Rebecca Summers, OT, CLT-LANA, CSR, Author at Lymphedema Therapy Source

February 6, 2026 By Rebecca Summers, OT, CLT-LANA, CSR

Using Your Voice

This month’s blog is dedicated to advocacy for providers.

Most people dealing with lymphedema aren’t aware of the behind-the-scenes challenges providers face when it comes to providing care. The administrative burden to small practices like mine is immense.

Lymphedema Treatment Act

In past blogs, I’ve brought attention to the Lymphedema Treatment Act (LTA) in blog posts: Oct-Dec 2023 & Feb-March 2024. After over a decade of struggles, the LTA was finally passed. As a result, Medicare now pays for lymphedema compression & treatment supplies. (Such costs were a huge barrier for many patients.) This time, I’m bringing attention to a related topic impacting providers.

Provider Impact

When patients are looking for providers, they generally seek providers in-network (providers who contract with their insurance plan to accept payment as opposed to out of network providers who may accept their insurance plan but don’t accept their payment as payment in full). Finding an in-network provider means lower cost for the patient. But it also means lower payment to the provider. In addition, providers are always paid for all services provided. While this may not be an immediate concern for patients who don’t feel the financial burden, it will be a concern in the long run as fewer providers opt to contract directly with insurers for in-network status — in a field in which there are already few qualified, trained lymphedema practitioners.

The good news is that just like with lymphedema legislation, there are avenues for change. This blog is an example of what providers (& patients) can do. In an age of technology in which Ai can do all the “heavy lifting,” there’s no excuse for not taking action. Such an opportunity presented itself this month.

_{Providers can experience burnout from patient care. This can be magnified by administrative burdens & reduced payments.}

Reduced Payments

My business contracts with numerous plans by insurers like Medicare, BCBS, Cigna (via American Specialty Network or ASH through which therapists must contract) & United Healthcare. My fee schedule is based off Medicare’s fee schedule. While a very few pay more, most insurers pay less, & more commonly they further reduce payment by not paying for certain services when done in the same session (such as CPT codes 97535 training & 29581 bandaging, or 97140 massage & 29581 bandaging). They consider these to be bundled services. However, they are often separate services which can standalone & are a necessary part of care. For example, manual lymph drainage (97140) & bandaging (29581 / 29584) are a part of nearly every lymphedema treatment session during the decongestion phase.

Added Fees

When insurance companies pay a provider for service, they often have “processing fees.” This fee is a percentage of what they pay you. (Providers already get charged a processing fee for accepting your payment via card – if they don’t pass it on to you.) American Specialty Network (a.k.a. “ASH” – contractor for Cigna therapy credentialing) charges $3.00 for each mailed check (less for electronic fund transfers). While a $3.00 fee—or a small percentage EFT fee—may seem minor in isolation, these costs accumulate over time. When combined across multiple payers and numerous claims, the total can become a significant financial burden for providers.

_{(Image of Lady Justice)}

Taking Action

What can providers do when they feel fee practices are too great of a burden? Write to the appropriate people: Representatives, Senators, & state Dept. of Insurance (who has insurance regulation oversight). You might even include your governor. You can read a sample letter here. In Texas, there is currently legislation pending passage to reduce these burdensome fees. It was initiated by Rep. Terry Canales, Rep. Tom Oliverson, & Rep. Lacey Hull. (Thank you, Representatives!) Please contact your elected officials to request support for HB 3863 whose goal is to protect providers from avoidable fees & ensure fair payment practices. Specifically, the bill prevents insurers from forcing providers to accept payments through virtual credit cards (VCCs) or any other method that charges extra fees. This ensures providers receive full payment without unnecessary costs.

Note: Though progress has been made with the LTA, more change is needed. Currently, Medicare doesn’t pay separately for training & education related to compression garments — despite the additional time needed to train & educate patients on several issues. Issues like how to don & doff garments, education on available aids that make getting compression on & off easier & how to use them, care of garments, replacement schedule, fit issues (measuring or remeasuring when changes are needed). These issues can take several additional sessions. When you’re not paid for your time & work, it increases burnout.

January 1, 2026 By Rebecca Summers, OT, CLT-LANA, CSR

Lymphedema Maintenance (part 2 of 2)

Last month, we discussed phase I (decongestion therapy) in lymphedema treatment. This month, we’ll pick up with phase II & also discuss adjuncts. If you’ve got lymphedema & made a New Year’s resolution, this post may help.

Phase II: Lymphedema Maintenance

Assuming a patient is compliant with guidelines, they should progress to phase II fairly predictably (the maintenance phase). This begins immediately after phase I & involves being fit with a compression garment to maintain the volume loss & fibrosis reduction attained in phase I. Sometimes the garment doesn’t fit quite right in the first try. So, a revised garment must be ordered. In my experience, patients frequently try to short cut this phase, too, by:

wearing elastic garments (off the shelf, circular-knit garments) instead of resuming bandaging while waiting for the revised garment
wearing the garment to be returned (which is improperly fit)
not wearing a night garment or using an inappropriate night garment.

