Lymphedema Awareness Atlanta Georgia

Lighthouse Lymphedema Network

11th Annual Lymphedema Education & Awareness Program

An educational and awareness conference for patients, caregivers and professionals!

at Piedmont Hospital

Richard H. Rich Auditorium

1968 Peachtree Road, NW, Building 77

Atlanta, Georgia

Saturday, October 18, 2008

7:30 am - 5:30 pm

Program includes:

What to expect of tissue after radiation? What is the physiology response of radiation? What does radiation do to the lymph nodes? - Peter Rossi, MD

How does vascular flow affect the lymphatics? - Ken Harper, MD

Expectations of surgery. - Christopher Hart, MD, FACS

The Lymphatic System, Wound Care, Infections and Treatment - Paula Stewart, MD

Parent Networking

Aquatic Exercises

The Connection of obesity and increased swelling in people with lymphedema and lipedema.

And more.

Additional information and registration form:

Lighthouse Lymphedema Network

Lighthouse Lymphedema Network

I wanted to make a special announcement that the Lighthouse Lymphedema Network
is now on Facebook.

You can join by going to: Lighthouse Facebook

There is also an area where you can post and participate.

AND - don't forget our upcoming program in October.

see the details for that at:

Lighthouse Lymphedema Network

**yes, I'm on it too :-)

Pat

Finding a Lymhedema Therapist

Finding a Lymhedema Therapist

How To Find a Lymphedema Therapist

It is important for the lymphedema patient to understand that there is an important difference between what we know of as massage therapy and the type of decongestive therapy that is the protocol treatment for lymphedema

Traditional massage therapy is not treatment for lymphedema.

This page will

1.) Explain the difference
2.) Link you to pages wherein you can locate a certified and properly trained lymphedema therapist in your area.

Pat

Schools of lymphedema therapy

To locate a therapists click on URL of school
From here you can locate locate and link to therapists all over the US, Canada, the United Kingdom, Ireland, Greece, Australia, New Zealand and Singapore

VODDER SCHOOL
Home Page: Therapist Finder:

Dr. Vodder School - North America PO Box 5701 Victoria, British Columbia, V8R 6S8 Tel: (250) 598-9862 Fax: (250) 598-9841

KLOSE TRAINING AND CONSULTING
LYMPHEDEMA THERAPY CERTIFICATION

Home Page:
Find a Therapist

Complex Lymphatic Therapy Courses - Casley-Smith Method

Home page:
CLT Courses 115 Leyden Street Decatur, GA 30030
Phone: 678-596-1785
CLTcourses@cs.com

ACADEMY OF LYMPHATIC STUDIES
Home Page:
Find a Therapist:

Norton School of Lymphatic Therapy
Home Page

Find a Therapist

Coast to Coast School of Lymphedema Management
Home Page
Find a Therapist
e-Mail: Information@lymphedemamanagement.com

Lymphology Association of North America
Home page:
Find a Therapist:

nATIONAL lYMPHEDEMA nETWORK
National Lymphedema Network
Find a Therapist

MLD UK
Manual Lymphatic Drainage in the United Kingdom
http://www.mlduk.org.uk/ Email: admin@mlduk.org.uk

CASLEY-SMITH-Australia

Home Page:
List of Therapists


Complex Lymphatic Therapy Courses US
http://www.casley-smith-lymphedema-courses.org/index.html

Traditional Massage Therapy in the Treatment and Management of Lymphedema
By Joachim Zuther, MT, PT

Editor's note: Joachim Zuther is the founder and director of the Academy of Lymphatic Studies in Sebastian, Florida. Mr. Zuther received his massage therapy degree in 1982 and his physical therapist degree in 1984, both from the School for Physical Therapy and Massage in Ulm, Germany.

Lymphedema is a common condition caused by a reduction in the transport capacity of the lymphatic system. The lymphatic system in the affected area is unable to respond to an increase in lymphatic loads. Massage therapy increases the amount of lymphatic load and can have negative effects on lymphedema if applied incorrectly. This article discusses the differences between massage therapy and the techniques known as manual lymph drainage (Vodder Technique) and the proper application of massage therapy when lymphedema is present.

