Lymphedema Information

Preoperative assessment enables the early diagnosis and successful treatment of lymphedema.

2008-05-14T13:30:05Z

Preoperative assessment enables the early diagnosis and successful treatment of lymphedema.

Cancer. 2008 Apr 21

Stout Gergich NL, Pfalzer LA, McGarvey C, Springer B, Gerber LH, Soballe P.

Breast Cancer Department, National Naval Medical Center, Bethesda, Maryland.

BACKGROUND: The incidence of breast cancer (BC)-related lymphedema (LE) ranges from 7% to 47%. Successful management of LE relies on early diagnosis using sensitive measurement techniques. In the current study, the authors demonstrated the effectiveness of a surveillance program that included preoperative limb volume measurement and interval postoperative follow-up to detect and treat subclinical LE.

METHODS: LE was identified in 43 of 196 women who participated in a prospective BC morbidity trial. Limb volume was measured preoperatively and at 3-month intervals after surgery. If an increase >3% in upper limb (UL) volume developed compared with the preoperative volume, then a diagnosis of LE was made, and a compression garment intervention was prescribed for 4 weeks. Upon reduction of LE, garment wear was continued only during strenuous activity, with symptoms of heaviness, or with visible swelling. Women returned to the 3-month interval surveillance pathway. Statistical analysis was a repeated-measures analysis of variance by time and limb (P </= .001) comparing the LE cohort with an age-matched control group.

RESULTS: The time to onset of LE averaged 6.9 months postoperatively. The mean (+/-standard deviation) affected limb volume increase was 83 mL (+/-119 mL; 6.5% +/- 9.9%) at LE onset (P = .005) compared with baseline. After the intervention, a statistically significant mean 48 mL (+/-103 mL; 4.1% +/- 8.8%) volume decrease was realized (P < .0001). The mean duration of the intervention was 4.4 weeks (+/-2.9 weeks). Volume reduction was maintained at an average follow-up of 4.8 months (+/-4.1 months) after the intervention.

CONCLUSIONS: A short trial of compression garments effectively treated subclinical LE. Cancer 2008. Published 2008 by the American Cancer Society.

Keywords

breast cancer • lymphedema • early detection • physical therapy • early intervention • compression • optoelectronic volumetry • subclinical lymphedema

Wiley InterScience

Congenital lymphedema of the upper extremity. A case report.

2008-04-22T12:14:36Z

Congenital lymphedema of the upper extremity. A case report.

Eur J Phys Rehabil Med. 2008 Mar

Sim YJ, Seo JH.
Department of Physical Medicine and Rehabilitation, Kosin University
College of Medicine, Busan, Republic of Korea.

This study presents an unusual case of primary lymphedema of the upper
extremity in a healthy 28-year-old woman. The onset of swelling of the
left upper extremity was observed at birth, but was not accurately
diagnosed until the patient visited our department. Diagnostic
assessment included evaluating the patient's history and laboratory and
radiological data, which were all normal except for the swollen upper
extremity and the lymphoscintigraphy findings. The patient was
diagnosed as suffering from primary lymphedema of her left arm.
Complete decongestive therapy was done and her swelling mildly improved.

Full text PDF file:

http://www.minervamedica.it/index2.t?show=R49Y2008N01A0089

Controlled, Comparative Study of Relation between Volume Changes and Interface Pressure under Short-

2008-03-14T14:26:08Z

Controlled, Comparative Study of Relation between Volume Changes and Interface Pressure under Short-Stretch Bandages in Leg Lymphedema Patients.

Dermatol Surg. 2008 Mar

Damstra RJ, Brouwer ER, Partsch H.

Department of Dermatology, Phlebology and Lymphology, Hospital Nij Smellinghe, Drachten, The Netherlands.

BACKGROUND
Pressure loss under short-stretch bandages (SSBs) is a well-known phenomenon and is thought to be related to bandage relaxation and poor quality of application.

AIM
The aim was to demonstrate that therapeutically intended volume reduction of the compressed leg is the most important cause for the loss of bandage pressure.

DESIGN
This was an experimental, controlled comparative study.

METHODS
In 20 patients suffering from lymphedema of the lower extremities and in 9 healthy persons, lower leg volume was measured by water displacement. After application of a pressure measurement device (Kikuhime) at the B1 region, SSBs were applied on one leg according to a standard protocol. Volume and pressure measurements were performed at 0, 2, and 24 hours in supine as well as standing positions.

RESULTS
A significant reduction of leg volume is already achieved 2 hours after bandage application, both in lymphedema patients and in normal controls. A further volume decrease of the lymphedematous legs is observed in the following 24 hours after application of a new bandage (-290 mL). The volume reduction is associated with a significant loss of bandage pressure from initial values over 60 mmHg by 37 and 48% in controls and lymphedema patients, respectively.

CONCLUSIONS
Inelastic, multilayer, multicomponent compression bandages lead to an immediate reduction of leg volume, both in lymphedematous and in normal legs. This therapeutically intended volume reduction seems to be the main reason for the fast decrease of the subbandage pressure.

PMID: 18336577 [PubMed - as supplied by publisher]

A labor of love

2008-02-23T10:22:50Z

A labor of love

Anne Flynn teaches classes and sells jewelry to aid lymphedema sufferers

Susan Schell

of the Gateway

Published: 02:36PM February 20th, 2008

A group of women stand in a circle, blowing bubbles through small, colorful plastic bubble blowers, and giggle. The laughter is just as important in this class as the stretching, toning and dancing that follows.

