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.

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.

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.