Blog - Lymphedema Therapy Source

November 1, 2023 By Rebecca Summers, OT, CLT-LANA, CSR

Compression Garments & Insurance (part 2)

As you know from last month’s blog, the Lymphedema Treatment Act (LTA) was passed in December of 2022. Most of 2023 has been spent with Heather Ferguson & others communicating with legislators & Medicare on what should be included in the bill coverage.

Bill Coverage

On page 45 of the “Medicare and You 2024” handbook,¹ it states if you have a diagnosis of lymphedema, Medicare will cover your medically gradient compression garments (with a physician’s prescription) at 80%. Coverage is for standard, off-the-shelf garments or custom-fitted garments. You’ll pay your 20% (unless you have a supplemental plan). Your part B deductible applies.

The proposed final rule is a more specific.² It states medically gradient compression garments (readymade or custom, Velcro or other) will be covered as well as bandaging supplies. Anyone providing these items must be enrolled with Medicare as a DME supplier & meet supplier standard requirements.

Where You Can Find a Supplier Who Can Bill For Compression Garments

You can use Medicare’s online search tool³ to search for a supplier capable of billing for the items. One concern I have is whether these will be competent fitters (vs standard DME suppliers whose knowledge is typically limited to basic sleeves & hose). Lymphedema Therapy Source plans to use a second business to bill for lymphedema supplies & compression (including pneumatic compression pumps). This will include a lengthy process of becoming an enrolled DMEPOS supplier, becoming accredited, meeting all DME supplier and quality standards, obtaining a surety bond & submitting claims to the appropriate Medicare contractor for DME. (No small task!)

Billing Codes⁴ (see updates at the end of page)

While therapy services are billed using CPT codes, products (or DME supplies) are billed with HCPCS Level II codes. Below is a list of expected codes & descriptions for lymphedema compression items covered by Medicare as a result of the Lymphedema Treatment Act.

HCPCS Codes for Compression Treatment Items:
Compression Hose
A6530 Gradient compression stocking, below knee, 18-30 mmHg each
A6531 Gradient compression stocking, below knee, 30-40 mmHg, each*
A6532 Gradient compression stocking, below knee, 40-50 mmHg, each*
A6533 Gradient compression stocking, thigh length, 18-30 mmHg, each
A6534 Gradient compression stocking, thigh length, 30-40 mmHg, each
A6535 Gradient compression stocking, thigh length, 40-50 mmHg, each
A6536 Gradient compression stocking, full length/chap style, 18-30 mmHg, each
A6537 Gradient compression stocking, full length/chap style, 30-40 mmHg, each
A6538 Gradient compression stocking, full length/chap style, 40-50 mmHg, each
A6539 Gradient compression stocking, waist length, 18-30 mmHg, each
A6540 Gradient compression stocking, waist length, 30-40 mmHg, each
A6541 Gradient compression stocking, waist length, 40-50 mmHg, each

Velcro (or other)
A6545 Gradient compression wrap, non-elastic, below knee, 30-50 mmHg, each*
A6549 Gradient compression stocking/sleeve, not otherwise specified

Compression Sleeves & Gloves
S8420 Gradient pressure aid (sleeve and glove combination), custom made
S8421 Gradient pressure aid (sleeve and glove combination), readymade
S8422 Gradient pressure aid (sleeve), custom made, medium -weight
S8423 Gradient pressure aid (sleeve), custom made, heavy -weight
S8424 Gradient pressure aid (sleeve), readymade
S8425 Gradient pressure aid (glove), custom made, medium -weight
S8426 Gradient pressure aid (glove), custom made, heavy -weight
S8427 Gradient pressure aid (glove), readymade
S8428 Gradient pressure aid (gauntlet), readymade

Other (including treatment supplies)
S8429 Gradient pressure exterior wrap
S8430 Padding for compression bandage, roll
S8431 Compression bandage, roll

There may be changes to some of these codes. For those with an asterisks (*), new HCPCS codes may be assigned when these items are used as surgical dressings (such as in the case of an open venous stasis ulcer).

***UPDATE 11/30/23***

Beginning in 2024, there will be 81 HCPSC codes specifically for lymphedema compression supplies (most will be new).

Where You Can Find More Information

Visit the Lymphedema Treatment Act for more information & an up-to-date status on the bill & its coverage: https://lymphedematreatmentact.org/faqs/.

A special thank-you to Heather Ferguson & her team for their ongoing fight to get the LTA passed.