At first glance, it seems like all fun and games — class instructor Anne Flynn hands out hats and feather boas and leads her students through a series of movements set to fun music. But the class is part of a groundbreaking exercise program called “The Lebed Method,” designed for cancer survivors and patients suffering from lymphedema and chronic illness.

An occupational therapist and lymphedema specialist, Flynn began teaching classes for multiple sclerosis sufferers last October and began implementing her training for cancer patients last month. Flynn said lymphedema is a condition where a person’s lymphatic system has been damaged, especially cancer patients who have been undergoing chemotherapy.

“The lymphatic system rids your system of waste,” Flynn said. “When it gets interrupted, junk stays in there. The excess protein causes the skin to become hard and leathery.”

The condition can also cause painful swelling in limbs or other parts of the body. Special garments designed for the condition are expensive, because they have to be custom-made to fit each individual.

“I originally started the class for MS patients who were telling me that their movement was better and their pain was down,” Flynn said. “There’s so many people with pain, and the people who really feel a decrease in pain is the population that exercises.”

Flynn teaches the Lebed classes at Allenmore Hospital in Tacoma and at the MultiCare Gig Harbor Medical Park on Point Fosdick Drive.

The Lebed program was designed by Sherry Lebed Davis and is recognized by the National Lymphedema Foundation. Lebed was a former dancer and breast cancer survivor from Seattle.

“She couldn’t move her arms and was weak from surgery,” Flynn said. “She found that slow stretches and exercises helped her improve tremendously, so she began setting up classes for other people. She took the program out of the mothballs.”

The Lebed Method has since earned national acclaim and has been featured on TV shows such as “Lifetime” and “The Today Show.”

“The Lebed method is widely known in cancer circles and in other countries,” Flynn said.

“It’s great for patients with lymphedema,” she added. “We focus on lymph-cleaning exercises. It’s a series of slow, steady stretches in a certain order. It’s like traffic on a freeway — you have to clear out one area before you can go down the road. This increases the pumping action of the lymph vessels and helps the flow of (the body’s) waste material.”

Flynn’s students will readily vouch for the wonders of the Lebed method: Laura Justice was diagnosed with MS in 2003 and has participated in the class since it started.

“This is something I look forward to every week,” she said. “Anne really started me moving and kept me moving. Her personality is so great. She makes this class so fun, and she’s fun to be with.”

Justice said the no-stress atmosphere of the class helped her relax and enjoy the exercises.

“She lets me sit in the chair if I’m fatigued,” she said. “She lets me work at my level and come in and do what I can do.”

Flynn said that when she took the Lebed training, she saw it addressed many physical problems.

“For cancer patients, their bodies have been their enemy,” she said. “I help them get back in touch with it in a good way. We have 10-minute water breaks that have turned into a support group. The students interact, but instead of being sad, their endorphins are flowing and they’re upbeat and filled with joy and hope.”

Flynn has a history of nurturing and caring, having worked in nursing homes for 11 years. She began specializing in lymphedema treatment four years ago and decided to augment her therapy with Lebed classes and was pleasantly surprised by the results.

“It’s very rewarding to see people improve so quickly,” she said. “I see results in every patient as long as they stick with it. And you don’t have to be an aerobics instructor to teach this class.”

Flynn’s interest in helping others has gone beyond her classes and into a personal hobby to help lymphedema patients purchase special compression garments. A sock can cost as much as $100 to $150 — a glove as much as $500.

Flynn fashions her own custom jewelry and sells it at the Healthy Reflections Boutique in Gig Harbor. The proceeds from the sales are donated to help patients who can’t afford to purchase the garments.

“A lot of people are without insurance, and elderly people are on a fixed income,” Flynn said.

Her jewelry is made from fine silver, sterling silver, freshwater pearls and handmade glass. Flynn fashions the glass into decorative beads and cooks it in a small kiln at her home.

“You shape the glass with torches and rods,” she said. “It’s a lot of fun. I use whatever colors I feel like using that day and the designs are kind of whimsical. When I work, I’m like a kid in a candy store.”

Reach reporter Susan Schell at 253-853-9240 or by e-mail at susan.schell@gateline.com.

Peninsula Gateway

http://www.gateline.com/106/story/686.html

Lymphatic venous anastomosis (LVA) for treatment of secondary arm lymphedema

2008-02-16T12:28:29Z

Lymphatic venous anastomosis (LVA) for treatment of secondary arm
lymphedema. A prospective study of 11 LVA procedures in 10 patients
with breast cancer related lymphedema and a critical review of the
literature.

Breast Cancer Res Treat. 2008 Feb 13

Abstract

Objective

The incidence of breast cancer related lymphedema (BCRL) varies
between 7-35% depending on the combination of treatment modalities.
Early detection of BCRL is crucial in order to start an effective non-
operative treatment program. Because of the lack of prospective
research on this topic, this study was undertaken to prospectively
determine the effect of Lympho Venous Anastomosis (LVA) on BCRL and
to review the current literature.

Study design and methods

Ten patients who were previously treated for breast cancer by
surgery, radiotherapy, and chemotherapy, and were unresponsive to 12-
weeks of non-operative treatment, underwent an LVA procedure (Degni-
Cordeiro). Objective measurements were gathered for circumferential
measurement and water volumetry, and quality of life. Various types
of lymphoscintigraphy were carried out pre-operatively and post-
operatively at 3 and 12 months. Treatment was embedded in a
multidisciplinary setting.

