Lymphedema Therapy Source, PLLC opened its doors in 2011 to provide lymphedema services to those in the Dallas-Fort Worth Metroplex. In 2018, we narrowed the geography of our therapy services, but we’re expanding in other ways in 2020!

Changes will be coming to our website beginning this month & continuing in the months to follow including the addition of ebooks, video content, an interactive blog & more. Stay tuned!

Jobst is a well-known company that has provided compression for lymphedema for years (as well as other conditions such as diabetes, pregnancy & wound care). They also make & sell orthopedic products, donning & doffing aids & bandages. Originally founded in Ohio by Conrad Jobst (from Germany) in 1950, they were acquired by a company called Beiersdorf AG from Germany in 1990 & were ultimately merged with other companies & are now known as BSN-JOBST. Their global headquarters is in Germany & their United States base is in North Carolina.

Specific to lymphedema, they sell garments that fall into various categories of flat or circular-knit & custom or ready-made as indicated below. The Custom Seamed* can be sewn as a glove, mask, vest or body suit as well as sewn as the more typical sleeves & lower leg styles.  Custom is an area where Jobst shines as they offer numerous options for individual needs.  Most ready-made products come in several color options with open or closed-toe choices.

Flat-Knit                                                                                           Circular-Knit

Custom Seamed*                                                                           (Custom) Seamless Soft

Custom Elvarex                                                                              (Custom) Bellevar

Custom Elvarex Soft (latex-free)                                                 (Ready-made) Jobst Bella Strong

Elvarex Soft Seamless (a latex- free & seamless)                     (Ready-made) Bella Lite

In addition to lymphedema garments, they have a few helpful donning aids. These include gloves, a stocking donner & a stocking slip aid for open-toe stockings.  As noted above, they sell a host of other products for a range of other conditions including numerous compression garments for vascular disorders.

 

References

http://www.jobst-usa.com

Dealer Handbook

The first manufacturer we’ll highlight is based right here in Texas.  FarrowMed was created by a wound care physician named Wade Farrow.  He came up with a product that allowed easy access to wounds but also provided compression that’s easy to put on & take off using Velcro as opposed to the customary compression hose.  The Farrow Wrap is a short-stretch fabric (like short-stretch bandages used in lymphedema treatment) which provides a low, steady resting compression & the needed high-working compression with activity to effectively facilitate fluid loss.  And, because it’s a short-stretch fabric, most of their garments can be worn day or night.  Though not superior to lymphedema bandaging, the FarrowMed products are a great solution for people with lower leg lymphedema or venous insufficiency.  Their product lines tend to be popular & the FarrowMed team not only demonstrate good customer service but Texas friendliness, too.

They offer arm, hand, leg & foot compression products as well as accessory items.  Some of their best items include the Trim-to-Fit compression (a garment that can be cut down as a limb reduces), the Classic line & the FarrowWrap LITE garments.  Additionally, their FarrowHybrid AD liners are a good substitute for the Velcro foot wraps for a less bulky compression option.  More information can be found at www.farrowmed.com.

 

In January’s blog, we said there are a number of factors that need to be considered when deciding whether to go the traditional route for long-term compression (i.e. hose or sleeves) or use an alternative. In this blog, we will finish our introduction by discussing some of these considerations.

The Reason for Swelling

The first area of consideration when choosing compression is the underlying reason for the swelling. Is the type of swelling pure lymphedema (i.e. swelling caused from an incompetent lymphatic system) or is the swelling due to impaired venous flow (i.e. venous insufficiency, paralysis, dependent positioning, DVT, etc.)? Flat-knit, custom garments are the recommended compression for lymphedema.¹ This is because of the high pressure required & the extent & form of swelling. Flat-knit provides a high working pressure & a lower resting pressure.  This is ideal when a person begins exercising or walking as the garment works against the tissue to facilitate lymph fluid movement.  Velcro options will maintain volume loss & may even facilitate drainage (some therapists use Velcro compression in place of bandaging during treatment, though this is not standard treatment & will not yield maximum results). While such an option can be convenient & cost-effective, it is not without downsides (such as bulkiness & numerous straps on longer garments that can become cumbersome, etc.). Velcro options are not superior to flat-knit, custom garments for pure lymphedema, but they are an alternative in some cases.

For others who have more of an edema-related swelling* (when the lymphatic system isn’t incompetent, it is just overwhelmed by the added volume caused by an impaired venous system), circular-knit stockings (& some Velcro products) are a good option. Circular-knit work differently than flat-knit.  Circular-knit have a low working pressure & a higher resting pressure which is primarily needed in cases of venous ulcers. In other localized edema conditions, elevation alone may resolve swelling but compression can provide comfort during sitting/standing times.