These decisions can cause refilling & regression.

As noted earlier, if a person begins phase I in stage II or III lymphedema, fibrosis is likely still going to be present to some extent at the end of treatment. But it should continue to gradually reduce in phase II with the appropriate compression & compliance.⁷

Phase II is generally “maintenance for life.”⁹ In my experience, when a person is compliant & sticks to the above protocol, phase II will maintain their lymphedema. And, lymphedema can continue to improve. However, people often, again, try shortcuts (i.e. no night garment, noncompliance with daily use of their daytime garment, etc.). On occasion, particularly if a person is in stage II or III lymphedema (or if they took shortcuts or have not been compliant), they may need to resume intensive phase I treatment in the future.

Phase II Adjuncts

There are several adjuncts to lymphedema maintenance. We just talked about one the past two blog posts. “Adjunct” means “supplement” or “auxiliary function,” not a standalone or essential role. In other words, these aren’t necessary components to maintenance. But some people may find some beneficial effects.

A chameleon appears to be one thing but is actually another. Like a chameleon, certain adjunct therapies may be seem to be a “cure” for lymphedema, but they may not be what they appear.

The following are examples of adjuncts for lymphedema.

Compression pumps^{10, 18}
Medications: Flavonoids, benzopyrones¹¹ & synbiotics¹⁸
Aquatics^{12, 18} – compression applied by water during exercise
Ultrasound^{13, 18} – uses sound waves to cause vibrations which may help with fibrosis but it can create friction & heat (which increases fluid creation).**
Hivamat^{13, 18}-uses an electrostatic field to create a deep, gentle oscillation in the tissue, which helps reduce fibrosis, inflammation & improve lymphatic flow
Rebounders¹⁶ – trampolines require you to use your muscles. As encouraged by any exercise, muscle contraction impacts lymphatic function by squeezing lymph vessels, which helps to propel lymph fluid through the body. While contraction increases interstitial fluid pressure and can compress vessels, the relaxation phase is crucial for allowing fluid to enter the lymphatics. Exercise causes an increase in blood flow (increasing fluid in the tissue spaces). Compression garments counteract this process by providing working pressure that promotes lymph fluid removal from the tissue space. So, it’s important to wear compression during any exercise to prevent refilling & to aid in the uptake of fluid in the lymphatic vessels.
Vibration^{14, 18} – stimulates the lymphatic system by causing rapid muscle contractions that help pump lymph fluid through the vessels. As with any exercise, it’s important to wear compression during use.
Diet¹⁷ – despite books & social media posts, there is no “lymphedema diet.” Nothing you eat is going to cure lymphedema. However, eating a poor diet & gaining weight can exacerbate lymphedema. Salt, sugar & alcohol consumption can negatively impact water retention & inflammation, thus exacerbating lymphedema.
Kinesio taping¹⁸ (elastic taping) may facilitate lymphatic drainage
Photobiomodulation (low-level laser)¹⁸ – red light therapy & near-infrared light can stimulate cellular function, reduce inflammation & enhance lymphangiogenesis & lymphatic motility
Extracorporeal shock wave therapy (ESWT)¹⁸ – a noninvasive treatment that uses acoustic shock waves to reduce fibrosis & enhance lymphangiogenesis (new lymphatic vessel growth).
Acupuncture and Moxibustion¹⁸** Acupuncture works by inserting fine needles into specific points on the body (up to two inches deep into skin) to stimulate biochemical reactions, while moxibustion uses heat from burning mugwort to warm acupuncture points.
Negative pressure (cupping)¹⁸** – creates suction, drawing the skin and tissue upward. This suction increases blood flow. It can also cause skin redness & discoloration that persists for some time after the procedure. According to Foldi, manual lymph drainage should be gentle & light in pressure (pressure sufficient to stretch the skin, not heavy enough to cause redness). This is because the lymph vessels are less than one millimeter in diameter on average with more superficial vessels being even smaller. (As a reference, 1 millimeter = 0.03937 inches.) If too much force is used in MLD (or otherwise), the delicate anchoring filaments can be injured or deeper lymphangions can go into spasm.”²⁰ Note: MLD force and compression-garment pressure behave completely differently physiologically and mechanically, even though both affect lymph flow. MLD involves directional shear, not uniform compression. That’s why pressure must be extremely low. Compression garments apply broad, evenly distributed, static external pressure across the entire limb (not directional shear).