Results

Post-operative volume measurements initially showed a 4.8% reduction
of lymphedema at 3 months and a 2% reduction after one year. Various
scintigraphic parameters showed some improvement. Quality of life
questionnaires reported minimal improvement. Reviewing the
literature, only retrospective studies were found; these reported
varying results for LVA procedures. The selection of patients,
classification of lymphedema, indications and types of LVA, and
additional therapeutic options were heterogeneous, not comparable,
and lacked a validated method of effect-assessment.

Conclusions

Our results showed a minimal reduction in volume of lymphedema
following LVA; in the literature, there was no convincing evidence of
the success of LVA. Non-operative treatment and elastic stockings are
still preferred by most patients with lymphedema, especially in early
stages with few irreversible changes.

Keywords: Lympho-venous anastomosis (LVA) - Microsurgery - Evidence-
based medicine - Lymphoscintigraphy - Inverse water volumetry -
Review - Breast cancer related lymphedema

Springerlink

http://www.springerlink.com/content/00016731188426w5/

Elephantiasis Nostras Verrucosa or "Mossy Foot Lesions" in Lymphedema Praecox

2008-01-19T15:11:14Z

Elephantiasis Nostras Verrucosa or "Mossy Foot Lesions" in Lymphedema
Praecox

Journal of the American Podiatric Medical Association
Volume 98 Number 1 66-69 2008

Report of a Case

Amy L. Duckworth, DPM *, Jugnoo Husain, MD and Patrick DeHeer, DPM
* St. John North Shores Hospital, Harrison Township, MI. Dr. Duckworth
is now with Northern California Orthopedic Centers, Carmichael, CA.
Department of Pathology, AmeriPath, Indianapolis, IN.
Private practice, Richmond, IN.

Corresponding author: Amy L. Duckworth, DPM, 6403 Coyle Ave, Ste 170,
Carmichael, CA 95608.

Abstract

Elephantiasis nostras verrucosa is a rare disorder that results from
chronic obstructive lymphedema. It is characterized clinically by
deforming, nonpitting edema; malodorous hyperkeratosis with
generalized lichenification; cobblestoned papules; and verrucous
changes, that often result in extreme enlargement of the involved body
part. Although elephantiasis nostras verrucosa is striking in clinical
appearance, biopsy reveals only moderately abnormal findings:
pseudoepitheliomatous hyperplasia with dilated lymphatic spaces in the
dermis, accompanied by chronic inflammation and fibroblast
proliferation. The term elephantiasis nostras (nostras means "from our
region") has traditionally been used to differentiate temperate zone
disease from the classic disease process, elephantiasis tropica, which
is defined by chronic filarial lymphatic obstruction caused by
Wuchereria bancrofti, Wuchereria malayi, or Wuchereria pacifica. We
present a case report of elephantiasis nostras verrucosa arising as a
result of lymphedema praecox. (J Am Podiatr Med Assoc 98(1): 66-69,
2008)

http://www.japmaonline.org/cgi/content/abstract/98/1/66

------------------------

For more information on this see:

Lymphedema Skin Plaque and Nodules

Elephantiasis nostras verrucosa

http://www.lymphedemapeople.com/phpBB2/viewtopic.php?t=86

Endermologie (with and without compression bandaging)--a new treatment option for secondary arm lymp

2007-12-24T14:11:05Z

Endermologie (with and without compression bandaging)--a new treatment option for secondary arm lymphedema.

Lymphology. 2007

** Editor's note:

This abstract is for information only. It is my personal opinion that other studies are needed to support claims that this might be a valuable treatment for lymphedema and studies are needed for leg lymphedema in addition to secondary
arm lymphedema. For further information on this subject, please refer to my page Endermologie

Pat

Moseley AL, Esplin M, Piller NB, Douglass J.

Department of Surgery, Lymphoedema Assessment Clinic, Flinders University and Medical Centre, Bedford Park, Adelaide, South Australia.

Two treatment protocols are presented using the LPG Endermologie system in combination with compression bandaging as a new treatment option for secondary arm lymphedema. Both protocols were applied 4 days a week for 4 weeks but differed in Trial II in time spent clearing the regions of the trunk adjacent to the swollen limb and the addition of a larger treatment head so that a greater area could be covered more quickly. The first protocol involved 24 women and the second involved 10 women. At the end of the treatment period, both protocols demonstrated overall reductions in limb volume (134mls; 18.3% p = 0.000 and 185mls; 28%, p = 0.002), limb fluid (182mls; 28%, p = 0.000 and 216mls; 33%. p = 0.014), truncal fluid (342mls; p = 0.002 and 290mls; p = 0.066), improvements in fibrotic induration in some lymphatic territories, and significant improvements in subject reporting of heaviness, tightness, tissue hardness and limb size. Trial II demonstrated additional benefits in terms of reduction in whole arm volume at 24 hours, improved fluid and arm volume reductions, and a significant improvement in subject reported arm range of movement. The additional time spent clearing the regions adjacent to the swollen limb in the second protocol appears to produce an increase in limb volume and limb fluid loss compared to the original treatment protocol.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=18062615&ordinalpos=10&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

Manipulative therapy of secondary lymphedema in the presence of locoregional tumors.