*It is important to note that generalized swelling (swelling throughout the body) is more likely an indication of a medical condition that could potentially be very serious. Medical treatment, not compression, is the appropriate intervention in this case. See blogs from March, August, November & December of 2014 for additional information.

The Required Style

Another consideration is the style or length. A good rule to follow is if there was swelling in an area before bandaging, then a garment needs to cover that area to prevent refilling when the bandaging phase is complete. For example, if a person has swelling in the leg that is present from the foot to above the knee, knee-high compression isn’t sufficient. If knee-high compression is chosen, swelling will inevitably return to above the knee.

The Location of Swelling

If swelling is present in the face or arm, for example, a garment will need to be custom-made & usually flat-knit. However, flat or circular-knit can be made in custom.

Chronic Infections

Some garments can be made with silver, an anti-microbial agent which may reduce infection risk. If recurrent infections are an issue, most likely other factors need to be addressed such as environmental hygiene, adherence to lymphedema precautions, unresolved swelling, compliance with previous compression, appropriateness of previous compression garment, etc.

Day vs Night Compression

Lymphedema patients typically require night compression. In such case, wearing hose or sleeves is not recommended. The primary concern is the compression level. Higher compression is tolerated & needed during the day, but less is needed at night in a recumbent position. There is a risk of ischemia (lack of blood flow) to an area if day garments are worn at night. Bandaging is the recommendation for night compression but some patients cannot do bandaging themselves & do not have assistance. Others simply will not be compliant due to the involved nature of multi-layer bandaging. There are foam sleeves for arms & legs that can be used with bandaging to reduce the steps. There are some foam options that have compression in them. Velcro may be a good option for night compression as well as straps are adjustable.

Patient Strength

Unfortunately, many times patients do not have sufficient help to don or doff garments. And, due to arthritis or other reasons, they may not have enough strength to put certain types of compression on. Hose can be difficult to get on an arm or leg. Challenges of strength, mobility & bilateral arm use can be just some of the barriers. There are several donning & doffing aids available which we will mention in future blogs. However, Velcro may be a suitable alternative & more cost effective when compression is needed at night, also.

In summary, aside from contraindications (such as impaired arterial blood flow or latex allergy), numerous considerations need to be considered when choosing the right compression. In our next blog, we’ll begin introducing the well-known manufacturers & some of their best selections for lymphedema.

 

References

¹Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 574. Germany: Urban & Fisher. Foldi, M, Foldi, E. (2006).

When it comes to choosing the right compression for lymphedema, there are a variety of manufacturers & options which can be overwhelming for a trained therapist let alone a patient. This blog will introduce a series of upcoming blogs highlighting well-known manufacturers & some of their most popular lymphedema compression options. We’ll also feature a few helpful donning aids.

What types of long-term compression are available? Hose & sleeves used to be the daytime options with self-bandaging recommended at night. This is still the “gold standard” in lymphedema, but now there are hybrid garments which have Velcro & alternative options for night compression.

There are numerous factors to consider when deciding whether to go the traditional route or consider an alternative. Does a person have help to put on a garment? Is strength an issue? Is arterial blood flow compromised? Is cost a factor? Is the condition pure lymphedema or is it a combination form (such as venous insufficiency or dependent positioning)? Is tissue hypersensitive? Is custom needed? Answering some of these questions will help in determining which garment might work the best in your particular situation. For our purposes, there are three categories of compression garments: Flat-Knit, Circular-Knit & Velcro/Other. Here is a brief overview:

