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

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

MLD After Burn Injury: Supporting Healing, Pain Relief, and Recovery

In Honor of the 25^th Anniversary of 9/11 (those who suffered burn injuries on 09/11/2001)

A severe burn affects far more than the skin. Survivors may experience prolonged swelling, inflammation, pain, hypersensitivity, itching, restricted movement, and scarring. Recovery therefore requires more than wound closure—it requires restoring tissue health, mobility, comfort, and function.

Manual lymphatic drainage (MLD) is a gentle, specialized technique designed to support lymphatic fluid transport. When appropriately incorporated into burn rehabilitation, MLD may help address several of the factors that can interfere with recovery.

Reducing edema and tissue congestion

After a significant burn, inflammation can cause substantial accumulation of fluid and proteins in the tissues. Excessive edema can increase tissue pressure, restrict movement, and contribute to discomfort. MLD is designed to facilitate lymphatic transport and the movement of excess interstitial fluid.¹

Burn-rehabilitation research supports edema management as an important component of recovery, with interventions such as compression associated with improvements in edema, range of motion, and hand function.²

Supporting the inflammatory environment

The lymphatic system transports excess interstitial fluid, proteins, cellular debris, and substances associated with inflammation. MLD facilitates clearance from congested tissues by increasing lymphatic transport and inflammatory signaling. This creates a more favorable environment for recovery.

Reducing pain

MLD influences pain through several mechanisms: Reducing edema can decrease tissue pressure. The gentle, rhythmic techniques used in MLD has a calming effect on the sympathetic nervous system and promotes parasympathetic activity associated with relaxation and pain modulation.⁶ Research examining pain and autonomic function has found an association between greater parasympathetic activity and greater capacity for pain inhibition as well.^{3, 7}

More specifically, nociceptors (pain receptors) send signals to the brain for the duration of a pain stimulus. Nerve fibers have a collateral pathway to an inhibitory cell which is connected to the “switch-cell” of the pain pathway. When MLD is performed correctly, touch receptors transform this impulse into an inhibition & interrupt the transmission of pain. Note: The inhibitory effect of MLD is not likely to work on very strong pain.⁶

Supporting movement and rehabilitation

Pain and swelling can create a cycle of guarding, stiffness, and reduced movement. By helping manage edema and discomfort, MLD can make movement easier and allow patients to participate more fully in therapeutic exercise and functional rehabilitation. This is particularly important after hand and extremity burns, where swelling and scar formation can significantly limit function.⁸

Supporting scar management

Persistent inflammation and edema can contribute to an unfavorable tissue environment during healing. MLD can complement other scar-management strategies by addressing edema and tissue congestion. Research on massage-based scar treatment in burn survivors has demonstrated improvements in symptoms such as pain and itching and helping to prevent development of certain scar characteristics (e.g. hypertrophic scars). A burn-trauma service evaluation involving myofascial-manual lymphatic drainage reported potential benefits involving secondary inflammation, scar hypertrophy, and tissue regeneration.⁹

The Bigger Picture

The potential benefits of MLD shouldn’t be ignored: reduced edema, less tissue congestion, improved comfort, support for mobility, relaxation, and possible influence on pain and autonomic regulation. However, MLD should not be considered a replacement for specialized burn care. It is best viewed as an adjunct to comprehensive rehabilitation, which may include: wound care, pain management, compression, elevation and positioning, therapeutic exercise, range-of-motion, scar management, physical and occupational therapy, and psychological support.