2007-12-21T05:12:50Z

Manipulative therapy of secondary lymphedema in the presence of
locoregional tumors.

Cancer. 2007 Dec 17

Pinell XA, Kirkpatrick SH, Hawkins K, Mondry TE, Johnstone PA.
Radiation Oncology Department, Emory University School of Medicine,
Atlanta, Georgia.

BACKGROUND: Complete decongestive therapy (CDT), including manual
lymphatic drainage (MLD) is a manipulative intervention of documented
benefit to patients with lymphedema (LE). Although the role of CDT for
LE is well described, to the authors' knowledge there are no data
regarding its efficacy for patients with LE due to tumor masses in the
draining anatomic bed. Traditionally, LE therapists are wary of
providing therapy to such patients with 'malignant' LE for fear of
exacerbating the underlying cancer, and that the obstruction will
render therapy less effective. In the current study, the authors'
experience providing CDT for such patients is discussed.

METHODS: Cancer survivors with LE were referred to therapists at 2
Atlanta-area clinics. CDT consists of treatment (Phase 1) and
maintenance phases (Phase 2). During Phase 1, the patient undergoes
manipulative therapy and bandaging daily until the LE reduction
plateaus; at that point, Phase 2 (self-care) begins. At the beginning
and end of Phase 1, LE is quantified and differences in girth volume
calculated. The results for patients completing Phase 1 therapy for LE
in the presence of locoregional masses were compared with results for
patients with LE in the absence of such disease. Both volume reduction
of the affected limb and number of treatments to plateau were
analyzed.

RESULTS: Between January 2004, and March 2007, LE of 82 limbs in 72
patients was treated with CDT and Phase 1 was completed. The median
number of treatments to plateau was 12 (range, 4-23 treatments); the
median limb volume reduction was 22% (range, -23 to 164%). Nineteen
limbs (16 patients) with associated chest wall/axillary or pelvic/
inguinal tumors had nonsignificant difference in LE reduction (P = .
75) in the presence of significantly more sessions to attain plateau
(P = .0016) compared with 63 limbs in 56 patients without such
masses.

CONCLUSIONS: Patients with LE may obtain relief with CDT regardless
of whether they have locoregional disease contributing to their
symptoms. However, it will likely take longer to achieve that effect.
Manipulative therapy of LE should not be withheld because of
persistent or recurrent disease in the draining anatomic bed. Cancer
2008. (c) 2007 American Cancer Society.

PubMed

Effectiveness of the treatment complex decongestive physiotherapy for extremity lymphedema.

2007-12-16T08:13:39Z

Effectiveness of the treatment-phase of two-phase complex decongestive physiotherapy for the treatment of extremity lymphedema.

Int J Clin Oncol. 2007 Dec

Yamamoto R, Yamamoto T.

Rhythmic Obstetrics and Gynecology Clinic, 4F-1, No. 26 Keiwa bldg., Kita 24, Nishi 4, Kita-Ku, Sapporo, 001-0024, Japan, rhythmic@minos.ocn.ne.jp.

BACKGROUND: Complex decongestive physiotherapy (CDP) consists of a two-phase treatment program and is the international standard therapy for lymphedema. However, this therapy is not performed at most hospitals in Japan.

METHODS: The subjects of the present study were 82 Japanese women with lymphedema of an extremity (median age, 64 years; range, 40-86 years). The volume of the affected extremity was compared before and after therapy, and the duration of the CDP treatment phase and rate of edema reduction were ascertained. The associations between the effect of CDP and duration of lymphedema, operative procedure, and radiotherapy were also investigated.

RESULTS: For patients with upper-extremity lymphedema, the median duration of the CDP treatment phase was 6 treatment days (range, 3-26 days), median reduction of edema volume was 328.7 ml (range, 76.6-1258.0 ml; P = 0.0014), and median rate of edema reduction was 58.9% (range, 42.7%-97.1%). For patients with lower-extremity lymphedema, the median duration of the CDP treatment phase was 10 treatment days (range, 2-35 days), median reduction of edema volume was 1573.7 ml (range, 293.9-3471.1 ml; P < 0.0001), and median rate of edema reduction was 73.4% (range, 29.2%-117.3%). Although no correlation was seen between duration of lymphedema and duration of the CDP treatment phase or rate of edema reduction, the degree of lymph node dissection tended to influence rate of edema reduction in patients with lower-extremity lymphedema.

CONCLUSION: In a study of Japanese women with lymphedema, CDP comprising a two-phase treatment program was clearly effective.

Springerlink

Locating a Certified Lymphedema Therapist

2007-11-22T14:38:00Z

Locating a Certified Lymphedema Therapist

It is important for the lymphedema patient to understand that there is an important difference between what we know of as massage therapy and the type of decongestive therapy that is the protocol treatment for lymphedema Traditional massage therapy is not treatment for lymphedema.

This page will

1.) Explain the difference

2.) Link you to pages wherein you can locate a certified and properly trained lymphedema therapist in your area.