• Flat-Knit – Most lymphedema garments (for pure lymphedema cases) are going to be flat-knit. This means that the garment is sewn in a flat manner & then stitched together (so a seam is visible). They are standard protocol for lymphedema because they affect the tissue in a manner similar to short-stretch bandaging. (Short-stretch bandages used in treatment not only maintain the volume that has been lost, but they have a massaging-effect on the tissue when the muscles are moving such as during exercise.) These are typically made in Europe, are more expensive than other types of compression & come in European compression class levels (Class I: 18-21  mmHg, Class 2: 23-32 mmHg, Class 3: 34-46 mmHg, Class 4: 49+mmHg) which require a prescription.
• Circular-Knit – Some combination-form lymphedema patients will benefit from this type of garment. This garment is sewn on a tubular machine which knits them in a circular manner. While they are cheaper to make & less expensive to buy, there are pros & cons to this garment. Because of how they are sewn, there is no seam, making them more esthetically attractive. They are also thinner & more stretchable. However, they have a tendency to roll & will readily bunch up & create pressure which can cause a wound. This typically happens in areas which have movement (joints such as the ankle or behind the knee). These garments affect the tissue in a manner similar to long-stretch bandages often used in wound care or venous disease. Long-stretch & ACE bandages work differently than short-stretch bandages. Long-stretch bandages have a longer stretch (they can be stretched out further) & higher pressure at rest (when a person isn’t moving). However, when a person is active (such as during exercise), the bandages easily stretch & do not have the same “massaging-effect” that short-stretch bandages do. People who sit at a desk all day or who have problems with their veins working properly will benefit the most from this type of compression garment.
• Velcro/Other – In more recent years, a hybrid form of compression has been created. This primarily includes Velcro options on a material more similar to short-stretch bandages. It’s a popular garment in wound care as the Velcro can be readily removed for dressing changes. These can be worn at night also & work well although they are not superior to bandaging. This is more cost-effective for many patients who cannot afford both day & night compression. The “other” category would be night garments with foam which are slipped over an extremity & provide compression or allow bandaging with fewer steps.

In the next blog, we’ll finish our introduction by talking about additional areas to consider before choosing the right compression garment such as the style, the use of silver & compression class.

Complete Decongestive Therapy (CDT) involves manual lymph drainage (MLD) & compression bandaging (as well as skin care & exercise).  In some instances, CDT should not be performed.  These occasions include:

1.  Active Infection caused by pathogens.  During localized infection, lymphatic vessels constrict to prevent pathogens & other harmful matter from escaping the area & entering the rest of the circulation.  When MLD is performed, the spasm may be counteracted.  This would allow normal flow to resume & potentially spread the toxin(s).  In general, a person needs to be on an antibiotic for 2-3 days with signs of improvement (no fever; swelling, redness, pain have subsided) before MLD may resume.  Some professionals wait up to 7-10 days before resumption as the inflammatory response can last that long.  The multi-layer compression bandaging may hinder the body’s inflammatory response.

2.  Deep Vein Thrombosis / Thrombophlebitis.  MLD stretches the skin & may potentially dislodge a blood clot.  Mild compression can be beneficial as it encourages clot adhesion to the vascular wall. It is recommended to have physician approval prior to application.

3.  Cardiac Edema.  All lymph fluid returns to the circulatory system at the venous angles.  In acute congestive heart failure, the heart is already overwhelmed by the volume of fluid being managed.  MLD only increased the load the heart must manage.  The same is true for bandaging.  Additionally, in acute cases of heart failure, the cause of swelling is the failing of the heart, so CDT will not help.

4.  Peripheral Artery Disease.  While MLD is not a concern, bandaging can compromise an already reduced arterial blood flow.  Arterial pressure in the foot below 70 mmHg (as measured by Doppler Ultrasound) is a contraindication for compression.

5.  Active Cancer.  Malignant tumors with a tendency to metastasize are an absolute contraindication for MLD as MLD only speeds up lymphatic flow & cancer travels via the lymphatic system or the cardiovascular system.  However, if a person is responding to chemo & the physician approves MLD, the massage may be performed (avoiding the immediate area of the tumor).  In other types of cancers, MLD may be permissible with physician approval.  Compression can be useful in helping to manage swelling.

There may be other occasions when aspects of CDT is not appropriate.

References

Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 416, 438, 527ff, 602. Germany: Urban & Fisher.

Kumar, V., Abbas, A., Aster, J. (2013). Robbins Basic Pathology (9^th ed.), location 1829, 1890. Pennsylvania: Elsevier Saunders.

Kasseroller, R. (1998). Compendium of Dr. Vodder’s Manual Lymph Drainage, p. 85, 174ff. Germany: Huthig GmbH.

http://www.merckmanuals.com/home/heart_and_blood_vessel_disorders/venous_disorders/deep_vein_thrombosis_dvt.html

http://www.veindirectory.org/qa/should-someone-with-blood-clot-wear-compression-stockings

In March, we looked at differences between edema & lymphedema, overviewing various causes of swelling.  In this post, we’ll take a deeper look at non-lymphedema causes of swelling (i.e. causes of edema).  If you’re not a medical professional, this post might be a little challenging.