References

Földi M, Földi E, Kubik S. Földi’s Textbook of Lymphology. Elsevier. (shop.elsevier.com)
Edger-Lacoursière Z, Deziel E, Nedelec B. Rehabilitation interventions after hand burn injury in adults: A systematic review. Burns. 2023. https://pubmed.ncbi.nlm.nih.gov/35662480/
Forte G, et al. Heart Rate Variability and Pain: A Systematic Review. Brain Sciences. 2022. https://pubmed.ncbi.nlm.nih.gov/35203917/
Myofascial-manual lymphatic drainage for burn trauma: a service evaluation. (pubmed.ncbi.nlm.nih.gov)
Massage, laser and shockwave therapy improve pain and scar pruritus after burns: a systematic review. Journal of Physiotherapy. 2024. (pubmed.ncbi.nlm.nih.gov)
Textbook of Dr. Vodder’s Manual Lymph Drainage
Mühlenpfordt I, Blakeslee SB, Everding J, Cramer H, Seifert G, Stritter W. Touching body, soul, and spirit? Understanding external applications from integrative medicine: A mixed methods systematic review. Front Med (Lausanne). 2022;9:960960. Published 2022 Dec 22. doi:10.3389/fmed.2022.960960. https://pmc.ncbi.nlm.nih.gov/articles/PMC9813495/
Edger-Lacoursière Z, Deziel E, Nedelec B. Rehabilitation interventions after hand burn injury in adults: A systematic review. Burns. 2023;49(3):516-553. doi:10.1016/j.burns.2022.05.005. https://pubmed.ncbi.nlm.nih.gov/35662480/
Loskotová A, Loskotová J, Suchanek I, Brychta P, Lipový B. Myofascial-manual lymphatic drainage for burn trauma: a service evaluation. Br J Community Nurs. 2017;22 Suppl 5(Sup5):S6-S12. doi:10.12968/bjcn.2017.22.Sup5.S6. https://pubmed.ncbi.nlm.nih.gov/28467220/

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

A-Fib and Swelling

There are many reasons for swelling—and not all of them are lymphedema. For example, did you know that atrial fibrillation (A-Fib) can sometimes lead to swelling? It can—but usually indirectly. A-Fib is one form of an irregular heart rhythm that can reduce how efficiently the heart pumps blood. In some people, especially those with underlying heart disease, this can contribute to fluid retention. In addition, some medications used to treat heart conditions can also cause swelling.

What is A-Fib

Atrial fibrillation (A-Fib) is the most common sustained abnormal heart rhythm. It begins in the heart’s upper chambers (the atria), most often in or near the left atrium around the openings of the pulmonary veins. Instead of contracting in a coordinated way, the atria quiver (fibrillate). This causes irregular electrical signals to reach the lower chambers (the ventricles), resulting in an irregular—and sometimes rapid—heartbeat.

Common symptoms include:

Swelling
Heart palpitations
Fatigue
Shortness of breath
Dizziness
Reduced exercise tolerance

The abnormal electrical activity most commonly starts in or near the left atrium, often around the openings of the pulmonary veins.

How Swelling Can Occur

While most people never get swelling, fluid retention can occur for several reasons:

Reduced pumping efficiency. During A-Fib, the atria don’t squeeze effectively. This can reduce how efficiently the heart fills and pumps blood, especially if the heart is already weakened.
Heart failure can develop or worsen. If A-Fib is very fast or persists for a long time, the heart muscle can become less effective. When the heart can’t pump blood efficiently, fluid can back up in the body.
Fluid backs up in the veins. When blood backs up, pressure in the veins increases. Fluid leaks from the blood vessels into surrounding tissues, causing edema (swelling).

Where Swelling is Seen

If the right side of the heart is affected—or if there is heart failure overall—fluid commonly collects in the legs, ankles, and feet. If the left side of the heart is affected, fluid is more likely to build up in the lungs, leading to shortness of breath rather than noticeable leg swelling.

This patient had leg & ankle swelling due to A-Fib and heart failure. They admitted to the hospital and had 12 pounds of “water weight” removed.

A few months later, swelling had reoccurred, but most resolved with medication change(s).

Who is most likely to develop swelling?

Swelling is more likely when AFib occurs along with:

Heart failure
Long-standing high blood pressure
Heart valve disease
Kidney disease
Certain medications

For example, calcium channel blockers such as diltiazem (Cardizem) and verapamil can cause swelling of the feet and ankles. These medications relax blood vessels, which can allow more fluid to move from the bloodstream into surrounding tissues. This type of swelling is a medication side effect and is different from swelling caused by heart failure.

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

Rethinking MLD Pressure (part 2)

Last month, we started a discussion about MLD pressure. Foldi always taught light pressure. Newer research indicates lymph vessels aren’t occluded until 86 mmHg. We’re continuing that topic this month.

**Why This Does Not Mean “Deeper Pressure Is Better”**

One of the most important conclusions from the study is often overlooked:

The researchers specifically noted that manual lymph drainage pressures applied by the hand are typically under 10 mm Hg, which remains well below lymphatic occlusion thresholds. (Sage Journals)

That matters because MLD is not intended to “force fluid through pipes.” Instead, it works by:

stimulating lymphatic vessel activity,
improving lymphangion filling,
enhancing rerouting through collateral pathways,
and supporting natural lymphatic pumping.

The study supports the idea that properly performed gentle MLD does not collapse lymphatics. In other words, Foldi’s gentle-pressure philosophy remains physiologically sound.