Lymphedema is defined as high-protein edema - an accumulation of water and protein in the tissues, caused by a decrease in the transport capacity of the lymphatic system. Lymphedema may be mild, moderate or severe; most often, it affects the extremities, but can also be present in other parts of the body.

Lymphedema can be classified as primary or secondary. In primary lymphedema, transport capacity is reduced as the result of a congenital malformation in the lymphatic system.6 Primary lymphedema may be present at birth, but more often develops later in life, with or without obvious cause. Secondary lymphedema is more common, and is caused by surgical interventions involving the lymphatic system. Lymph node dissections, radiation therapy, or incisions that disrupt the natural pathways of the lymphatic system affect the ability of the lymphatics to drain lymphatic loads out of the affected extremity. Secondary lymphedema may arise immediately after surgery or years later.

What Are Lymphatic Loads?

The lymphatic system is not a closed circulatory system; it works according to the one-way principle. Its main purpose is to drain from the interstitium substances that cannot be absorbed by the venous end of the blood capillaries. These substances, called lymphatic loads, consist of water, protein, cells and fat.5

What Is the Transport Capacity of the Lymphatic System?

Transport capacity is the highest possible lymph flow per unit of time.4 The relation of the physiological resting lymph flow to the transport capacity of a healthy lymphatic system is approximately 1:10.7 This means that the lymphatic system is able to transport 10 times the volume of the normal amount of lymphatic loads. When primary or secondary lymphedema is present, the transport capacity of the lymphatic system falls below the physiological level of water and protein load (mechanical insufficiency).

Massage Therapy vs. Manual Lymph Drainage (MLD)

The term massage means “to knead” (Gr: massain) and is used to describe forms of “classical” or “Swedish” massage.10 The word is often misused to describe the techniques of manual lymph drainage, which is a gentle, manual treatment technique used in combination with compression therapy, skin care and decongestive exercises. The techniques of MLD are used to effectively treat primary and secondary lymphedema1 and postsurgical and posttraumatic swelling. Migraine headache, chronic venous insufficiencies and edema of other genesis present additional indications. MLD also has a detoxifying effect.

If applied correctly, MLD increases the activity of lymph vessels and moves interstitial fluid; it exerts little pressure on the skin3 and does not cause any increase in local arterial blood flow.

Effects of Massage Therapy on the Skin

The basic strokes used in massage (e.g., petrissage, effleurage, tapotement, vibration and friction) are generally applied with more pressure than manual lymph drainage techniques. The effects of massage strokes are not limited to suprafascial tissues (e.g., the skin), but also cause reactions in subfascial areas such as muscles, tendons and ligaments. Massage strokes can increase local arterial blood flow and venous and lymphatic return, and can also loosen subcutaneous adhesions.

Many massage therapy publications list edema as one of the indications for these techniques.8 This statement, while correct, is often misleading if the distinction between edema and lymphedema is not established. Edema is suprafascial tissues can be caused by various problems, including inflammation or impaired venous return (valvular insufficiency, pregnancy, or prolonged sitting and/or standing). With edema, the lymphatic system remains intact but is overloaded. This condition, called dynamic insufficiency, results in the accumulation of water in the tissues. Massage therapy may be beneficial for some forms of edema, but is contraindicated for others. It should not be applied without prior consultation with a physician.

On the other hand, lymphedema is always caused by mechanical insufficiency of the lymphatic system; water and protein accumulates in the tissues. As discussed earlier, in the case of mechanical insufficiency, the transport capacity of the lymphatic system falls below the physiological level of water and protein load and is not able to appropriately respond to an increase in lymphatic loads.

Negative Effects of Massage Therapy on Lymphedema

Most massage strokes cause an increase in arterial blood flow (active hyperemia) in skin areas where such techniques are applied. Active hyperemia is accompanied by an increase in blood capillary pressure and subsequent increase in ultrafiltration of water in the area of the blood capillaries. This process results in more water accumulating in the interstitial spaces. Water represents a lymphatic load. Due to mechanical insufficiency, the lymphatic system will not be able to manage this additional water load. If massage therapy to lymphedemateous tissues, an increase in swelling may result.