UPDATE 01/05/24

Lymphedema HCPCS billing codes have been published & are listed here. A person must have one of the following diagnosis codes:

I89.0 (lymphedema, not elsehwere classified)
I97.2 (postmastectomy lymphedema)
I97.89 (Other postprocedural complications and disorders of the circulatory system, not elsewhere classified)
Q82.0 (hereditary/primary lymphedema)

References
¹ https://www.medicare.gov/publications/10050-Medicare-and-You.pdf
² https://lymphedematreatmentact.org/wp-content/uploads/2023/07/LTA-Section-Home-Health-Rule.pdf
³ https://www.medicare.gov/medical-equipment-suppliers/
⁴ LTA Home Health Rule, p. 13

October 1, 2023 By Rebecca Summers, OT, CLT-LANA, CSR

Compression Garments & Insurance Coverage

Even though the legislation was submitted over 10 years ago to government delegates, the Lymphedema Treatment Act is still not widely recognized by most people who have lymphedema. Yet passage of the bill (which was accomplished Dec. 23, 2022) is so important to lymphedema care. It will become effective Jan. 1, 2024. Why is it important to lymphedema?

Lymphedema Care

Lymphedema treatment has two phases. Phase I is decongestion. This is the therapy phase when CDT is administered. (CDT is complete decongestive therapy & involves manual lymph drainage, bandaging, skin care & exercise.) Once maximum reduction is attained in therapy, the next step is fitting with a compression garment (usually for day & night). This is a part of Phase II (the maintenance phase).

Maintenance Phase

Compression garments are mandatory for lymphedema maintenance. Without them, swelling will promptly recur, & the reduction obtained during therapy will be lost. There are a few different types of compression.

Flat-knit (usually custom-made, but readymade is available) – daytime garment
Circular-knit (usually readymade, but custom is available) – daytime
Velcro (commonly used in wound care or as a night option) – day or night
Foam sleeves (nighttime use) – night
(Note: Self-bandaging at night is the textbook recommendation for lymphedema maintenance.)

Recommended Compression

While circular-knit & Velcro can be used in some edema-related cases (such as venous edema) or combination edema-lymphedema cases (such as phlebolymphedema), the recommended compression for lymphedema is custom, flat-knit. One reason is the fact the many lymphedematous extremities don’t fit into the readymade dimensions. Another reason is the way flat-knit garments are made. While other garments provide compression, flat-knit provides the best containment. Flat-knit also aids in softening hardened, fibrotic tissue caused by lympedema. Finally, flat-knit is a thicker fabric less prone to bunching & causing pain in joints (such as ankles & behind knees).

Cost & Insurance

The downside to compression is cost. Compression should be replaced every 6 months (to a year) because it loses its effectiveness as fibers wear out.¹ Many insurance carriers follow Medicare’s guidelines, & until 2024, Medicare won’t cover the cost of lymphedema compression. Here’s where you come in! (For more on cost, see the below video clip.)

Lymphedema Treatment Act (LTA)

The Lymphedema Treatment Act was passed in December of 2022. But the legislation details are still being worked out. Heather Ferguson is the founder of this legislation. She sends out a newsletter with updates. And she needs your help. Please read the below letter, & contact your insurance company. Heather makes it easy for you by providing templates & links.

LETTER: https://ltstherapy.com/wp-content/uploads/2023/09/LTA-1.pdf
Action Item #1: click here
Action Item #2: click here

References
¹ Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 595. Germany: Urban and Fisher. Foldi, M., & Foldi, E. (2012). Foldi’s Textbook of Lymphology (3rd ed.). Urban and Fisher.

September 2, 2023 By Rebecca Summers, OT, CLT-LANA, CSR

Why Would Treatment Not Work (Part 3)

Reason 3 – Medical Staff or the Patient

In parts 1 & 2, we looked at two reasons CDT (complete decongestive therapy) may not work.

Combined edema & lymphedema

Inappropriate application of CDT (such as leaving one of the four components of treatment out, incorrectly applying technique or inadequate frequency).”

In part 3, we’ll look at the medical professionals & the patient’s role.

(photo by Pexels/Leeloo Thefirst)

Medical Doctors

A doctor may incorrectly diagnose a person with lymphedema, or they may overlook another condition causing swelling that is not lymphedema. And/or these other conditions causing swelling may not have been adequately treated. Additionally, compression garments recommended by a physician may not be the appropriate type or the right compression class.

Therapists

Therapists may also be a reason CDT doesn’t work. First, the therapist may not have actually gotten appropriate training (i.e. they may not have attended a 135-hour lymphedema training course in CDT yet say they “treat lymphedema”). Second, they may have attended an appropriate CDT program to treat lymphedema but may not have sufficient experience. According to Foldi,¹ “Therapeutic success cannot be expected if errors are made in administering the treatment. The necessity of daily treatment has already been noted. Furthermore, we must again emphasize that a … therapist who has just received a certificate authorizing him or her to perform CDT is a novice & needs to get experience.” The text continues, “A “10-year rule” states that it takes approximately a decade of heavy labor to master any field!” The following are listed as the most common errors made by therapists.