Pat

Schools of lymphedema therapy

From here you can locate locate and link to therapists all over the US, Canada, the United Kingdom, Ireland, Greece, Australia, New Zealand and Singapore

Home Page: http://www.vodderschool.com/index.cfm

Therapist Finder: http://www.vodderschool.com/therapist_search.cfm

Dr. Vodder School - North America PO Box 5701 Victoria, British Columbia, V8R 6S8 Tel: (250) 598-9862 Fax: (250) 598-9841

LYMPHEDEMA THERAPY CERTIFICATION

Home Page: http://www.klosetraining.com/

Find a Therapist: http://www.klosetraining.com/pages/therapistdirectory.html

Home Page: www.acols.com

Find a Therapist: http://www.acols.com/FindaTherapist.aspx

Home Page: http://www.nortonschool.com/

Find a Therapist: http://www.nortonschool.com/therapistreferrals.html

Home Page: http://www.lymphedemamanagement.com/

Find a Therapist

http://www.lymphedemamanagement.com/members.asp

e-Mail: Information@lymphedemamanagement.com

Home page: http://www.clt-lana.org/

Find a Therapist: http://www.clt-lana.org/therapists/default.asp

National Lymphedema Network

http://www.lymphnet.org/

Find a Therapist: http://www.lymphnet.org/resourceGuide/manualDrainage.htm

Manual Lymphatic Drainage in the United Kingdom

http://www.mlduk.org.uk/ Email: admin@mlduk.org.uk

Home Page: http://www.lymphoedema.org.au/

List of Therapists

http://www.lymphoedema.org.au/therapst.html

Complex Lymphatic Therapy Courses US

http://www.casley-smith-lymphedema-courses.org/index.html

By Joachim Zuther, MT, PT

Editor's note: Joachim Zuther is the founder and director of the Academy of Lymphatic Studies in Sebastian, Florida. Mr. Zuther received his massage therapy degree in 1982 and his physical therapist degree in 1984, both from the School for Physical Therapy and Massage in Ulm, Germany.

Lymphedema is a common condition caused by a reduction in the transport capacity of the lymphatic system. The lymphatic system in the affected area is unable to respond to an increase in lymphatic loads. Massage therapy increases the amount of lymphatic load and can have negative effects on lymphedema if applied incorrectly. This article discusses the differences between massage therapy and the techniques known as manual lymph drainage (Vodder Technique) and the proper application of massage therapy when lymphedema is present.

Lymphedema is defined as high-protein edema - an accumulation of water and protein in the tissues, caused by a decrease in the transport capacity of the lymphatic system. Lymphedema may be mild, moderate or severe; most often, it affects the extremities, but can also be present in other parts of the body.

Lymphedema can be classified as primary or secondary. In primary lymphedema, transport capacity is reduced as the result of a congenital malformation in the lymphatic system.6 Primary lymphedema may be present at birth, but more often develops later in life, with or without obvious cause. Secondary lymphedema is more common, and is caused by surgical interventions involving the lymphatic system. Lymph node dissections, radiation therapy, or incisions that disrupt the natural pathways of the lymphatic system affect the ability of the lymphatics to drain lymphatic loads out of the affected extremity. Secondary lymphedema may arise immediately after surgery or years later.

The lymphatic system is not a closed circulatory system; it works according to the one-way principle. Its main purpose is to drain from the interstitium substances that cannot be absorbed by the venous end of the blood capillaries. These substances, called lymphatic loads, consist of water, protein, cells and fat.5

Transport capacity is the highest possible lymph flow per unit of time.4 The relation of the physiological resting lymph flow to the transport capacity of a healthy lymphatic system is approximately 1:10.7 This means that the lymphatic system is able to transport 10 times the volume of the normal amount of lymphatic loads. When primary or secondary lymphedema is present, the transport capacity of the lymphatic system falls below the physiological level of water and protein load (mechanical insufficiency).

The term massage means “to knead” (Gr: massain) and is used to describe forms of “classical” or “Swedish” massage.10 The word is often misused to describe the techniques of manual lymph drainage, which is a gentle, manual treatment technique used in combination with compression therapy, skin care and decongestive exercises. The techniques of MLD are used to effectively treat primary and secondary lymphedema1 and postsurgical and posttraumatic swelling. Migraine headache, chronic venous insufficiencies and edema of other genesis present additional indications. MLD also has a detoxifying effect.

If applied correctly, MLD increases the activity of lymph vessels and moves interstitial fluid; it exerts little pressure on the skin3 and does not cause any increase in local arterial blood flow.

The basic strokes used in massage (e.g., petrissage, effleurage, tapotement, vibration and friction) are generally applied with more pressure than manual lymph drainage techniques. The effects of massage strokes are not limited to suprafascial tissues (e.g., the skin), but also cause reactions in subfascial areas such as muscles, tendons and ligaments. Massage strokes can increase local arterial blood flow and venous and lymphatic return, and can also loosen subcutaneous adhesions.

Many massage therapy publications list edema as one of the indications for these techniques.8 This statement, while correct, is often misleading if the distinction between edema and lymphedema is not established. Edema is suprafascial tissues can be caused by various problems, including inflammation or impaired venous return (valvular insufficiency, pregnancy, or prolonged sitting and/or standing). With edema, the lymphatic system remains intact but is overloaded. This condition, called dynamic insufficiency, results in the accumulation of water in the tissues. Massage therapy may be beneficial for some forms of edema, but is contraindicated for others. It should not be applied without prior consultation with a physician.

On the other hand, lymphedema is always caused by mechanical insufficiency of the lymphatic system; water and protein accumulates in the tissues. As discussed earlier, in the case of mechanical insufficiency, the transport capacity of the lymphatic system falls below the physiological level of water and protein load and is not able to appropriately respond to an increase in lymphatic loads.