The Difference Between Compression and MLD

The study also helps clarify confusion between:

manual lymph drainage pressure, and
compression therapy pressure.

Compression garments and pneumatic compression devices may use substantially higher pressures than hands-on MLD. The researchers warned that if compression pressures exceed lymphatic occlusion pressure, collectors and initial lymphatics could temporarily collapse during inflation phases. (Sage Journals)

This distinction is critical in clinical practice.

Foldi-based Complete Decongestive Therapy (CDT) has always emphasized that:

MLD prepares and stimulates lymphatic pathways,
compression maintains fluid reduction,
exercise activates the muscle and lymphatic pumps,
and skin care protects vulnerable tissues.

The therapies work together — but they do not work the same way.

What This Means for Therapists Today

The 2016 findings encourage a more evidence-based discussion around lymphatic pressure without abandoning traditional lymphology principles.

For certified lymphedema therapists, the takeaway is not to use heavier pressure. Instead, the study reinforces several clinical ideas:

1. Gentle Pressure Can Still Be Effective – MLD does not require deep force to stimulate lymphatic transport.

2. Vessel Filling Matters – Lymphatic flow is intermittent. Proper sequencing and preparation techniques — central clearing, proximal-to-distal preparation, and rhythmic repetition — may improve lymphatic filling and flow.

3. Precision Matters More Than Intensity – Direction, sequencing, stretch, and rhythm likely influence outcomes more than raw pressure.

4. Compression Must Be Individualized – Higher pressure is not automatically better, especially in compromised or fibrotic tissues.

Modern Imaging Is Validating Traditional Lymphology

One of the most fascinating aspects of this research is how modern imaging technology is beginning to visually confirm concepts long taught in Foldi-based education.

The lymphatic system is dynamic, contractile, and responsive — not passive.

Near-infrared fluorescence imaging allows researchers to watch lymphangions contract and observe fluid movement in real time, offering a new scientific window into therapies that were previously understood mostly through clinical outcomes and practitioner experience. (Sage Journals)

As lymphatic science evolves, the future of lymphedema care will likely combine:

traditional clinical wisdom,
advanced imaging,
individualized pressure strategies,
and deeper understanding of lymphatic biomechanics.

The Foldi principles are not being replaced. They are being explained more clearly than ever before.

References
¹ Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 526. Germany: Urban and Fisher.
² Belgrado, J.-P., Vandermeeren, L., Vankerckhove, S., Valsamis, J.-B., Malloizel-Delaunay, J., Moraine, J.-J., & Liebens, F. (2016). Near-infrared fluorescence lymphatic imaging to reconsider occlusion pressure of superficial lymphatic collectors in upper extremities of healthy volunteers. Lymphatic Research and Biology, 14(2), 70–77. https://doi.org/10.1089/lrb.2015.0040

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

Rethinking MLD Pressure (part 1)

What Foldi’s Principles and New Lymphatic Research Tell Us

For decades, manual lymph drainage (MLD) has been guided by one central principle from the Foldi school of lymphedema treatment: lymphatic vessels are delicate, superficial, and highly responsive to pressure.¹ Therapists are taught to use slow, rhythmic, skin-stretching movements rather than deep tissue force. Now, modern imaging research is helping explain why that approach works — and where MLD pressure thresholds may actually lie.

A landmark 2016 study published in Lymphatic Research and Biology used near-infrared fluorescence lymphatic imaging (NIRFLI) to directly observe lymphatic flow in real time.² The researchers discovered that superficial lymphatic collectors tolerated much higher occlusion pressures than previously believed, with an average occlusion pressure of approximately 86 mm Hg in healthy subjects. (Sage Journals). At first glance, that finding may seem to contradict traditional Foldi-based MLD concepts emphasizing gentleness in applying MLD pressure. In reality, the research actually reinforces many of Foldi’s core principles.

The Foldi Philosophy: Pressure Is Not the Goal

The Foldi method, developed by Michael Földi and Ethel Földi, teaches that successful lymphatic treatment depends on:

stimulating superficial lymphatic vessels,
encouraging lymphangion contraction,
reducing tissue congestion,
and redirecting fluid toward healthy drainage territories.

The emphasis has always been on precision over force.

Traditional Foldi training warns against aggressive massage because excessive pressure may:

collapse superficial lymphatics,
increase capillary filtration,
irritate tissues,
or worsen inflammation and fibrosis.