Gross technical errors (such as failing to remove a bra which causes constriction)
Failure to treat the patient on a daily basis
Failure to apply bandages properly

Patients

Surprisingly, some patients may cause “artificial lymphedema” through constriction of a tourniquet or other means (& in some cases, deny it for reasons such as disability income). But in most situations (in my experience), failure on the part of a patient is due to non-compliance. Non-compliance can be not showing up for appointments, removing bandages to shower, not performing exercises prescribed, or not wearing a compression garment (including separate daytime & nighttime garments which are typically needed for pure lymphedema).

References
1 Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 281-282. Germany: Urban and Fisher. Foldi, M., & Foldi, E. (2012). Foldi’s Textbook of Lymphology (3rd ed.). Urban and Fisher.

August 1, 2023 By Rebecca Summers, OT, CLT-LANA, CSR

Why Would Treatment Not Work (Part 2)

Reason 2 – Inadequate Treatment

In part 1, we looked at one reason CDT may not work. In part 2, we’ll look at the important components of lymphedema treatment.

Complete Decongestive Therapy (CDT) involves (4) pillars of treatment:

1. Manual lymph drainage (MLD)
2. Multilayer compression bandaging
3. Skin Care
4. Exercise

If one of these is lacking (particularly 1, 2 & 4), a patient will not maximize their potential. Let’s look at each of these individually.

Manual Lymph Drainage

The purpose of MLD is to remove the protein in the interstitial tissue space. (The protein accumulation is due to damage of the lymphatic system – from a birth defect or a secondary cause.) Bandaging without MLD might squeeze the “water” from the tissue space, but it won’t remove the protein (neither will diuretics). That’s a specific function of MLD. And if protein attracts water, what will the result be? More swelling.

I’ve recently read & heard that there isn’t proof that MLD works. But there is research to back the efficacy of MLD.

In a 2017 study published in the Lymphatic Research and Biology Journal, near-infrared imaging was used to track a dye (indocyanine green) in nine healthy participants before & after a 15-minute period of MLD followed by a compression garment for 10 minutes applied to the arm. Images were taken at the forearm & elbow. There was a statistically significant improvement in the movement of lymph fluid & the speed of transport. At baseline, lymph transport speed was 6.7 millimeters per second (mm/s). This increased to 13.3 mm/s after MLD! Speed increased by 10.5 mm/s after use of a compression garment.³
Another study published in 2011 also used near-infrared imaging to assess the speed of lymph contractile function before & after MLD. Results showed lymph transport speed increased by 23% in symptomatic limbs (ones with lymphedema) & 25% in asymptomatic limbs (ones without lymphedema).⁴

Characteristics of MLD include a gentle, 2-way stretch of the skin (approximately 1 stretch per second⁸) that create a “pulling & shear force.”¹² If too much pressure is applied, anchoring filaments of the initial lymphatic vessels close to the skin’s surface may be damaged. If MLD strokes are performed too fast or too firm, lymphangions may spasm.⁸Frequency of MLD should be daily in Phase I (the decongestion phase).¹ If MLD is not administered correctly or with less frequency than recommended, results will show it.

Multilayer compression bandaging

Compression is an essential part of CDT. According to Foldi’s Textbook,¹ a study from the European Journal of Cancer assessed the outcome of MLD in breast cancer-related lymphedema. The study found that MLD reduces limb volume & dermal (skin) thickness in the upper arm.⁵ In contrast, the 9^th edition of the Munich Cancer Center manual reported a deterioration in arms of women with lymphedema who received lymph drainage but did not wear compression sleeves.

The International Lymphoedema Framework publishes a best practice guideline for compression.⁶ The upper body guideline states, “The application of a compression garment results in constant pressure on the skin when the limb is at rest (resting pressure). When the muscles contract, expand and then relax (e.g. during exercise), they transiently press against the resisting garment and so the tissue pressure in the limb increases temporarily.” This pressure increase “compresses the adjacent dermal lymphatics and because the collecting and larger lymphatics are valved, these vessels pump passively so that lymph flows up the arm without the lymphatics having to contract.” In other words, the resistance provided by compression increases tissue pressure &, as a result, lymph movement.

Other benefits of compression include softening of fibrotic tissue & improving the venous pump function.¹⁰ Foldi states, “In lymphedema, one should always use the maximum compression that is tolerated by the patient.”⁷(A 2016 study found 84 mmHg compression stopped lymphatic flow.⁸ This is extremely high pressure. Compression seldom goes above ~46 mmHg in lymphedema garments & limb size should be considered. Smaller circumferences like fingers & arms will not tolerate the same compression that legs might.)