Most massage strokes cause an increase in arterial blood flow (active hyperemia) in skin areas where such techniques are applied. Active hyperemia is accompanied by an increase in blood capillary pressure and subsequent increase in ultrafiltration of water in the area of the blood capillaries. This process results in more water accumulating in the interstitial spaces. Water represents a lymphatic load. Due to mechanical insufficiency, the lymphatic system will not be able to manage this additional water load. If massage therapy to lymphedemateous tissues, an increase in swelling may result.

Additionally, superficial lymphatics are extremely vulnerable to external pressure. Traditional massage techniques can cause focal damage to anchoring filaments and the endothelial lining of lymph vessels.2 This possible damage to lymphatics, and the potential increase in arterial blood flow, must be avoided.

If lymphedema is present, the application of massage therapy is contraindicated in the affected extremity and the trunkal area bordering the extremity (ipsilateral trunkal quadrant). Massage therapy is also contraindicated in these areas in patients who have undergone surgery involving the lymphatic system, but when lymphedema is not yet present (latency stage of lymphedema). This is often the case in postmastectomy/lumpectomy patients who have also undergone removal or radiation of the axillary lymph nodes. The absence of visible lymphedema in these patients indicates that, although reduced by the surgical procedure, the transport capacity of the lymphatic system is still sufficient enough to remove water and protein from the tissues. The balance between the reduced transport capacity of the lymphatic system and the lymphatic loads may be fragile, and any additional disturbance may trigger the onset of lymphedema.

As previously discussed, massage therapy increases the lymphatic load of water (and often cells), and may further decrease the transport capacity of the lymphatic system by causing additional damage to those lymphatics still intact following surgical procedures.

In patients with primary lymphedema affecting one leg, massage therapy should not be applied to the contralateral extremity, since malformation of the lymphatic system may also be present in this leg.5

The application of massage techniques (those discussed, and any technique that may cause an increase in arterial blood flow) in lymphedemateous limbs and bordering trunkal quadrants may trigger the onset of lymphedema or worsen existing lymphedema.

In instances of upper-extremity lymphedema, massage therapy may be applied safely to the lumbar/gluteal area and to the lower extremities. Negative effects on lymphedema may result if massage strokes are apllied to the neck/upper trapezius area. Likewise, neck, thorax and upper-extremities may be treated with massage when lower-extremity lymphedema is present; the lumbar and gluteal areas on the opposite side, and the unaffected lower extremity, present areas “at risk” and should be treated with caution.

1. Consensus document of the International Society of Lymphology Executive Committee: The diagnosis and treatment of peripheral lymphedema. Lymphology 1995:28, pp113-117. 2. Eliska O, Eliska M. Are peripheral lymphatics damaged by high-pressure manual massage? Lymphology 1995:28, pp21-30. 3. Földi E. Massage and damage to lymphatics. Lymphology 1995:28, pp1-3. 4. Földi E, Földi M, Clodius L. The lymphedema chaos. Ann Plast Surg:22, pp505-15. 5. Földi M, Kubik S. Lehrbuch der Lymphologie. Gustav Fischer Verlag, Germany 1999. 6. Greenlee R, Hoyme H, Witte M, et al. Developmental disorders of the lymphatic system. Lymphology 1993:26, pp156-68. 7. Olszewski W. Peripheral Lymph: Formation and Immune Function. CRC Press, Boca Raton, FL 1985. 8. Tappan F. Healing Massage Techniques. Appleton and Lange 1988. 9. Weissleder H, Schuchhardt C. Lymphedema Diagnosis and Therapy. Kagerer Kommunikation, Bonn 1997. 10. Zuther J. Treatment of lymphedema with complete decongestive physiotherapy. NLN Newsletter 1999:11(2).

Detection of postoperative lymphedema in patients with breast cancer

2007-11-16T14:30:33Z

Detection of postoperative lymphedema in patients with breast cancer

Ceska Gynekol. 2007

Halaska M, Strnad P, Chod J, Malá I, Nováková M, Stankusová H, Kolarík D, Feldmár P, Rob L.

Gynekologicko-porodnická klinika 2. LF UK a FN Motol, Praha. mhalaska@centrum.cz

OBJECTIVE: Lymphoedema is a severe postoperative complication after treatment of many malignancies. It is a pathological accumulation of extracellular water (ECW). Early diagnostic tool is needed. Multifrequency bioimpedance analysis (MFBIA) is a method for detection of changes in ECW.

TYPE OF STUDY: Prospective study. Setting: Dept. of Obstetrics and Gynaecology of the 2nd Medical Faculty, Charles University, Prague.

METHODS: We measured a control group of 72 women and a group of 74 patients undergoing a breast cancer surgery during 18 month after the surgery by MFBIA and circumferency. Characteristics of the patients were recorded. The detection of lymphoedema was done using MFBIA, circumferency measurement and upon the symptoms of the patients.

RESULTS: The average age in the controll and tested group was 40,1 and 58,9 years. The average size of the tumour, grade and positivity if oestrogen receptors was 15,1 mm, 2,04 and 43%. In 23 patients (21%) complete lymphadenectomy was performed, in 51 patients (79%) a detection of sentinel lymph node was performed. Lymphoedema was detected in 8 women (11%). In these patients MFBIA detected lymphoedema 9 month earlier in total than other methods.