Personally, I would avoid the above adjuncts marked with an asterisks as they cause hyperemia (an increase in blood flow) which increases lymphatic load & could exacerbate lymphedema. The exception is activities in which you have or use compression (such as aquatics or exercise). In Foldi’s words, “[a]t a minimum, methods that result in hyperemia should be avoided wherever possible.^{19, 20}

References
¹ Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 273. Germany: Urban and Fisher.
² Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 245, 322. Germany: Urban and Fisher.
³ Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 246. Germany: Urban and Fisher.
⁴ Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 272. Germany: Urban and Fisher.
⁵Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 281. Germany: Urban and Fisher.
⁶ Adjuncts – Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 282. Germany: Urban and Fisher.
⁷ Fibrosis – Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 273-274. Germany: Urban and Fisher.
⁸Inpatient – Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 273. Germany: Urban and Fisher.
⁹ For life – Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 274. Germany: Urban and Fisher.
¹⁰ Pumps – Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 283. Germany: Urban and Fisher.
¹¹ Meds – Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 283. Germany: Urban and Fisher.
¹² Aquatics – Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 559 Germany: Urban and Fisher.
¹³ Ultrasound & Hivamat – Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 560. Germany: Urban and Fisher.
¹⁴ Vibration – Rauch F, Sievanen H, Boonen S, et al. Whole-body vibration and blood flow and muscle oxygenation: a meta-analysis. Clin Physiol Funct Imaging. 2015;35(2):97–104. (This meta-analysis shows that whole-body vibration (WBV) increases peripheral blood flow — a mechanism potentially relevant to lymphatic drainage.)// Casarotto RA, Tonezzer T, Munaretto Timm Baiocchi J, Harari D. Effects of the vibratory platform on the treatment of lymphedema post-breast cancer surgery: case studies. World Physiotherapy Congress Proceedings. 2022.
¹⁵ RLT – Carati CJ, Anderson SN, Gannon BJ, Piller NB. Treatment of postmastectomy lymphedema with low-level laser therapy: a double-blind, placebo-controlled trial. Cancer. 2003;98(6):1114–1122. // Ridner SH, Poage-Hooper E, Kanar C, Doersam JK, Bond SM, Dietrich MS. A pilot randomized trial evaluating low-level laser therapy as an alternative treatment to manual lymphatic drainage for breast cancer–related lymphedema. Oncol Nurs Forum. 2013;40(4):383–393. // Li K, Zhang Z, Liu NF, Feng SQ, Tong Y, Zhang JF, et al. Efficacy and safety of far infrared radiation in lymphedema treatment: clinical evaluation and laboratory analysis. Lasers Med Sci. 2017;32(3):485–494. // Ueno N, Fukuzawa H, Oshima T, et al. Far infrared radiation therapy for gynecological cancer–related lymphedema is an effective and oncologically safe treatment: a randomized-controlled trial. Lymphology. 2021;54(3):141–150.
¹⁶ Rebounders – https://www.thecancerspecialist.com/2019/08/01/the-benefits-of-rebounding-in-the-prevention-and-management-of-lymphedema/
¹⁷ Diet – Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 269, 305. Germany: Urban and Fisher.
¹⁸ https://lymphnet.org/page/position-papers (National Lymphedema Network Position Paper on maintenance)
¹⁹ Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 559. Germany: Urban and Fisher.
²⁰ Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 526. Germany: Urban and Fisher.

December 1, 2025 By Rebecca Summers, OT, CLT-LANA, CSR

Lymphedema Maintenance (part 1 of 2)

The past two months we reviewed compression pumps. Pumps can be an adjunct to therapy maintenance.⁶ But pump use shouldn’t be a standalone plan for lymphedema treatment or maintenance. What is the recommended maintenance program for lymphedema?

Phase I: Decongestive Lymphedema Treatment

First, a person should complete phase I (decongestion) which involves complete decongestive therapy (CDT). CDT is composed of:

manual lymph drainage
multi-layer short-stretch bandaging
skin care
decongestive exercise.

Duration

The duration of this phase depends on the severity of lymphedema. It also depends on the frequency of treatment (which should be daily & bandages should remain on until the next therapy session).⁴ And it depends on comorbidities (such as vein disease, heart failure, renal failure, etc.) being diagnosed & properly treated.⁵

If a person is in stage I lymphedema, CDT generally lasts about 2 weeks. If stage II lymphedema (depending on how advanced within stage II), CDT lasts approximately 4-6 weeks. If stage III lymphedema, CDT may last 6-8 weeks or more (& it’s recommended to be treated several times a day according to Foldi).¹Below is a reference for the stages.

Lymphedema Stages

Stage I (the reversible stage) – It’s caused by accumulation of interstitial (lymph) fluid.² And it’s characterized by pitting edema & reduction in swelling with elevation. There isn’t usually pain in lymphedema,³ but there may be pain in this stage associated with early congestion.
Stage II (the spontaneously irreversible stage) – It’s caused by excess growth of connective (scar) tissue. It’s characterized by fibrosis & fat tissue growth. The swelling becomes more hard & doesn’t go down with elevation. There may be discoloration (brownish discoloration) to the involved tissue.
Stage III (elephantiasis) – It’s caused by the accumulation effect of stage II leading to extensive fibrosis & fat tissue growth. There are deep creases, fungal infections, recurrent cellulitis infections & some people may even become immobile.

