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.

This post is intended primarily for therapists to serve as a resource, giving insight into how lab values can be helpful.

A person may be referred for lymphedema treatment but have a mixed condition of lymphedema plus another diagnosis (for example, Congestive Heart Failure or Renal Dysfunction). How is treatment affecting them? Sometimes a patient may be referred but not be appropriate for treatment. Besides your medical history & assessment, lab values can provide you with confirmation of why you shouldn’t be seeing them or how your treatment is affecting them.  Consider these scenarios:

Scenario 1 – A patient is in the hospital & is referred for lymphedema treatment. You notice they have a diagnosis of congestive heart failure. Should you treat them? If heart failure is the underlying cause of swelling, we know the answer is no; once the condition is medically managed, their swelling will reduce.  But what if heart failure is co-existing with another component causing lymphedema?

Scenario 2 – How about a person with lymphedema who has one kidney? You might have concerns moving fluid may overwhelm their renal function & induce renal failure. What resource can you use to monitor a patient’s tolerance?

Scenario 3 – A person presents with soft, symmetrical, bilateral leg swelling that includes the thighs & abdomen. That in itself is a warning sign but what else might you use to determine the underlying cause & give reason for not treating them?

The answer to these questions lies in the use of lab values. These are especially helpful in an acute care setting but they may beneficial in other settings as well. If you have lab values as a reference, when reviewing them ask, “Are these values high, low or normal?” “Are they trending up or down?” Use the pattern seen the past couple of days to determine not only if they are stable enough to tolerate treatment but to monitor how they are tolerating treatment once it has begun. If the answer indicates a decline in function, treatment should be delayed & the patient re-assessed later for appropriateness.

Some of the most common & helpful lab values include:

Brain Natriuretic Peptide (BNP) – A hormone secreted by the heart as a result of volume overload.  Range: >100 pg/dL indicates heart failure is present.

Blood Urea & Nitrogen (BUN) – Urea & nitrogen are formed in the liver due to breakdown of dietary protein which is excreted in urine. BUN measures liver metabolic function & the excretory function of the kidneys.  Range: >20 mg/dL can indicate congestive heart failure or myocardial infarct.  <6 mg/dL can indicate malnutrition & liver failure.

Creatinine – A by-product of muscle metabolism & an indicator of renal function.  Range: >1.3 mg/dL may be a result of renal dysfunction or congestive heart failure.

Albumin (ALB) & Prealbumin (PAB) – Albumin is the primary protein for maintaining colloid osmotic pressure in the vascular & extravascular spaces. It prevents fluid from leaking into the interstitium. Low levels of albumin leads to peripheral edema &, potentially, hypotension. It is often used as an indicator of malnutrition as it is a more readily available test.  However, it has a 21-day half-life & is slower to respond to nutritional changes. Prealbumin is the better indicator of nutritional status because it changes more quickly.  Albumin Range: < 3.5 g/dL can indicate infection, inflammation & malnutrition.  Prealbumin Range: < 19 indicates malnutrition.

References:

Smith-Gabai, H. (2011). Occupational Therapy in Acute Care. Bethesda, MD: American Occupational Therapy Association.

Malone, D., & Lindsay, K. (2006). Physical Therapy in Acute Care. Thorofare, NJ: SLACK Incorporated.

Is all swelling lymphedema?

No.  There are two main categories of lymphedema: Primary & Secondary.  In these conditions, a defining characteristic is an accumulation of protein-rich fluid.  There is a third category of swelling that is edema & typically there is an underlying medical issue in this case.  To further explain:

Primary Lymphedema is an abnormal development of the lymphatic structures leading to poor lymphatic drainage.  This abnormal development includes any of these forms:  Aplasia (lymphatic channels haven’t been developed or are absent); Hypoplasia (underdeveloped lymphatic structures with lymph nodes being less in number &/or size); Hyperplasia (too many lymphatic structures with abnormal valves contributing to reflux).  Primary lymphedema is a congenital defect that can appear at birth or later in life.

Secondary Lymphedema is more common & a condition that is acquired due to trauma to the lymphatic system (such as from surgery, cancer treatment, infections, lymph node removal, Cellulitis, etc.).  In the United States, breast cancer is the leading cause of secondary lymphedema.  World-wide, the leading cause is Filariasis.

Additional related conditions that can lead to an abnormal lymphatic state include Lipedema, Obesity, Chronic Venous Insufficiency, Chronic Regional Pain Syndrome, Dependent positioning & Immobility (such as after a stroke or spinal cord injury), Congestive Heart Failure, Malnutrition & Kidney Disorders among other conditions.

1. National Lymphedema Network (www.lymphnet.org)

“NLN” is an excellent resource for education & keeping up with lymphedema news.  It covers information ranging from research & case studies to insurance & news.  To have the most in-depth access, you must be a member.

2.  Lymphoedema.org (http://www.lymphoedema.org/)

The Lymphoedema Support Group is a national support group in the United Kingdom which exists to educate patients. (Notice the spelling of “lympoedema” is the common European version of lymphedema.)

3.  LymphActivists.org (http://www.lymphactivist.org/)

This is a site developed by the husband of patient who experienced cancer & subsequent lymphedema.  Its purpose is to serve as a resource for patients & therapists to navigate the insurance world & also be a resource for lymphedema education.

4.  Lymphedema People (http://www.lymphedemapeople.com/)

Resource created by patients for patients.

5.  Step Up-Speak Out (www.stepup-speakout.org)

A site created by women with post-breast cancer lymphedema to provide education & resources to patients & others.

6.  European Society for Lymphology (http://www.lymphology.eu/)

Primarily a resource for medical professionals, this site contains up-to-date articles on Lymphedema & a free online journal.

7.  Lymphedema Treatment Act (http://lymphedematreatmentact.org/)

Founded by The Lymphedema Advocacy Group, this site is dedicated to maintaining up-to-date information on the Lymphedema Treatment Act.  (The Lymphedema Treatment Act is legislation HR3877, designed to improve Medicare health insurance coverage for patients with lymphedema.)

8.  American Lymphedema Framework Project (https://www.alfp.org/)

A partner in the larger International Lymphoedema Framework, the “ALFP” is dedicated to raising awareness & improving the care of patients with lymphedema.

9.  American Cancer Society (http://www.cancer.org/search/index?QueryText=lymphedema)

This link provides a resource specifically for cancer-related lymphedema.

10. Lymphology Association of North America (https://www.clt-lana.org/index.html)

“LANA” is a website primarily for therapists but it’s a great place to discover additional resources & to find therapists who have been through a lymphedema training school (135 hours or more of training) AND have passed the national certification exam.  (The latter isn’t necessary to treat lymphedema patients but it indicates a higher level of experience.)  Unfortunately, the site isn’t always current with therapists who have passed their exam.

And one to grow on:

Lymphatic Education & Research Network (http://www.lymphaticnetwork.org/)

The Lymphatic Education & Research Network is an organization dedicated to doing what their name suggests: Lymphatic research & education.