1. Experience – Does this person have recent lymphedema experience?  If their experience is just having finished a training program, there will be a learning curve; there’s no teacher like experience. A “new grad” may do very well, especially if they have worked in this setting or are familiar with the types of comorbidities that may go along with a patient’s lymphedema (such as Chronic Venous Insufficiency, Obesity, Cellulitis, Cancer, etc.).  They should also know when underlying conditions are a cause of edema & not true lymphedema; an experienced clinician will have had more time to reinforce other causes of swelling like CHF, Renal Failure, Malnutrition, DVT & what to do or not do.

2. Familiarity with Practice Setting – Is this setting familiar to this new hire? For example, if they have never worked in acute care & have no wound care experience, they may be overwhelmed by the lack of supplies in the department.  Instead of the material with which they were trained (Stockinette, foam or cotton & short-stretch bandages), they have access to wound care supplies (such as Kerlix, Abdominal pads, Tubigrip, ACE bandages, wound care kits).  They may not know what to do with these items.  As another example, maybe this is a traditional setting such as outpatient.  If they’re already familiar with the flow of outpatient, applying their acquired lymphedema skills won’t be as taxing an effort.  They may not have experienced the full course of treatment from start to finish (i.e. from evaluation to garment fitting – permitting familiarity with vendors & appropriate compression levels), but they’ll have one less hurdle to overcome – an unfamiliar setting.

3. Mentors – Do you have mentors available? It’s hard to have a check off list for competencies if you don’t have an experienced CLT on staff to administer & assess these competencies. It’s also difficult to give insight or guidance when a difficult case is presented or Cellulitis has never been seen or they don’t have a wound care background & haven’t seen chronic venous insufficiency. Has the mentor attended the same training school as the new hire? While the basics will be the same, the technique or MLD sequence may be slightly different; they may or may not have been trained in the use of ACE bandaging versus short-stretch bandages, etc.

4. Orientation – Are you willing to slowly break them in if they are not familiar with your administrative tasks (i.e. Are you willing to train them in your documentation process until they are comfortable or do you want someone who is ready for a full caseload immediately)?

5. Communication – Repeat what you think you understand during the interview. Communication is key. Even though you may be ready for relief by adding a team member, don’t overlook ensuring mutual understanding of your needs & their experience & ability. Also, don’t overlook communicating expectations. For example, if this is “PRN” position, have you clearly communicated scheduling? Consider this scenario: You hire a “PRN” but don’t want them to be on the clock if they don’t have a patient scheduled. Their hours are 1:00 – 5:30 pm Monday, Wednesday, Friday. If their first patient has been at 2:00 & suddenly you schedule a 1:00 for them, how will they know? Consider the small details during orientation.

Hiring a Lymphedema Therapist to start a new program or to take part of the load can be a great experience for both of you.  Be sure to ask the right questions to ensure you get the perfect candidate & that it’s a smooth transition.

1. Have a mentor. A lot of information is put into the 135-hour (or more in some cases) training course you attend. If the information is new to you, it’s a lot to process & remember. There will be questions that come up when treating patients or things you didn’t learn that you thought you did. A mentor is invaluable. Often times your course instructor can be this person.

2. Begin to treat immediately (& in a traditional setting like outpatient, if possible). Not only will your new skills begin to be honed & perfected while fresh, but if practicing in outpatient, you will get a comprehensive knowledge of treatment from start to finish (including knowledge of vendors & what compression types & levels are appropriate for which patients). If you start in a setting like acute care, on the other hand, a patient may discharge before being ready for compression garments or you may not see lymphedema patients regularly or supplies may be different than you were trained with, etc. A traditional setting will permit you to solidify the basics before being put into a setting requiring creativity & additional knowledge.

3. Practice in a familiar setting. If you’re familiar & experienced in your current work setting, that’s one hurdle you won’t have to jump. But if you’re trying to navigate & adjust to a new setting in addition to applying newly acquired lymphedema skills in that setting, it will be a double challenge. At the very least, ensure you have a mentor.

4. Be conservative in treatment. For example, if a person presents with swelling in both legs, once you determine they’re appropriate for treatment, don’t start by bandaging both legs & the abdomen in your first treatment. Instead, after a comprehensive assessment & history, begin with bandaging the most swollen extremity first. Ensure the patient had no problems or complaints the next visit. If not, then consider progressing to the second leg. If you aggressively bandage, you could overload a person’s cardiac or renal function.