Compression is an important component of CDT. If it is lacking in the treatment phase or maintenance phase, there will not be sufficient volume reduction or containment. If compression bandages are removed between sessions, refilling will occur. And if bandages are not applied correctly, there can be adverse consequences such as increased swelling or pressure wounds.

Skin Care

Good hygiene & using acidic products more like the skin’s natural pH level will reduce itching & improve skin texture. These will also help mitigate potential infections due to a compromised skin barrier.

Exercise

When the body is at rest, only a minor amount of lymph is formed.¹² Movement is key to lymph creation. Exercise engages the muscle pump. Singing, deep breathing & laughing are excellent ways to engage the diaphragm & compress the most important lymph vessel in the body (the thoracic duct).¹¹ Exercising with compression increases tissue pressure (& so lymph movement) & softens fibrosis in extremities (helping to reduce volume).

In summary, all aspects of CDT are important components. If one is overlooked or administered inadequately, CDT may fail at worst or results may be subpar at best.

References
1 Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 272. Germany: Urban and Fisher. Foldi, M., & Foldi, E. (2012). Foldi’s Textbook of Lymphology (3rd ed.). Urban and Fisher.
2 https://www.lympho.org/publications
3 Lopera C, Worsley PR, Bader DL, Fenlon D. Investigating the Short-Term Effects of Manual Lymphatic Drainage and Compression Garment Therapies on Lymphatic Function Using Near-Infrared Imaging. Lymphat Res Biol. 2017;15(3):235-240. doi:10.1089/lrb.2017.0001
4 Tan IC, Maus EA, Rasmussen JC, et al. Assessment of lymphatic contractile function after manual lymphatic drainage using near-infrared fluorescence imaging. Arch Phys Med Rehabil. 2011;92(5):756-764.e1. doi:10.1016/j.apmr.2010.12.027
5 Williams AF, Vadgama A, Franks PJ, Mortimer PS. A randomized controlled crossover study of manual lymphatic drainage therapy in women with breast cancer-related lymphoedema. Eur J Cancer Care (Engl). 2002;11(4):254-261. doi:10.1046/j.1365-2354.2002.00312.x
6 Moffatt, CJ, et al. International Lymphedema Framework. (p. 13)
7 Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 273. Germany: Urban and Fisher. Foldi, M., & Foldi, E. (2012). Foldi’s Textbook of Lymphology (3rd ed.). Urban and Fisher.
8 Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 526. Germany: Urban and Fisher. Foldi, M., & Foldi, E. (2012). Foldi’s Textbook of Lymphology (3rd ed.). Urban and Fisher.
9 Belgrado JP, Vandermeeren L, Vankerckhove S, et al. Near-Infrared Fluorescence Lymphatic Imaging to Reconsider Occlusion Pressure of Superficial Lymphatic Collectors in Upper Extremities of Healthy Volunteers. Lymphat Res Biol. 2016;14(2):70-77. doi:10.1089/lrb.2015.0040
10 Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 568-569. Germany: Urban and Fisher. Foldi, M., & Foldi, E. (2012). Foldi’s Textbook of Lymphology (3rd ed.). Urban and Fisher.
11 Shields, J. (1992). Lymphology, v25, n4, Dec. 1992, p. 147* & Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 550. Germany: Urban and Fisher. Foldi, M., & Foldi, E. (2012). Foldi’s Textbook of Lymphology (3rd ed.). Urban and Fisher.
12 Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 198. Germany: Urban and Fisher. Foldi, M., & Foldi, E. (2012). Foldi’s Textbook of Lymphology (3rd ed.). Urban and Fisher.
* https://lymphaticyoga.net/deep-breathing-and-the-lymphatic-system/ cites Dr. Shields as saying, “Deep diaphragmatic breathing stimulates the cleansing of the lymph system by creating a vacuum effect which pulls the lymph through the bloodstream.” I cannot find this statement in the cited article posted by the author. (https://journals.uair.arizona.edu/index.php/lymph/article/view/17643/17366)

July 3, 2023 By Rebecca Summers, OT, CLT-LANA, CSR

Why Would Treatment Not Work? (Part 1)

Once in a while, lymphedema treatment may not work for an individual. Why would that be? One reason may be the type of swelling.

(Disclaimer: I’ve never experienced a case when properly administered lymphedema treatment did not work & the person had pure, uncomplicated lymphedema.)

Pure vs combined forms of lymphedema

Lymphedema can be pure & uncomplicated, or it can be combined. Pure, uncomplicated lymphedema means primary injury to the lymph system (such as lymph node removal). Combined means a combination of edema & lymphedema.

