of blockage, everything slows down and begins to accumulate backward along the path of flow. If the feet and ankles are swollen, it generally means that there is a blockage “up ahead.”

Even in slender young people, we sometimes see signs of lymphedema in the legs. This appears as “heavy ankles” or as a little pouch of fat on the inside curve of the knee area. When present in this portion of the population, we usually find that the individual is not getting the right exercise and eating largely of the wrong foods, or just the opposite. Many joggers, tennis players, and aerobic exercise enthusiasts exercise and eat properly, but they get this problem because repeated hard impact will slow lymph movement.

In the middle age and senior group, we may see a different, but very common, problem - shuffling the feet instead of walking comfortably. When you cannot lift your feet to step properly, you may just accept that you probably have an “arthritic problem.” Many times, you may have a large mass of lymph fluid behind your knee that has pooled, and then hardened. Imagine the pain this would cause. It would be like strapping a tennis ball behind your knee and then attempting to walk!

There is more than one cause of lymphedema in the lower extremities. The ones mentioned above are just some of the more common ones.

Tips to Avoid Blockage:

Do not wear tight jeans or tight under garments. Do not cross the knees when sitting; cross feet at the ankles instead. For the exercise enthusiast, integrate some form of slow, rhythmic exercise - yoga and pilates are excellent, as is walking. Bouncing on a trampoline is excellent - no need to jump. Bend your knees and get a gentle bounce going for a minimum of 12-15 minutes a day. If balance is a concern, hold onto a stationary item or purchase a balance bar that attaches to your trampoline. Also, if wheel chair bound, place your feet on the trampoline and have someone else bounce it for you - you will receive a positive benefit from this. Lie on a slant board. And, as always, drink plenty of clean water, practice deep belly-breathing, and eat plenty of fresh, unprocessed foods. Caution: In the case of congestive heart failure, be absolutely sure to check with your health care practitioner before attempting any form of exercise and, of course, no slant-boarding! “Creating free lymphatic movement through the body is a vital part of any healing process.”

Linda Fisher owns the Lympathic Wellness Center in Santa Maria.

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