5. Be selective in where you work. If you aren’t able to use your skills in your current work setting & plan to seek new employment, be selective about where you choose to work. No matter how excited or anxious you are to put your new skill set to practice, if you get an uneasy feeling during the interview process (or even immediately after hire), consider working elsewhere. Red flags might include:

• tension between employees or a sense of communication breakdown
• the impression they are overwhelmed & anxious to get relief
• a lack of receptiveness to a request for guidance or supervision
• insufficient time given to learn their documentation process

Being a Certified Lymphedema Therapist is a rewarding area of expertise.  Congratulations on your accomplishment!  And, starting out with the right resources & support can make it even more fulfilling.

Sinusitis is a chronic or recurring inflammation of the mucous membrane layers of the paranasal sinuses. It occurs when foreign bodies (such as pathogens or allergens) enter the nasal cavity & are recognized by the immune system, triggering an allergic reaction or infection.¹ So, how can Manual Lymph Drainage help?

Interestingly, our recognition today of Manual Lymph Drainage came from sinusitis & research done by Dr. Emil & Estrid Vodder. In the early 1930s, Dr. Vodder & his wife were working as massage physical therapists on the French Riviera & treating several Englishmen & women with chronic colds. These patients had one thing in common: swollen neck lymph nodes. Despite the lymphatic system being virtually ignored in that day, Dr. Vodder decided to treat the swollen nodes with massage & he did so with great results.²

When a foreign particle or bad antigen (such as a virus, bacteria, allergen, etc.) enters the body through the nose, it encounters the body’s first line of defense: a mucosa lining. This lining has lymphoepithelial tissue which contains lymphocytes.³ These lymphocytes (white blood cells) react & develop antibodies (immunoglobulins) in the lymph nodes specific to this particular “invader.” So, the next time it enters the body, it encounters a mounted defense (a second & third line of defense: inflammation & targeted attack). This time the body reacts by triggering special immune cells (mast cells) which have been coated with this antibody. The mast cells target the invader & give off histamine which dilates the blood vessels in the nose, causing swelling. The dilation increases blood flow to speed up the transport of nutrients, oxygen & lymphocytes. And, paranasal mucus secretion is increased. This swelling & secretion can block drainage in the nasal cavity & fluid pressure builds up in the sinuses leading to sinus headaches⁴ & congestion that can trigger sinus infections. (This process accounts for the redness, swelling, heat & sometimes pain associated with inflammation.)

Manual Lymph Drainage helps by decongesting the tissue through increasing the speed of lymphatic flow.⁵ Additionally, immunity is bolstered because pathogens are hastened to lymph nodes where they are filtered & contained & production of antibodies is increased.

It’s important to note that while an acute inflammation due to a pathogen is always a contraindication for MLD, acute allergic reaction is as well because the histamine generated from the body’s response (which is localized) can be spread throughout the body, becoming systemic. (Lymph angions temporarily spasm to reduce lymph transport & contain the invader until the body is able to gain the “upper hand.”) If a person has had a sinus infection, for example, but they have been on an antibiotic for approximately 2-3 days & symptoms are improving, then MLD can be provided. In the case of chronic ear, nose & throat infections or allergies, MLD can help for reasons noted above.⁶

 

Sources:

¹Tortora, G., Grabowski, S. (1996). Principles of Anatomy & Physiology (8^th ed.), p. 703. New York: HarperCollins College Publishers.

²Wittlinger, H., Wittlinger, G. (1998). Textbook of Dr. Vodder’s Manual Lymph Drainage (6^th ed.), pgs. 17-21. Germany: Karl Haug Verlag.

³Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 8. Germany: Urban & Fisher.

⁴Tortora, G., Grabowski, S. (1996). Principles of Anatomy & Physiology (8^th ed.), p. 176. New York: HarperCollins College Publishers.

⁵ Tan, I., Maus, E., Rasmussen, J., Marshall, M., Adams, K., Fife, C., Smith, L, Chan, W., Muraca, E. (2011).  Assessment of Lymphatic Contractile Function After Manual Lymph Drainage Using Near-Infrared Fluorescence Imaging, Archives of Physical Medicine & Rehab, 92(5), 756-764.

⁶Kasseroller, R. (1998). Compendium of Dr. Vodder’s Manual Lymph Drainage, pgs.142-143, 174-175. Germany: Huthig GmbH.