In my experience, people get tired of bandaging after 2 weeks. They often seek shortcuts. For example:

– ending therapy before fibrosis is adequately reduced (note: some fibrosis will likely persist if a person initiates therapy during stages II or III of their lymphedema)⁷
– removing bandages before the next session
– using only (1) set of bandages, not washing bandages between sessions for better recoil & compression
– canceling a session here & there, missing consistent daily treatment.

These behaviors impact outcome. Of course, there can also be other “hiccups” during therapy. For example, a pressure wound develops & must be addressed, compression slips down between sessions or gets wet during toileting or bathing. These events are more likely when people aren’t treated as they are in Germany (i.e. inpatient hospitalization with focused, daily lymphedema therapy).⁸ Sometimes things just happen. But these events can prolong phase I & expectations should be clear in advance to avoid added disappointment.

Next month, we’ll pick up with phase II in part 2 of this blog on Lymphedema Maintenance. (References will be cited in that post.)

November 1, 2025 By Rebecca Summers, OT, CLT-LANA, CSR

Compression Pumps (part 2)

Last month we noted there are several differences among pumps. And not all pumps are appropriate for all conditions. When it comes to lymphedema, the wrong pump has potential to do more harm than good. This month, we’re picking up with the types of compression pumps available.

Types of Compression Pumps (continued)

2. Non-Pneumatic Pumps – Non-pneumatic compression pumps use mechanical forces (rather than air) to apply compression. For example, Koya Medical (Dayspring device) uses shape-memory alloy springs that generate compression when activated by electrical current, causing the alloys to contract. This creates mechanical compression without air. These systems typically consist of a sleeve placed on a limb, and compression is delivered in a sequential or gradient pattern. Because they are lightweight, battery-powered, and allow mobility, users can often move or walk during treatment. (This is unique for lymphedema.) They are also generally quieter than pneumatic systems. (For those located in Dallas, Tx, Koya Medical relocated to the state in 2025.)

Common Uses:

Management of chronic lymphedema
Supporting lymphatic drainage in active patients
Enhancing treatment adherence through mobility

Examples of Devices:

Dayspring by Koya Medical

It’s important to note: Because they are lighter, less bulky and allow mobility, compliance may be improved. However, one downside from a therapist’s perspective is the sleeve doesn’t cover the hand (or the foot if on the leg). The concern is the potential to contribute to swelling in the hand and foot. Koya Medical believes that hand swelling is unlikely as they provide a mild compression glove and people are meant to be active, so a person is using their hand muscles to help reduce swelling. Another downside is the pump doesn’t first decongest the trunk as we do in manual lymph drainage lymphedema treatment. This is important in pure lymphedema as the swelling involves a quadrant of the trunk due to the drainage path of the lymph system. So, a patient may need to be taught how to first open the lymph drainage path and initiate drainage if using this pump, etc.¹

^{Well Pump – Public Domain (Pixabay)}

Are Pumps Necessary for Lymphedema?

Many people (especially pump manufacturers & distributors) won’t agree, but in my experience treating patients with lymphedema, pumps are generally not needed. In fact, Foldi’s Textbook of Lymphology doesn’t recommend them. However, compression pumps have advanced since their writing. The National Lymphedema Network (NLN) recognizes this, but the NLN still considers a pump to be an adjunct to therapy, not a standalone or a necessary component to treatment.^1,2

I would agree & have a few reservations about pumps in general:

Insurance may pay several thousand dollars for one (as much as $8,000 in some cases – or more) but patients grow tired of using them. Patient complaints include:
- pump hoses are heavy & hard to put on or take off (elderly may not have the strength)
- the daily pumping schedule recommended (sometimes twice a day) is too time-consuming
- doesn’t always seem to help or the improvement doesn’t last without using compression garments
Patients are frequently not informed about the contraindications or don’t know when they should stop using a pump
Frequent pump use may worsen heart or kidney disease as it moves more fluid through the body & increases the load these organs must process. Too often, this isn’t well-monitored. At a minimum, people should monitor weight & blood pressure regularly in cases of “compensated” heart or kidney disease (as well as taking note of how they feel after pump use).

What are the best pumps for lymphedema?

Assuming you, your therapist & doctor have decided a pump would be beneficial for you, what are the best compression pumps for lymphedema? If dealing with pure lymphedema, first, ensure there is a trunk component like a vest or shorts. If there isn’t, ensure you’ve been taught how to decongest before pumping & how to clear after pumping. Second, ensure there are several chambers which pump proximally (at the root of the extremity) & works outward to decongest before pumping distal to proximal. For example, in right arm lymphedema due to breast cancer, be sure the pump begins pumping to decongest nearer the axilla & works outward toward your hand slowly, in segments, before pumping from the hand up to the axilla. Below are a list of potential manufacturers, but be sure the model chosen fits the recommendation: advanced, programmable, sequentially gradient compression (pneumatic or not). (Note this rules out most inexpensive, Amazon-purchased pumps.)