Non-lymphedema causes of swelling can be generalized (i.e. systemic, throughout the body) or it can be localized.  We’re focusing on generalized edema.  This is caused by a medical underlying condition & patients are not appropriate for Complete Decongestive Therapy (i.e. CDT) which is used in lymphedema treatment.  In fact, treatment could cause harm because all fluid (including lymph) is returned to the heart.  Moving large amounts of fluid increases cardiac burden & could also overwhelm kidney function.  Additionally, because the reason for swelling is not mechanical insufficiency of the lymphatic system (which causes protein accumulation in the interstitium & lymphedema), CDT is not appropriate as it will not help.  So, what are these causes of swelling which are not lymphedema?

1. Increased hydrostatic pressure (increased venous pressure).  In this case, fluid is not being returned to the heart as it should be & capillary venous pressure is increased.  Fluid begins to back up in the feet & ankles, legs & sometimes the abdomen.  A primary example of this would be right-sided congestive heart failure.¹
2. Increased fluid osmotic pressure in the interstitium.  This occurs because of increased capillary permeability (increased arteriolar dilation) which allows greater amounts of protein to leave the blood.  An example of this would be a thyroid disorder (i.e. Hypothyroidism).²
3. Decreased plasma (blood) osmotic pressure.  In this case the body is losing too much protein.  Kidney failure & malnutrition would be prime examples of this.^3,4
4. Hyponatremia (sodium retention).  Sodium is the most abundant electrolyte in extracellular fluids & is the major determining factor of extracellular fluid osmotic pressure.  Diarrhea, vomiting, heart failure & other causes can be reasons the body retains salt.^5,6

 

¹Kumar, V., Abbas, A., Aster, J. (2013). Robbins Basic Pathology (9^th ed.), location 3972. Pennsylvania: Elsevier Saunders.

²Kumar, V., Abbas, A., Aster, J. (2013). Robbins Basic Pathology (9^th ed.), location 3872. Pennsylvania: Elsevier Saunders.

³Kumar, V., Abbas, A., Aster, J. (2013). Robbins Basic Pathology (9^th ed.), location 3860. Pennsylvania: Elsevier Saunders.

⁴Tortora, G., Grabowski, S. (1996). Principles of Anatomy & Physiology (8^th ed.), p. 619. New York: HarperCollins College Publishers.

⁵Kumar, V., Abbas, A., Aster, J. (2013). Robbins Basic Pathology (9^th ed.), location 4009. Pennsylvania: Elsevier Saunders.

⁶Tortora, G., Grabowski, S. (1996). Principles of Anatomy & Physiology (8^th ed.), p. 838. New York: HarperCollins College Publishers.

Normal skin has a hydrolipid film & protective acidic coating. Skin care is an important component in lymphedema care as the skin is a barrier which helps to prevent infections. Everyday soaps & lotions are not sufficient in skin care for lymphedema. One reason is the pH level. For example, soap is strongly alkaline which destroys the skin’s lipid & protective acidic layers. Another reason is that some have adverse effects. For example, Petroleum or Mineral Oil are occlusive agents & can irritate the skin. Below is a guideline for skin care which should be done daily.

• Cleansing skin – Soap-free, mild cleaning lotions or medicated body washes are recommended. These cleansing products are pH neutral (pH 7) or slightly acidic (pH5). One example of a soap-free product is Eucerine Body Wash.  Another good product to use is Cetaphil (a dermatology-recommended product which is pH-balanced).  Be sure to dry between skin folds & toes/fingers when washing.
• Lotion – Natural products or mild, medicinal products most similar to the skin’s external composition are preferred. Examples include Eucerine, LipoLotion, HydroLotion & Cetaphil. Some patients prefer the plant-based Burt’s Bees lotion as an alternative or EmerginC.

Note: Lanolin (found in many lotions) has an allergic potential but Lanolin Alcohol (a highly purified form) does not. The latter form is good for skin care as it is most similar to the skin’s dermal lipid layer & is found in Eucerine.

Tip: Monitor your skin for signs of a fungal infection (odor, redness, rash, etc.). Areas that are warm & moist (such as skin folds, groin & feet) are prone to fungal infections (especially yeast infections, in particular if you have been taking an antibiotic). There are different types of fungal infections: Athete’s Foot (Tinea Pedis); Tinea Versicolor; Ringworm (Tinea Corporis); Jock Itch (Tinea Cruris); & Yeast (Candidiasis).