Lymphedema vs edema in combined forms

Swelling has different causes. When the swelling is caused by a damaged lymphatic system allowing protein to accumulate, it is lymphedema. When the lymphatic system is intact (whether there is protein accumulation or not), it’s edema. Another way of describing swelling is to say: One cause of swelling is lymphedema. Everything else is edema. Knowing what type of swelling a person has & why will impact treatment & treatment outcome.

“It must be emphasized that after the diagnosis of lymphedema has been made & its etiology has been determined, a comprehensive examination is necessary in order to detect possible accompanying diseases.” ¹ (Pexels photo by Maksim Goncharenok)

Lymphedema has one cause: A damaged (or blocked) lymphatic system. Edema has numerous possible causes (trauma, post-op swelling, infection, heart or kidney problems, liver or dietary problems, vein problems, hormones, etc.) While aspects of lymphedema treatment (such as bandaging) may help edema in some cases, the cause of edema must be determined & medically treated to resolve.

“If accompanying diseases [causing edema] are undiagnosed &/or untreated, CDT [complete decongestive therapy or lymphedema treatment] will not be successful.” ² (In some cases, treating someone can even be a contraindication until the edema & its cause has been treated.)

Reasons Lymphedema Treatment May Not Work

Reason 1 – It’s a Combined Form
It is possible for a person to have both lymphedema (an impaired lymph system) & edema (non-lymphatic cause of swelling) at the same time. (It is also possible for chronic edema to cause a secondary lymphedema!) While lymphedema treatment will improve the lymphedema type of swelling, it will not resolve the edema or fix the problem causing it (such as heart or kidney failure, etc.). The medical cause of edema must be discovered & medically treated to resolve the edema.

In combined form (when lymphedema & edema occur together), lymphedema treatment should improve the lymphedema. But the edema will still create an influx of fluid until the edema cause is medically treated (& adequately treated).

References
^{1, 2} Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 257, 281. Germany: Urban and Fisher. Foldi, M., & Foldi, E. (2012). Foldi’s Textbook of Lymphology (3rd ed.). Urban and Fisher.

June 1, 2023 By Rebecca Summers, OT, CLT-LANA, CSR

Breast Cancer: What to Expect in Treatment

If you or your doctor decide you need to see a therapist for lymphedema, what should you expect? And if you do get treatment, will it work?

In the Beginning

The first session will be an evaluation to assess the status of your lymphedema. A therapist will gather background information such as your past medical history and take baseline measurements. They may also take photos (particularly if you have wounds). This session will enable the therapist to establish a plan of care outlining what they plan to do to in treatment and collaborate with you on goals.

Phase I – Complete Decongestive Therapy

Subsequent sessions will involve treatment and education. This is Phase 1. Treatment for lymphedema is complete decongestive therapy (CDT) which includes manual lymph drainage, bandaging, skin care and exercise. Let’s look at each one of these components.

(Hands Massage photo by Andreas 160578-Pixabay)

Manual lymph drainage is a medical massage used to stimulate lymphatic fluid movement. It is used to decongest the swollen area and re-route fluid to healthy lymph nodes when appropriate. It’s a slow, rhythmic manual technique that has numerous benefits outside of lymphedema for general health and wellness. But in this case, it is specifically used to remove stagnant lymph fluid causing swelling in an extremity. The massage is also very gentle and light so as to avoid damaging the fragile lymphatic vessels that sit near the skin’s surface. The exception is when there is fibrotic tissue (tissue that has become firm due to congestion and inflammation caused by a damaged or impaired lymphatic system.
Bandaging is an essential part of treatment. It is done with several layers of special bandages called short-stretch bandages (this type of compression bandage stretches a short distance when pulled). These are applied over a padding layer and provide resistance during movement or exercise. The bandages help break down fibrotic tissue and stimulate lymph movement. But they also prevent fluid that has been removed from refilling an area that is being decongested.
Skin care is important because your skin is a barrier to bacteria. And skin changes are seen in lymphedema as the condition progresses. Initially, skin becomes thicker. Later papules (bumps), hyperkeratosis (excess skin growth), discoloration and other skin changes can occur. As this continues, your risk of a cellulitis infection goes up. Education about appropriate skin products and skin protection should be a component of skin care.
Exercise promotes lymph movement through muscle pumping action. While most any movement is beneficial, deep breathing and use of the involved extremity will likely be part of your exercise program.

Phase 2 – Maintenance

At the end of treatment, you will need a compression garment for maintenance (most likely one for daytime and another for night use). This is Phase 2. Some therapists will fit you for these, but many therapists will refer you to someone else who specializes in fitting garments.

Example of a garment (in this case: open-toe, circular-knit hose)

The above is the gold standard and conservative treatment for lymphedema. The next question is: Does treatment work? While there is anecdotal evidence, fortunately, there is scientific research backing the claims of CDT and the individual components of this treatment (and has been for many years).^1-3

Once in a while, treatment may not be effective. Why would this be? We’ll look at that next time.