Bio Compression Systems
Lympha Press
Airos Medical
Tactile Medical
Runner-up: Koya Medical

References
1 Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 282. Germany: Urban and Fisher.
2 https://lymphnet.org/page/position-papers

October 13, 2025 By Rebecca Summers, OT, CLT-LANA, CSR

Compression Pumps (part 1)

Compression pumps may be known by different names. For example, “pneumatic compression pumps” or in a hospital setting, you may have heard the term “SCD” (sequential compression device). One refers to a type of pump while the other refers to the mode of compression delivery. This blog will overview the different types of pumps as well as their mode of delivery.

Pumps (in the medical sense) are devices advertised to improve blood and lymph circulation. More specifically, they may be used to prevent blood clots (such as after surgery), support wound healing, reduce post-operative swelling, or improve edema from venous insufficiency. But there are several differences among pumps. And not all pumps are appropriate for all conditions. When it comes to lymphedema, the wrong pump has potential to do more harm than good.

Types of Compression Pumps

Pneumatic
- Pneumatic compression pumps use air pressure to apply external compression to limbs or other body parts. They’re composed of a sleeve which is placed around a limb. An external air pump inflates an air chamber (sometimes there is more than one air chamber) to provide compression. This can occur all at once, or when there are multiple chambers, it can be in a specific sequence (see also “Mode of Delivery” below).
- Regarding sequence, the inflation pattern may vary depending on the device (e.g. sequential vs. simultaneous inflation). Most are available in programmable models with adjustable settings and cycles. Some include a trunk component (e.g. Flexitouch, LymphaPress, Biocompression) to decongest first before moving to the swollen extremity (as we do in manual lymph drainage). These are used while seated or lying down. Duration is typically 45 minutes to an hour each day (sometimes twice per day depending on your doctor’s recommendation).
- Compression can be administered in an intermittent manner (compression is delivered at intervals or cycles, mimicking muscle contractions) or in a gradient (applying compression in a gradually reducing manner, with higher pressures distally & lower pressures proximally). When intermittent, there’s an inflation phase (i.e. “muscle contraction” pushing blood or fluid upward or proximally) followed by a deflation phase (i.e. “muscle relaxation” allowing refilling). Even this has variances: For example, some pumps have cycles allowing distal chambers to relax while a proximal chamber contracts (this can cause backflow). Other pumps or cycles maintain distal compression while the next chamber contracts.

Models:

1. single-chamber pumps – the entire sleeve inflates and deflates as one unit
2. sequential pumps – chambers inflate in a sequence from distal to proximal
3. advanced gradient pumps – chambers inflate sequentially and stay inflated until the cycle ends to prevent fluid backflow.

Examples of Devices:

SCDs (Sequential Compression Devices)
AIROS 6 and 8
Flexitouch
Lympha Press
Biocompression 3004

Bio Compression Systems, Inc.

2. Non-pneumatic

The next type of compression is non-pneumatic. We’ll pick up that topic next month (with a company located right here in the Dallas, Tx area).

September 1, 2025 By Rebecca Summers, OT, CLT-LANA, CSR

Can You Cheat in Lymphedema? (part 2)

We’re continuing a patient story from last month. (Click here for part 1)

The patient we’ve been following received a daytime CCL 2 sleeve & glove (she also wanted to try a gauntlet). She also received her CCL 1 sleeve & glove which she wanted to try for night use (instead of the recommended protocol of bandaging or a foam sleeve).

What Happened?

Five weeks after getting her daytime sleeve/glove, she had issues with finger swelling & arm refilling. She wasn’t resting well at night either. She stopped using the CCL 1 garment & used the same CCL 2 sleeve at night. When she returned to see me, she seemed angry (with me) for her outcome. When there’s a deviation from the protocol, the outcome will be affected.

I noted the likelihood of using a CCL 2 daytime sleeve/glove at night, especially when sleeping with elbow bent, as contributing to her forearm swelling & worsening fibrosis. While resuming bandaging was the best idea, she was adamant she wasn’t going to do that again. I said the next best option would be to get a nighttime foam sleeve. It should help reduce the forearm fibrosis which would help reduce the swelling. She agreed.

(collaboration with a local garment rep on best night garment in this case)

Intervention

This patient chose to continue wearing her daytime CCL 2 sleeve/glove (23-32 mmHg) before being fit for the night garment. (She hadn’t been re-reduced with bandaging.) That meant, the nighttime garment would likely be bigger than it should be. The fitter tried to compensate for this by decreasing the circumferences. (I had the manufacturer’s local rep do the fitting.)

Outcome

It took several weeks for the nighttime garment to arrive. The patient continued wearing the CCL 2 sleeve & glove during this time. (She did come in for bandaging one session prior to the arrival of the night garment.) The night garment was a little short & a little big, but the patient agreed to try it at night. After a few nights, she felt she was doing well & seeing progress.

(photo sent by pt after removing the night garment in the morning; she had worn it several nights)

When she returned to see me, she was happy with her status. Because the night sleeve wasn’t quite as long as it could have been (or the patient hadn’t been able to keep it up near the shoulder because it was a too large around the upper arm), there was some refilling around the shoulder. But her other numbers were improved as her fibrosis softened with the chipped foam sleeve.