The 2016 NIRFLI study adds important nuance to this understanding.

What the 2016 Study Actually Found

Researchers observed lymph flow in healthy volunteers using fluorescent imaging while gradually increasing pressure with a transparent cuff. They combined this with a specialized MLD approach called the “Fill & Flush Drainage Method” to keep lymphatic vessels actively filled during testing. (Sage Journals)

Their findings included:

Mean lymphatic occlusion pressure: 86 mm Hg
No significant differences between age, gender, or side of the body
Previous studies may have underestimated occlusion pressure due to imaging limitations and insufficient vessel filling during testing (Sage Journals)

Earlier estimates had suggested lymphatic occlusion occurred around 24–40 mm Hg. This new research challenged that assumption. (Sage Journals)

This doesn’t mean deeper or more pressure is better. Find out why in the next blog…

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

What’s Needed for Insurance Coverage of Compression

Over the past couple of months, we’ve discussed staying up to date with Medicare coverage of compression following the passage of the Lymphedema Treatment Act, as well as how to determine coverage from other payers, like commercial or Medicare Advantage plans. Once you know what your plan covers, the next step is understanding what’s needed to submit a valid claim. Fortunately, these requirements are fairly consistent across Medicare and other insurance providers.

The Script: Your Doctor’s Order²

A script is simply a doctor’s order for your compression garments or therapy services. Usually, either your DME (durable medical equipment) supplier or your therapist will send this to your doctor for signature.

A valid script must include:

Your name (as the patient) and date of birth
Your insurance member ID
Diagnosis code
Ordering doctor’s name, signature, and date
Doctor’s NPI (National Provider Identifier) used for billing
The specific item needed, including strength if applicable, and any non-standard accessories
Quantity of items
Laterality (which side—left or right)

How often the item(s) should be dispensed.

The Item Needed – Billing Codes

Insurance pays for your therapy services or compression garment based on codes.

For services, CPT codes (current procedural terminology codes) are used. For example, in lymphedema, when your therapist does an evaluation (i.e. a service), a code like 97165 may be used (for occupational therapists) or 97161 (for a physical therapist). If education is provided, 97535 may be used.

For compression garments (supplies or products), HCPCS codes¹ (Healthcare Common Procedure Coding System codes) are used. For example. A knee-high hose (not custom) with a strength level of 30-40 mmHg & a silicone band to prevent slipping is known as:

A6552 – GRADIENT COMPRESSION STOCKING, BELOW KNEE, 30-40 MMHG, EACH
A6593 – ACCESSORY FOR GRADIENT COMPRESSION GARMENT OR WRAP WITH ADJUSTABLE STRAPS, NOT-OTHERWISE SPECIFIED.

Supporting Evidence

Insurance typically requires documentation to support your claim. Examples include:

Therapy notes: Usually an evaluation and at least one daily visit note

Having the proper script, correct billing codes, and supporting documentation makes it much more likely your claim will be approved.

References
1 Lymphedema Compression Treatment Items – Correct Coding and Billing – Revised
2 Supplier Manual – Chapter 3 Supplier Documentation
3 SWOs – Article Detail – JA DME – Noridian

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

Pre-Steps to Ensure Coverage of Compression

Last month, we discussed helpful resources for staying up to date on compression coverage and billing related to Medicare. This month, we’re shifting focus to other types of insurance payers.

Understanding Other Payers

Insurance providers such as Medicare Advantage plans and commercial insurers (like Blue Cross Blue Shield) have their own policies regarding compression coverage. Because these policies can vary, it’s important to understand a few key factors before moving forward:

Is prior authorization required?
What is the medical policy for lymphedema compression?
Are there specific clinical payment or coding guidelines?

Key Terms to Know

Prior Authorization (“Prior Auth”) is approval from your insurance plan for a specific item or service before it’s provided. In most cases, the durable medical equipment (DME) company supplying your compression garments will handle this process. However, you should still confirm:

Whether the DME company is in-network or out-of-network (this can affect your out-of-pocket cost)
Whether prior authorization is required under your specific plan

You may also want to call your insurance company directly using the customer service number on the back of your insurance card to verify if prior authorization is required. If you do call, request a call reference number for your records.