References
1 Michopoulos E, Papathanasiou G, Vasilopoulos G, Polikandrioti M, Dimakakos E. Effectiveness and Safety of Complete Decongestive Therapy of Phase I: A Lymphedema Treatment Study in the Greek Population. Cureus. 2020;12(7):e9264. Published 2020 Jul 19. doi:10.7759/cureus.9264
2 Foldi Textbook of Lymphology
3 Lymphedema A Concise Compendium of Theory and Practice

April 2, 2023 By Rebecca Summers, OT, CLT-LANA, CSR Leave a Comment

Breast Cancer: Preventing Lymphedema

Is there any science behind it?

There are several recommendations for a person at risk of developing lymphedema and for those who have lymphedema (to prevent an exacerbation episode). But in the past year, I’ve heard some people say there’s no evidence backing up these precautions. Is that true?

^{RTCNCA, CC BY-SA 3.0 https://creativecommons.org/licenses/by-sa/3.0, via Wikimedia Commons}

Recommendations

First of all, what are the recommendations? The National Lymphedema Network (NLN) has a page of Position Papers (a summary of their position on topics). They have one called “Risk Reduction.”¹ It was established by their medical committee in 2012. It needs updating but the overall recommendations haven’t changed. If you have lymphedema, the NLN recommends you:

1. Have regular check-ups with a lymphedema specialist (likely to take measurements and assess any problems, garment fitting, etc.)
2. Notify your healthcare provider of any changes in your arm
3. Maintain a healthy body weight (or lose weight if obese)
4. Exercise (see the blog post on exercise here)
5. Wear your compression garments and replace them every 6 month to 1 year
6. Prevent cellulitis infections (and immediately treat any signs or symptoms of infection)
7. Maintain good skin care
8. Avoid trauma of the affected arm (such as needle sticks, bug bites, etc.)
9. Avoid constriction of the affected limb (such as tight bands, restrictive clothing, blood pressures)
10. Avoid extreme heat or cold (such as hot showers, sitting in a sauna)
11. Inform any surgeon of your lymphedema if surgery is planned
12. Avoid stasis (i.e. see exercise above and avoid sitting or standing for long periods)
13. Consider consulting a vein specialist for treatment if you have varicose veins or spider veins
14. Wear your compression and move around during air travel (note it doesn’t say “don’t fly”)

If you are at risk for lymphedema (i.e. if you’ve had lymph nodes removed and/or radiation), the guidelines are nearly the same with a few modifications (such as wearing a compression sleeve). These precautions are backed up by the Foldi Textbook of Lymphology² (a source I often reference).

For NLN guidelines, visit www.lymphnet.org.

(Photo by energepic.com/Pexels)

Rationale behind the recommendations

The NLN explains the rationale behind these precautions. However, it also notes there is limited research backing these recommendations. In theory (and many therapists would say in practice), these precautions make sense. Anything that could increase the blood flow will increase the lymphatic load. And anything that increases lymphatic load can increase your risk of lymphedema development or exacerbation. That doesn’t mean you will experience lymphedema or an exacerbation – just that you could.

My thoughts

Based on the theory and based on my experience of treating patients (and when they first developed symptoms of lymphedema), I recommend patients follow these guidelines. Next month, we’ll look at how to monitor your arm for potential lymphedema development or exacerbation based on symptoms. We’ll also learn how to measure your arm for baseline measurements.

References
1 https://lymphnet.org/position-papers
2 Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 268-270. Germany: Urban and Fisher.

March 1, 2023 By Rebecca Summers, OT, CLT-LANA, CSR

Breast Cancer: Why See A Therapist

One word no one wants to hear is “cancer.” And when the diagnosis is given, a million thoughts run through a person’s mind. “Am I going to die?” “Will I lose my hair?” “Will I lose my breast?” As if the questions aren’t enough, the bombardment of medical terms and doctor specialties may ensue.

What’s lymphedema got to do with it?

In this early stage, the thought of potential lymphedema development is not a high priority (if it’s even discussed at all).

I’ve heard many stories from patients who were not told about the potential risk of developing lymphedema after lymph node removal and/or radiation. At a minimum, anyone going through cancer who has a lymph node removed and/or radiation should at least be given a handout on the signs and symptoms of lymphedema, what it is and what to do if signs and symptoms appear. Being given education about cellulitis and receiving baseline limb measurements would be an added benefit.