(final visit after wearing night foam sleeve: volume 26.3 cm)

Can You Cheat the System?

Short answer: No. The protocol for lymphedema treatment exists to maximize the best outcome by softening fibrosis & decongesting tissue. Once this process is complete, a patient is ready for their maintenance day & night garment fitting. They should remain bandaged until both garments are in place.

This patient’s course was prolonged & a bumpy ride to get to her conclusion. But in the end, she was happy with her status. That’s what matters most. Sometimes a patient’s goals aren’t solely to maximize reduction. Convenience or interference with daily routines may trump the “ideal outcome.” It’s important to ask a patient what their goal is & to monitor this goal during the course of therapy as it may change.

August 1, 2025 By Rebecca Summers, OT, CLT-LANA, CSR

Can You Cheat in Lymphedema? (part 1)

Many people are tempted to shortcut the therapy process in lymphedema. Instead of bandaging, they only want manual lymph drainage (MLD). Or instead of MLD, they only want to bandage. Or they may stop treatment early (or skip therapy & go right to a compression garment). Is it possible to “cheat” in therapy? Yes, it is. But just like shortcutting or changing a recipe, the outcome will be affected.

Protocol

The recommended protocol for lymphedema treatment (according to Foldi) is to bandage daily during the decongestion phase.¹ Once volume plateaus & a patient is not expected to make further progress, they are fit with a custom, flat-knit, daytime sleeve/glove & they are to bandage at night for the maintenance phase.² (Or, alternatively, a special nighttime garment like a foam sleeve might be used.)

A patient with left arm lymphedema due to breast cancer was tiring of bandaging & driving to appointments after ~10 sessions of daily treatment. Her arm fibrosis hadn’t maximized in reduction nor had the swelling, but she had made decent progress.

(evaluation – visit 1: total left arm volume 27.9 cm)

(after 10 sessions: total left arm volume 26.9 cm)

She wanted to proceed with getting fit for her custom, flat-knit sleeve & glove in a class 2 (23-32 mmHg). She would continue working on her arm fibrosis herself. In addition, she didn’t want to bandage at night (or get an alternative night garment like a foam sleeve which looked hot & bulky). She wanted to try using a daytime sleeve and glove at night in less compression instead – a class 1 (18-21 mmHg). I wasn’t wholly supportive of this idea, but I agreed to try it.

Waiting for the custom sleeve & glove

Custom garments can take 2-3 weeks to receive. During the waiting period, a person should remain bandaged. However, therapy sessions can usually reduce in frequency. In this case, the pt remained bandaged 3x/week until the daytime garments arrived.

What was the outcome? Find out next month.

References
¹ Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 272. Germany: Urban and Fisher.
² Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 273, 574-581. Germany: Urban and Fisher.

July 3, 2025 By Rebecca Summers, OT, CLT-LANA, CSR

Difference Between Edema and Lymphedema — And Why It Matters

As a certified lymphedema therapist, one of the most important things to understand (& to help your patient understand) is the difference between edema and lymphedema. While both involve swelling, they have different causes, underlying mechanisms, and treatment needs. Most importantly, proper diagnosis is essential, because if we don’t treat the whole picture, therapy won’t work as well as it should or it may actually even make swelling worse.

What Is Edema?

Edema refers to swelling caused by excess fluid in the body’s tissues. It often results from underlying medical conditions like:

Congestive heart failure
Kidney or liver disease
Venous insufficiency (poor vein function)
Medications
Immobility or prolonged sitting/standing
Hormones

Edema is usually soft, pits easily when pressed, and may improve with elevation or diuretics. It’s caused by issues in the vascular (blood) system and the effect on capillaries. It is not caused by issues with the lymphatic system. Edema sometimes affects the entire body, but often it affects the lower body due to positioning and gravity.

What Is Lymphedema?

Lymphedema is a chronic condition caused by dysfunction in the lymphatic system. When lymph vessels or nodes are damaged, removed, or malformed, protein-rich fluid builds up in the tissues, leading to persistent swelling — most commonly in the arms or legs.

There are two types:

Primary lymphedema: A congenital or hereditary issue with lymphatic development.
Secondary lymphedema: Acquired, often due to surgery, cancer treatment, trauma, or infection.

Lymphedema may initially improve with diuretics but diuretics will make lymphedema worse in the long-run. Lymphedema doesn’t resolve on its own. It requires Complete Decongestive Therapy (CDT), a specialized, multi-step treatment approach including manual lymph drainage, compression therapy, skincare, and therapeutic exercise.

When Edema and Lymphedema Coexist

Sometimes, patients have a combination of both edema and lymphedema. For example, chronic venous insufficiency (edema) and secondary lymphedema. This is known as phlebolymphedema. Combined form can be more difficult to manage than lymphedema alone.