CONCLUSION: MFBIA is a low-cost and precise method for the detection od early stage postoperative lymphoedema. We recommend to incorporate MFBIA into standard dispensatory plan of every patient combined with circumferency measurement.

PubMed

Lymphedema - Medicare - What You Can Do

2007-11-10T12:32:55Z

Lymphedema - Medicare - What You Can Do

I'd like to start everyone off with the following three steps. Take on as much as you all can but don't over-do. I know we all have limited time and energy. The first thing to do is to get your lymphedema under control, then we can start educating and lobbying.

1. If you have recently been denied compression bandages, garments or devices, and you are still within the time period for an appeal, let's get the appeal going. I'll supply the proper forms and help you fill them out. If you have paid for compression materials and have not been formally denied, I'll send you a Medicare claim form. Otherwise I'll help you write a claim letter.

2. I must also know whether you wish to work towards national Medicare legislation or State legislation for the diagnosis and treatment of lymphedema.

Tell me your 9-digit ZIP code and I'll tell you the name and contact info for your legislators with suggestions as to the best ones to contact.

3. When you have some spare time, call your legislators to urge them to support (or introduce) legislation which affects your ability to access quality lymphedema care. Some current bills are as follows:

Stopgap legislation has been introduced in both the Senate and House (S. 543 Nelson/H.R. 1459 Tanner) that would freeze implementation of 75% Rule and prevent additional access problems for individuals requiring lymphedema
treatment.

The House recently passed the Children's Health and Medicare Protection (“CHAMP”) Act of 2007, which includes a freeze in the implementation of the 75% Rule at the 60% threshold indefinitely.

The legislation would also allow patients' co-morbidities to continue to be considered for purposes of meeting
the 75% Rule quota.

In March 2005 CMS changed their interpretation of the Social Security Act to limit coverage of manual lymph drainage to physical and occupational therapists, thereby eliminating coverage of treatment by specially-qualified nurses, physicians, osteopaths, chiropractors and massage therapists. This effectively
reduced the numberof available trained therapists by some 30 percent. A number of lymphedema treatment clinics around the country have already been forced to close as a result of this policy change. H.R. 1846 Towns attempts to partially rectify this ill-advised policy by restoring physician authority in
selecting qualified medical personnel to perform “incident to” services.

Also in March 2006 lymphedema was exempted automatically from therapy caps that were re-imposed on January 1, 2006. But in January 2007 exemption was made dependent on existence of a co-condition. This constitutes another roadblock to access to physician-prescribed treatment for lymphedema patients. S. 450
Ensign/H.R. 748 Becerra would permanently eliminate therapy caps.

Thanks for helping.

Bob

Robert Weiss, M.S.
Lymphedema Treatment Advocate

Email: LymphActivist@aol.com

Lymphedema - Medicare News (Not Good)

2007-11-09T04:25:22Z

Lymphedema - Medicare News (Not Good)

My proposal to CMS to add over 150 new and revised codes to the HCPCS Codebook for lymphedema treatment supplies was just rejected again by the CMS HCPCS Workgroup in Baltimore. This was very depressing because they never referred to my legal and medical arguments--only stated that "no insurer (i.e. Medicare, Medicaid, Private Insurance Sector) identified a national program operating
need to establish unique codes to distinguish all the products listed in this application. Existing codes adequately describe the array of products available."

This reiterates my feeling that I have not gotten the required support from providers, suppliers, patients, manufacturers to convince "Medicare, Medicaid and the Private Insurance Sector" that there could be a "program operating need", and that there is a proposed solution to the problem which has a rational legal and medical basis. My record with Medicare Administrative Law Judges recently, since developing my "prosthetic devices" argument, is 4 favorable, 1
unfavorable decisions. Two cases have been appealed to the Medicare Appeals Council in Washington. My argument, in brief, is that compression bandages, garment and devices meet the definition in the Social Security Act of "prosthetic devices" when used in the standard treatment of lymphedema, and are covered by Medicare. They are usually denied because they do not meet the policies on surgical dressings benefit category, which is not their medical use or their benefit category.

I am in the process of preparing a formal request for a national coverage analysis on the coverage of the treatment of lymphedema that would lead to a new national coverage determination and policy, but progress is slow. I am also preparing a formal request to SADMERC for a reclassification of compression sleeves and bandages from uncovered S-codes to covered L-codes, and of compression stockings used in treatment of lymphedema from uncovered A-codes to covered L-codes. The request is also to add codes for other compression garments which are not currently described.

Another important reason for reclassifying compression garments from A-codes (Secondary surgical dressings) to L-codes (prosthetic devices) is that the specifications for elastic compression garments are different for the two functions, and the costs can be different. For example, an off-the-shelf elastic compression stocking used to hold a primary dressing on a venous ulcer (A-code) is reimbursed at $43.27. A custom flat-knit stocking used in the treatment of a lymphatic leg (L-code) has far more stringint technical specifications and costs far more than the circular-knit elastic stocking to manufacture.

Differences in use, medical requirements, manufacturing costs, etc warrant two different code groups.

I hope that I can get more support from patients, providers, suppliers and manufacturers this coming year in my efforts to get CMS to change their lymphedema treatment coverage policies. Only by appealing every denial of medical treatment for lymphedema can we impress on CMS that there IS a program operating need for new coverage policies and codes. Denials are based on non-relevant
policies, HCPCS codes are being used incorrectly, and there are inadequate codes for the medically necessary coverable items used every day by lymphedema patients.