Photo by Pexels / Anna Tarazevich

How to recognize lymphedema onset

If you’ve been diagnosed with cancer, and you’ve had one or more lymph nodes removed (and/or radiation), you are at risk for developing lymphedema. How do you recognize this swelling condition? Here are signs and symptoms of lymphedema development according to stage:

stage 0 (latency): no visible swelling but the involved area may feel heavy or achy
stage I (reversible): protein begins to accumulate, visible swelling is present, elevation reduces swelling
stage II (spontaneously irreversible): fibrosis (firmness) develops, pitting becomes more difficult, cellulitis infection may occur
stage III (elephantiasis): tissue no longer indents (non-pitting) & becomes more firm, skin changes occur (hyperkeratosis, papillomas), lobules form, cellulitis infections may be common

Next month, we’ll look at recommendations to prevent lymphedema. Is there any science behind those recommendations?

February 1, 2023 By Rebecca Summers, OT, CLT-LANA, CSR

Contraindications to MLD

One of the more popular posts I’ve written is about contraindications to treatment (time when treatment should not be done). Lymphedema treatment includes manual lymph drainage (MLD), multi-layer short-stretch bandaging, skin care and exercise. Both MLD & bandaging have specific precautions.¹

General Precautions

The general precautions for MLD include:
– Active infection (caused by pathogens)
– Untreated cardiac failure
– Renal failure

There’s a relative contraindication for MLD:
– Malignant lymphedema (active cancer is causing the swelling)

Specific Precautions

But there are also specific precautions for MLD depending on where it is performed on the body. A sequence for MLD typically starts at the neck where the fluid drains. It doesn’t matter if swelling is in the legs, arms, head or elsewhere. But not all people will be appropriate for a neck sequence due to specific contraindications. For example, if someone has a cardiac arrhythmia related to an atrioventricular block or “AV-block” (referring to a block of the AV node in the heart’s electrical system). Doing a neck sequence could potentially stimulate the vagus nerve and cause cardiac arrest.

Understanding General Precautions (Active Infection)

So why are the general precautions a concern? In the case of an active infection caused by a pathogen (like bacteria in a cellulitis infection), performing MLD may cause the infection to spread. Fascinatingly, even though arterial & lymphatic flow increases during inflammation, in local inflammation, lymph vessels near the site of infection constrict. Thisprevents bacteria from escaping and entering the rest of the circulation. In performing MLD, this spasm could be relaxed, allowing normal flow to resume. The bacteria might then be allowed to move into the rest of the body & the infection could become systemic (i.e. sepsis).

(Untreated Heart Failure)

In the case of untreated heart failure, the concern is increasing pressure. The pressure in the veins returning blood to the heart near each collar bone (clavicle) is usually low. This is where lymphatic fluid returns to the body’s blood circulation. In untreated heart failure, the pressure is increased in these veins. Stimulating lymph flow with MLD would only add more fluid to a congested area and further increase the pressure. This can contribute to heart damage.

(Kidney Failure)

In the case of kidney failure, there is swelling in the body (often the lower part of the body). MLD would increase the amount of fluid returning to the heart and subsequently to the kidneys, increasing the fluid they must filter. This could overtax them. But the main reason MLD is not performed is because it would be of no use (if swelling being treated is due to kidney failure). That’s because kidney-caused swelling is edema, not lymphedema. The lymph vessels are already working as hard as they can to help get rid of the excess fluid. MLD speeds up lymphatic flow but beyond its normal high-working speed.

(Active Cancer)

In the case of cancer, MLD is a relative precaution. Meaning, there’s some room for discernment. The primary reason for avoiding MLD in the case of cancer is the potential to spread the cancer cells. (Cancer spreads through one of two ways: blood or lymph flow.) However, according to Foldi, molecular biology showed metastasis formation is an active process controlled by the cancer cells themselves. For example, cancer cells secrete a protein called vascular endothelial growth factor C (VEGF-C). ² This is responsible for creating new lymphatic vessels within and around a tumor from existing ones (lymphangiogenesis). Nonetheless, many therapists prefer to avoid the area of the tumor to avoid any potential accusation of / or potential of hastening cancer cell transportation.

It’s also important to know if a patient is receiving adequate cancer treatment and that the cancer is responding. One note: Some suggest avoiding MLD for 2-3 days after chemo to allow the drug(s) to remain in the body and do their job. Others suggest proceeding with MLD to help distribute the chemo throughout the body and to use gloves to prevent transmission of chemo through the skin to the therapist. I would tend to side with the former group (avoid MLD – at least in the area of the body directly affected by the tumor¹). But it’s important to check with the oncologist before providing any treatment.

References
1 Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2^nd ed.), p. 275-276. Germany: Urban and Fisher. Foldi, M., & Foldi, E. (2012). Foldi’s Textbook of Lymphology (3rd ed.). Urban and Fisher.
2 Yan, H., Zhang, C., Wang, Z. et al. CD146 is required for VEGF-C-induced lymphatic sprouting during lymphangiogenesis. Sci Rep 7, 7442 (2017). https://doi.org/10.1038/s41598-017-06637-7

January 1, 2023 By Rebecca Summers, OT, CLT-LANA, CSR

Avoid using Your Arm – Really?