Here’s why this matters: when other underlying medical conditions are present and not addressed, CDT by itself won’t be enough (and may even cause harm). As Földi’s Textbook of Lymphology states: If accompanying diseases are undiagnosed and/or untreated, CDT will not be successful.¹

This is an essential reminder for both patients and healthcare providers: we can’t treat lymphedema in isolation if other health issues are contributing to the swelling. Whether it’s heart failure, uncontrolled diabetes, or kidney disease, these conditions must be addressed in tandem with lymphedema care.

Why This Matters

Misidentifying edema as lymphedema — or vice versa — can lead to ineffective treatment. Diuretics won’t help pure lymphedema. Compression alone won’t solve swelling due to heart or kidney disease. And CDT may fall short if other conditions are left untreated.

A comprehensive evaluation by a lymphedema therapist and appropriate medical workup can lead to more accurate diagnosis, better treatment plans, and improved outcomes.

Conclusion

If you’re dealing with chronic swelling, don’t settle for a one-size-fits-all explanation. Seek a thorough assessment that looks at the whole picture. When all contributing factors to swelling are treated, we set the stage for long-term success.

References
1 Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 281. Germany: Urban and Fisher.

June 1, 2025 By Rebecca Summers, OT, CLT-LANA, CSR

MLD and a Woman’s Menstrual Cycle (part 2)

Last month, we looked at what happens during a woman’s period. This month, we’ll talk about how MLD can help.

Symptoms MLD May Help

In the second half of a cycle (the luteal phase), all kinds of unwelcomed symptoms can emerge. These can include bloating, cramps, weight gain, mood swings, fatigue, constipation, headaches & food cravings. These symptoms are caused by the rise & sudden, sharp drop of progesterone (& estrogen) when there is no egg fertilization (i.e. pregnancy). This hormone shift can affect brain chemistry, especially serotonin, which influences mood and emotion.

Bloating & Water Retention – Progesterone affects fluid balance by acting on the kidneys and blood vessels. Its drop can cause fluid to accumulate, leading to bloating, breast tenderness, and mild weight gain.
Cramps (Dysmenorrhea) – As hormone levels fall, the body produces prostaglandins to help shed the uterine lining. These chemicals cause the uterus to contract, which can lead to pain and cramping. Higher prostaglandin levels = more intense cramps.
Constipation – High progesterone (& estrogen) slows down smooth muscle contractions in the digestive tract (motility). This can lead to slower digestion and constipation, especially in the days following ovulation.
Headaches – Estrogen influences how blood vessels expand and contract and affects neurotransmitters like serotonin. When estrogen drops, it can trigger headaches or migraines, especially in those sensitive to hormonal changes.
Fatigue – The body goes through energy-intensive changes during the luteal phase, and the falling hormones can also impact thyroid function and serotonin, leading to tiredness or sleep disruption.
Food Cravings – Estrogen and progesterone influence insulin sensitivity and appetite-regulating neurotransmitters like dopamine and serotonin. The drop can cause cravings (especially for sugar and carbs), which temporarily boost serotonin and make you feel better — at least short-term.
Mood Swings & Irritability – Estrogen and progesterone affect brain chemistry, including: Serotonin (mood), GABA (calmness and anxiety) & Dopamine (pleasure and motivation). When these hormones drop, serotonin levels can dip, contributing to irritability, anxiety, sadness, or mood swings. Sensitivity to this drop varies. Some women experience mild PMS while others experience more severe PMS.

How MLD May Help

MLD increases lymphangiomotion (lymph pumping). By doing so, inflammatory particles & excess fluid are removed. In addition, proper MLD has a very relaxing effect on the body. So, it could help mood. Unfortunately, I’m not aware of any impact on food cravings!

Bloating and Water Retention – MLD gently stimulates the lymphatic system, which is responsible for removing excess fluid and waste from tissues. By improving lymph flow, it can reduce puffiness, bloating, and that heavy, swollen feeling often reported in the days before menstruation.
Breast Tenderness – Swollen, tender breasts are often caused by fluid buildup and hormonal shifts. MLD around the neck, armpits, and chest area can reduce this fluid accumulation and ease discomfort.
Headaches (from fluid pressure) – If headaches are partially due to congestion in the head and neck, MLD may help by encouraging drainage and reducing pressure.
Fatigue (mild benefit) – Some women report feeling more energized after MLD, likely due to improved circulation and detoxification, though this effect varies from person to person.
Constipation – After ovulation, progesterone levels rise before dropping. During this rise, progesterone has a relaxing effect on smooth muscle, including the muscles of the gastrointestinal (GI) tract. This causes slower gut motility (i.e. food moves more slowly through the intestines) which can lead to harder stools, less frequent bowel movements and bloating and gas. Gentle abdominal MLD techniques may improve circulation of lymphatic fluid around the intestines and abdominal organs, reducing congestion, inflammation, or sluggish movement. It can also help reduce fluid retention and bloating in the abdomen, which can make constipation feel worse. With less abdominal pressure, the bowel may move more freely.³
Mood – While MLD may not directly affect mood, it can help with reducing stress and tension, which may indirectly support better mood regulation & feelings of well-being.