And if CMS does not chose to understand the issue, and in the absence of a lymphedema lobby, we must rely on legislators' constituents (that means YOU) to create the awareness of a need for legislative change.

Robert Weiss, M.S.
Lymphedema Treatment Advocate

Lymphedema People Online Support Groups

2007-11-04T13:20:25Z

Lymphedema People Online Support Groups

Join us as we work for lymphedema patients everywhere:

Advocates for Lymphedema

Dedicated to be an advocacy group for lymphedema patients. Working towards education, legal reform, changing insurance practices, promoting research, reaching for a cure.

http://health.groups.yahoo.com/group/AdvocatesforLymphedema/

Subscribe: AdvocatesforLymphedema-subscr...@yahoogroups.com

Pat O'Connor

Lymphedema People / Advocates for Lymphedema

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Children with Lymphedema

The time has come for families, parents, caregivers to have a support group of their own. Support group for parents, families and caregivers of chilren with lymphedema. Sharing information on coping, diagnosis, treatment and prognosis. Sponsored by Lymphedema People.

http://health.groups.yahoo.com/group/childrenwithlymphedema/

Subscribe: childrenwithlymphedema-subscr...@yahoogroups.com

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Lipedema Lipodema Lipoedema

No matter how you spell it, this is another very little understood and totally frustrating conditions out there. This will be a support group for those suffering with lipedema/lipodema. A place for information, sharing experiences, exploring treatment options and coping.

Come join, be a part of the family!

http://health.groups.yahoo.com/group/lipedema_lipodema_lipoedema/?ygu...

Subscribe: lipedema_lipodema_lipoedema-subscr...@yahoogroups.com

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MEN WITH LYMPHEDEMA

If you are a man with lymphedema; a man with a loved one with
lymphedema who you are trying to help and understand come join us and discover what it is to be the master instead of the sufferer of lymphedema.

http://health.groups.yahoo.com/group/menwithlymphedema/

Subscribe: menwithlymphedema-subscr...@yahoogroups.com

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All About Lymphangiectasia

Support group for parents, patients, children who suffer from all
forms of lymphangiectasia. This condition is caused by dilation of the lymphatics. It can affect the intestinal tract, lungs and other
critical body areas.

http://health.groups.yahoo.com/group/allaboutlymphangiectasia/

Subscribe: allaboutlymphangiectasia-subscr...@yahoogroups.com

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Lymphatic Disorders Support Group

While we have a number of support groups for lymphedema... there is nothing out there for other lymphatic disorders. Because we have one of the most comprehensive information sites on all lymphatic disorders, I thought perhaps, it is time that one be offered.

DISCRIPTION

Information and support for rare and unusual disorders affecting the lymph system. Includes lymphangiomas, lymphatic malformations, telangiectasia, hennekam's syndrome, distichiasis, Figueroa syndrome, ptosis syndrome, plus many more. Extensive database of information available through sister site Lymphedema People.

http://health.groups.yahoo.com/group/lymphaticdisorders/

Subscribe: lymphaticdisorders-subscr...@yahoogroups.com

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Teens with Lymphedema

http://health.groups.yahoo.com/group/Teens_with_Lymphedema/

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All About Lymphoedema - Australia

http://au.groups.yahoo.com/group/All_About_Lymphoedema/

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All About Lymphedema

For our Google fans, we have just created this online support group in Google Groups:

Homepage: http://groups-beta.google.com/group/All-About-Lymphedema

Group email: All-About-Lymphedema@googlegroups.com

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Lymphedema Research

http://groups.google.com/group/lymphedemaresearch

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Lymphedema Friends

http://groups.aol.com/lymphedemafriend

If you an AOL fan and looking for a support group in AOL Groups, come and join us there.

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Let's Talk ! Lymphedema patients Group - UK

http://groups.msn.com/LetsTalkLymphedemapatientsGroup/_whatsnew.msnw

Lymphedema Information

Preoperative assessment enables the early diagnosis and successful treatment of lymphedema.

Congenital lymphedema of the upper extremity. A case report.

Controlled, Comparative Study of Relation between Volume Changes and Interface Pressure under Short-

A labor of love

Anne Flynn teaches classes and sells jewelry to aid lymphedema sufferers

Susan Schell

of the Gateway

Reach reporter Susan Schell at 253-853-9240 or by e-mail at susan.schell@gateline.com.Peninsula Gatewayhttp://www.gateline.com/106/story/686.html

Lymphatic venous anastomosis (LVA) for treatment of secondary arm lymphedema

Elephantiasis Nostras Verrucosa or "Mossy Foot Lesions" in Lymphedema Praecox

Endermologie (with and without compression bandaging)--a new treatment option for secondary arm lymp

Manipulative therapy of secondary lymphedema in the presence of locoregional tumors.

Effectiveness of the treatment complex decongestive physiotherapy for extremity lymphedema.

Locating a Certified Lymphedema Therapist

Detection of postoperative lymphedema in patients with breast cancer

Lymphedema - Medicare - What You Can Do

Lymphedema - Medicare News (Not Good)

Lymphedema People Online Support Groups

Reach reporter Susan Schell at 253-853-9240 or by e-mail at susan.schell@gateline.com.

Peninsula Gateway

http://www.gateline.com/106/story/686.html