How to Research Coverage

When reviewing coverage details on an insurer’s website, use these specific search terms to find accurate information:

1. Medical Policy. This outlines what the insurer considers medically necessary, including:

Eligibility criteria
Diagnosis codes
Required documentation
Coverage limitations

2. Clinical Payment/Coding Guidelines (CPCG). These explain how services and items should be billed, including:

HCPCS/CPT codes
Quantity or frequency limits
Rules for custom vs. off-the-shelf garments
Distinctions between DME and supplies

For example, if you’re insured through Blue Cross Blue Shield of Texas, try:

“BCBS TX medical policy lymphedema 2025”
“BCBS TX clinical payment coding guidelines compression therapy 2025”

Tip: Always include the current year in your search to ensure you’re reviewing the most up-to-date policies, as coverage rules can change annually.

Important Cost Considerations

Beyond coverage rules, it’s essential to understand your financial responsibility:

Deductible: Do you have a deductible for DME? If so, how much have you met this year?
Co-insurance: What percentage of the cost are you responsible for after meeting your deductible?

Final Notes

Your doctor will need to provide:

A signed order (prescription) for the compression item
Supporting clinical documentation (such as therapy notes)

While the DME company typically handles most of the paperwork and coordination, understanding the process ahead of time can help you avoid surprises and feel more confident navigating your coverage.

March 10, 2026 By Rebecca Summers, OT, CLT-LANA, CSR

Staying Up-To-Date with Insurance Coverage for Compression

Staying informed about insurance rule changes related to the Lymphedema Treatment Act is essential for both patients and providers. Since the law’s implementation under Centers for Medicare & Medicaid Services Medicare Part B in 2024, updates to coverage guidelines, billing requirements, and documentation standards continue to evolve. Keeping up with these changes helps ensure patients receive the compression garments and supplies they need without unnecessary delays or coverage issues.

Lymphedema Treatment Act Summary

For years, individuals living with lymphedema struggled to get Medicare coverage for compression garments and related supplies. Sometimes patients couldn’t afford to buy the necessary items to maintain volume loss in therapy, or they had to substitute with substandard items. Lymphedema Treatment Act (LTA) changed that.

The Lymphedema Treatment Act is a federal law that requires Medicare to cover compression garments and other lymphedema treatment supplies when they are prescribed by a physician for a patient diagnosed with lymphedema and documentation supports medical necessity.

A new category for lymphedema compression was created (instead of being classified as standard “durable medical equipment”). The law was passed by Congress on December 23, 2022 (as part of the Consolidated Appropriations Act of 2023) after more than a decade of patient advocacy and legislative effort. It went into effect January 1, 2024.

What’s Covered

Medicare Part B now covers off-the-shelf and custom-fitted compression garments, wraps, bandaging systems, and accessories used for treating lymphedema — including donning and doffing aids, padding, fillers, linings, and zippers.^1,2

Coverage includes frequency guidelines such as three daytime garments every six months and two nighttime garments every two years per affected body part.
Coverage only applies to items prescribed for diagnosed lymphedema and requires adherence to Medicare’s documentation and billing rules.

A person must have a diagnosis of:

I89.0 – Lymphedema, not elsewhere classified
I97.2 – Postmastectomy lymphedema syndrome
I97.89 – Other postprocedural complications and disorders of the circulatory system, not elsewhere classified
Q82.0 – Hereditary lymphedema

Where to Get Compression Garments

You must purchase compression from a Medicare supplier. Therapists & therapy clinics can be suppliers, but they must go through the credentialing process as a Durable Medical Equipment supplier (i.e. have a state DME license, additional DME insurance, etc.) & meet supplier standards. (Lymphedema Therapy Source is a DME supplier for our patients.)

Staying Informed

There are changes and updates to this federal law. Below are a couple of good sites to follow to stay informed about those changes:

Compression Alliance Video on Billing Updates: US Medical Compression Alliance
Lymphedema Advocacy Group: https://lymphedemaadvocacygroup.org/

The U.S. Medical Compression Alliance (USMCA) is an industry coalition of medical device manufacturers that focuses on improving care and access to medical compression therapy for patients with venous and lymphatic diseases (such as lymphedema and chronic venous insufficiency).

Conclusion

The Lymphedema Treatment Act didn’t just change a policy — it changed lives. It means that patients can now get the compression supplies they need without prohibitive out-of-pocket costs. And because Medicare often sets the standard that private insurers follow, this law has the potential to widen coverage across many plans, expanding access even beyond Medicare beneficiaries.

References
1 https://lymphedemaadvocacygroup.org/lta-coverage-rules
2 https://www.cgsmedicare.com/jc/pubs/news/2023/12/cope147943.html

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.)