Caution

MLD is not a standalone treatment for PMS. It works best when combined with hydration, fiber, movement, and sometimes probiotics or dietary adjustments. Pending a doctor’s approval, NSAIDS like Ibuprofen or heating pads may be helpful for severe cramps. And, in some cases, birth control pills can help regulate a cycle & improve symptoms. With any medication, it’s important to be aware of side effects. And be aware that deep abdominal techniques are contraindicated during menses.

Cycle Idiopathic Edema

While talking about PMS, it’s a good idea to mention another condition: Idiopathic cyclic edema (ICE). ICE is a condition that resembles PMS but is different. Besides similar symptoms, women often have two good weeks followed by two bad weeks of swelling. Oddly, even though considered edema, it is a protein-rich fluid. So, MLD & compression can be helpful.¹ It mostly affects women & causes daily, unpredictable swelling, especially in the legs, hands, face, and sometimes abdomen, with no identifiable underlying disease. (The term “idiopathic” means the exact cause is unknown, and “cyclic” refers to the pattern of swelling that comes and goes, often worsening throughout the day.) Although the cause is not clear, a number of hormones (particularly the luteinizing hormone)¹ are postulated to be involved. Altered vascular permeability and increased lymph formation may also be part of the disorder.²

References
¹ Kasseroller, R. (1998). Compendium of Dr. Vodder’s Manual Lymph Drainage, pg.111. Germany: Huthig GmbH.
² Sabatini S. Hormonal insights into the pathogenesis of cyclic idiopathic edema. Semin Nephrol. 2001;21(3):244-250. doi:10.1053/snep.2001.21651
³ Wittlinger, H., Wittlinger, G. (1998). Textbook of Dr. Vodder’s Manual Lymph Drainage (6^th ed.), pg. 87. Germany: Karl Haug Verlag.

May 1, 2025 By Rebecca Summers, OT, CLT-LANA, CSR

MLD and a Woman’s Menstrual Cycle (part 1)

(Caution: This month’s blog may be a bit awkward for male readers.) A patient recently came into the office seeking relief from symptoms related to her menstrual cycle. Her primary complaints were bloating and weight gain. She had a wedding coming up and wanted to look her best. Can manual lymph drainage (MLD) help with symptoms related to a woman’s period? Let first look at what occurs during a woman’s cycle.

The Cycle

Every month (if things work like they should), a woman goes through a series of steps through which the body prepares for possible pregnancy. The cycle typically lasts 28 days (but the range varies from 21 to 35 days). And it’s regulated by hormones. (If you’ve read past blogs, you may have learned hormones can cause swelling because of how they influence the permeability of the capillary bed, allowing fluid and proteins to escape the blood stream and enter the tissue space.)

Days 1-5: The period. This is when there is active bleeding as the uterine lining sheds. Hormone levels are lower, especially estrogen.

Symptoms: Cramping, bloating, fatigue, mood changes which subside towards the end.

Days 1-13: Follicular Phase. The pituitary gland releases FSH (follicle-stimulating hormone), stimulating the ovaries to produce follicles. One becomes dominant and matures into an egg. Estrogen increases, helping rebuild the uterine lining. Days 8-14 are the best times to get pregnant as there’s an increased chance the sperm will be present when an egg is released (on day 14), but days 8-19 are a conservative window.

Symptoms: Higher energy, mental clarity, clearer/glowing skin, increased sex drive, higher confidence, cervical mucus becomes clearer, stretchier, and more slippery (like egg whites) to help sperm travel easier as ovulation approaches.

Day 14: Ovulation. A few days before ovulation, there’s a surge in LH (luteinizing hormone) triggering the release of the mature egg from the ovary (ovulation) on day 14. This is the most fertile time; sperm can survive up to 5 days, and the egg lives about 24 hours.

Symptoms: Same as the follicular phase. In addition, the breasts and labia may become more sensitive, tender and/or enlarged.

Day 15-28: Luteal Phase. If there is no pregnancy, the empty follicle becomes the corpus luteum (Latin for “yellow body”), which secretes progesterone to thicken the uterine lining for possible pregnancy. If that doesn’t happen, the corpus luteum breaks down, progesterone drops and menstruation begins.

Symptoms: If no pregnancy occurs, PMS symptoms occur (the symptoms women usually want relief from).

PMS Symptoms

PMS stands for Premenstrual Syndrome. But there are numerous acronyms that substitute meaning: “Pass My Snacks,” “Prepare to Meet Satan,” “Pardon My Sensitivity,” “Pizza and Mood Swings,” and “Please Make it Stop” are among the contenders. The symptoms of PMS can include bloating, cramps, weight gain, mood swings, fatigue, constipation, headaches, food cravings. They’re caused by the rise and sudden, sharp drop of progesterone when there is no pregnancy. This hormone shift can affect brain chemistry, especially serotonin, which influences mood and emotion. When the changes are extreme or severe, it’s called Premenstrual Dysphoric Disorder.

How can MLD help? Find out next month!