(Part 3)

In this final post on arm use after breast cancer, we’ll take a look at research-backed strengthening. But first, an announcement.

Announcement

from the Lymphedema Treatment Act website

The Lymphedema Treatment Act (LTA) passed Congress³ just before Christmas (passing the House of Representatives – Bill H.R. 3630 on 11/17/22¹ & Senate – Bill S.1315 on 12/23/22²). This means compression garments will be covered by Medicare. Say thank you to your congressmen & women by sending an email here.

Research Says

According to research, how should you safely, progressively strengthen your arm to avoid causing or exacerbating lymphedema? (Disclaimer: This is my general conclusion of the articles I reviewed. Be sure to ask your certified lymphedema therapist what the best protocol is for your situation before engaging in any exercise. Proper form is important, and you should not experience pain with exercise. Stretching & strengthening should be done slowly and with control.)

Step One – Warm Up and Stretch

According to the Pal study,¹ participants started with 10 minutes of cardiovascular warm-up followed by brief stretching of the muscles to be strengthened.

Step Two – Focus on the Core

Participants then did 5-15 minutes of core strengthening (spine stabilizing and abdominal exercises) to prevent injury during arm strengthening.

There are 29 pairs of muscles that make up the core.⁴ The study doesn’t specify which core muscles were targeted. But I anticipate these would include the glutes and paraspinal muscles,² transverse abdominus, quadratus lumborum and obliques.

According to a Sports Medicine article,⁴ proper core strengthening might start with:

Cat camel (or cat cow) stretch. This is a common Yoga stretch done in a quadruped position on the hands and knees.
Abdominal bracing variations (it’s important to properly engage the abs through abdominal bracing exercises before advancing core exercise).
Bird dog pose (alternating arm and leg lifts in quadruped) or planks to engage paraspinal muscles. Modified versions of side planks (such as standing side trunk flexion) might be added to engage quadratus lumborum and obliques before doing floor side planks. (For a more robust and difficult core-strengthening program, visit here.³But know that many people will need to start with easier, modified versions.)

The number of repetitions will vary according to a person’s fitness and status. Anywhere from 5-10 reps of each is a good place to start and working up to 15 reps.

Step Three – Strengthening

Start with no weight or 1 lb. (You can also use a low-resistance Theraband.) If there are no changes in symptoms or lymphedema-onset by the next week, increase weight by 0.5 or 1 lb.

^{(Two 2 Kg. weights image licensed under Creative Commons Zero by Pixabay/Pexels)}

The goal is to reach 3 sets per exercise* in the first 3-4 weeks. As a general rule, increase weight after 4 consecutive sessions lifting the same weight for 10, 10, and 12 reps for sets 1, 2, and 3, respectively.¹

Tips:
1. If there are changes in symptoms, the exercise thought to be causing the problem should be skipped or a lighter weight should be used until symptoms clear up.
2. If 2 sessions are missed, deconditioning may result. Resistance should be reduced and gradually increased as outlined above.
3. Monitor symptoms weekly for changes indicating decline (i.e. swelling, tightness, discomfort, etc.) and measure monthly¹ (or more often if you want to be more vigilant).

*Exercises might include: Chest press, lat pull-down, bicep curl, triceps extension, lateral arm raise, wrist curl ⁵among others.

Step Four – Repeat Step One with Cool Down Stretching (hold positions for 30 seconds)

References (blog)
1 Schmitz KH, Troxel AB, Cheville A, et al. Physical Activity and Lymphedema (the PAL trial): assessing the safety of progressive strength training in breast cancer survivors. Contemp Clin Trials. 2009;30(3):233-245. doi:10.1016/j.cct.2009.01.001
2 https://www.healthline.com/health/paraspinal-muscles#takeaway
3 https://www.mayoclinic.org/healthy-lifestyle/fitness/multimedia/core-strength/sls-20076575
4 https://journals.lww.com/acsm-csmr/Fulltext/2008/01000/Core_Stability_Exercise_Principles.14.aspx
5 Cormie P, Singh B, Hayes S, et al. Acute Inflammatory Response to Low-, Moderate-, and High-Load Resistance Exercise in Women With Breast Cancer-Related Lymphedema. Integr Cancer Ther. 2016;15(3):308-317. doi:10.1177/1534735415617283

References (Lymphedema Treatment Act)
¹ https://www.congress.gov/bill/117th-congress/house-bill/3630
² https://www.congress.gov/bill/117th-congress/senate-bill/1315/text
³ https://buddycarter.house.gov/news/documentsingle.aspx?DocumentID=10733