 

References
Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 625-626. Germany: Urban & Fisher.
http://health.howstuffworks.com/skin-care/problems/medical/5-types-of-skin-fungus5.htm
http://www.cetaphil.com.au/Faqs.aspx

Congestive heart failure (CHF) primarily occurs when the heart cannot pump enough blood to meet the body’s demands or when the heart can only meet the body’s demands by pumping blood at a higher-than-normal filling pressure.¹ While there can be an acute cause of CHF, it is frequently a slow, cumulative condition caused by work overload & fatigue or progressive loss of myocardium (a.k.a. heart muscle).²

Starling’s Law

Though not the first to do so, the physiologist Ernest Starling recognized the correlation between a muscle fiber being stretched & an ejection reaction. This correlation is known as “Starling’s Law.” He noted when muscle fibers are stretched, they react by contracting (due to autonomic nervous system sensory receptors in the muscle). He also recognized the strength of this contraction is dependent upon the length of the fiber.³ The heart muscle fibers are most lengthened at rest (during diastole – or dilation – when a chamber of the heart is refilling). In short, the heart (the atrium), when filled with blood, stretches & stretch receptors inside the muscle sense the filling & so react by contracting. The force of this contraction depends on the size of the load & on the muscle fibers being relaxed & lengthened (stretched) by the load.

As long as the heart remains strong, it can continue to pump blood effectively. However, after managing an increased load over an extended period of time, the heart begins to fatigue, reducing its contraction strength & the load it expels. Consequently, the body does not receive as much blood as it needs & the venous flow begins to back up. This increases pressure in the veins (which normally have a lower pressure) & forces fluid back into the tissues. Symptoms depend on which part of the heart is fatiguing. Eventually, the heart will fail. In some cases (depending on the reason), digitalis is effective.

Simplified Summary of Heart Failure

1. Heart Failure due to Mechanical Insufficiency or “Low-Output Failure” – The volume is normal but the heart is impaired. Digitalis is effective.
2. Heart Failure due to High-Output Failure or “Dynamic Insufficiency” – The heart is healthy but the volume is abnormal due to an underlying medical condition. When digitalis is given in this scenario, it will not help (the heart is already working as hard as it can).⁴ Examples include Grave’s Disease (the thyroid must be treated to reduce the cardiac load), arteriovenous fistula (the fistula must be removed) or anemia.
3. Combination High & Low-Output failure – The underlying medical reason for increased volume will eventually cause damage to the heart, leading to mechanical insufficiency or low-output failure. If the primary cause is low-output (where the heart is impaired but can manage the volume load when resting), the patient will need to reduce activity to reduce overexertion which would increase the volume & lead to the High-Output & Low-Output combined form of heart failure.⁵

Simplified Summary of Lymphatic Failure

In a similar manner, a portion of the lymphatic structures (lymph angions) are often likened to hearts because they have smooth muscle & stretch receptors lining them, enabling them to contract when filled with lymph fluid.⁴ Interestingly, the lymphatic system is not only activated by the internal stretching due to increased internal angion pressure but also “by the external stretching stimulus produced by massage.”⁵ Just as digitalis is sometimes appropriate & helpful in certain cases of heart failure, manual lymph drainage is sometimes effective in cases of swelling, in particular, in lymphedema.

1. Swelling due to Mechanical Insufficiency or “Low-Output Failure” (i.e. Lymphedema) – The volume is normal but the lymph structures are impaired. Manual lymph drainage is effective.
2. Swelling due to “High-Output Failure” or “Dynamic Insufficiency” (i.e. Edema) – The lymphatic structures are normal but the volume isn’t. If manual lymph drainage is attempted in this scenario, it will not help (the lymphatic system is already working as hard as it can).⁶
3. Combination Lymphedema & Edema or “Low & High-Output Failure” – Either there is an underlying medical cause contributing to an unusual excessive amount of volume that healthy lymph structures have been coping & eventually fatigue, or the impaired lymph structures have managed the usual volume but an unexpected event causes a volume increase (such as rigorous exercise, air travel, etc.) which overwhelms them.

References

¹ Kumar, V., Abbas, A., Aster, J. (2013). Robbins Basic Pathology (9^th ed.), location 18740. Pennsylvania: Elsevier Saunders.

² Kumar, V., Abbas, A., Aster, J. (2013). Robbins Basic Pathology (9^th ed.), location 18747. Pennsylvania: Elsevier Saunders.

³Starling EH. The Linacre Lecture on the Law of the Heart. London, UK: Longmans, Green and Co; 1918.

⁴ Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 209. Germany: Urban & Fisher.

⁵ Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 202. Germany: Urban & Fisher.

⁶ Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 212. Germany: Urban & Fisher.