Additionally, superficial lymphatics are extremely vulnerable to external pressure. Traditional massage techniques can cause focal damage to anchoring filaments and the endothelial lining of lymph vessels.2 This possible damage to lymphatics, and the potential increase in arterial blood flow, must be avoided.

Conclusions

If lymphedema is present, the application of massage therapy is contraindicated in the affected extremity and the trunkal area bordering the extremity (ipsilateral trunkal quadrant). Massage therapy is also contraindicated in these areas in patients who have undergone surgery involving the lymphatic system, but when lymphedema is not yet present (latency stage of lymphedema).

This is often the case in postmastectomy/lumpectomy patients who have also undergone removal or radiation of the axillary lymph nodes. The absence of visible lymphedema in these patients indicates that, although reduced by the surgical procedure, the transport capacity of the lymphatic system is still sufficient enough to remove water and protein from the tissues. The balance between the reduced transport capacity of the lymphatic system and the lymphatic loads may be fragile, and any additional disturbance may trigger the onset of lymphedema.
As previously discussed, massage therapy increases the lymphatic load of water (and often cells), and may further decrease the transport capacity of the lymphatic system by causing additional damage to those lymphatics still intact following surgical procedures.

In patients with primary lymphedema affecting one leg, massage therapy should not be applied to the contralateral extremity, since malformation of the lymphatic system may also be present in this leg.5

The application of massage techniques (those discussed, and any technique that may cause an increase in arterial blood flow) in lymphedemateous limbs and bordering trunkal quadrants may trigger the onset of lymphedema or worsen existing lymphedema.
In instances of upper-extremity lymphedema, massage therapy may be applied safely to the lumbar/gluteal area and to the lower extremities. Negative effects on lymphedema may result if massage strokes are apllied to the neck/upper trapezius area. Likewise, neck, thorax and upper-extremities may be treated with massage when lower-extremity lymphedema is present; the lumbar and gluteal areas on the opposite side, and the unaffected lower extremity, present areas “at risk” and should be treated with caution.

References
1. Consensus document of the International Society of Lymphology Executive Committee: The diagnosis and treatment of peripheral lymphedema. Lymphology 1995:28, pp113-117. 2. Eliska O, Eliska M. Are peripheral lymphatics damaged by high-pressure manual massage? Lymphology 1995:28, pp21-30. 3. Földi E. Massage and damage to lymphatics. Lymphology 1995:28, pp1-3. 4. Földi E, Földi M, Clodius L. The lymphedema chaos. Ann Plast Surg:22, pp505-15. 5. Földi M, Kubik S. Lehrbuch der Lymphologie. Gustav Fischer Verlag, Germany 1999. 6. Greenlee R, Hoyme H, Witte M, et al. Developmental disorders of the lymphatic system. Lymphology 1993:26, pp156-68. 7. Olszewski W. Peripheral Lymph: Formation and Immune Function. CRC Press, Boca Raton, FL 1985. 8. Tappan F. Healing Massage Techniques. Appleton and Lange 1988. 9. Weissleder H, Schuchhardt C. Lymphedema Diagnosis and Therapy. Kagerer Kommunikation, Bonn 1997. 10. Zuther J. Treatment of lymphedema with complete decongestive physiotherapy. NLN Newsletter 1999:11(2).

Lymphedema Compression Pumps

Put a crowd of lymphedema patients, therapists and doctors together and nothing will start a heated debate like the topic of using pneumatic compression pumps for the treatment of lymphedema.

Compression pumps were at one time a standard of treatment for lymphedema. These older types referred to simply as compression pumps consist of an inflatable garment for the arm, leg, or foot and an electrical pneumatic pump that fills the garment with compressed air. The garment is intermittently inflated and deflated with cycle times and pressures that vary between devices. These antiquated devices have been replaced by intermittent/ sequential pumps which consist of numerous chambers that inflate one at a time while moving up the arm or leg. Due to complications such as genital lymphedema and possible further damage to existing superficial lymphatics, many patients and medical professionals are no longer in favor of using compression pumps to treat lymphedema.

Time for a new dialogue and re-evaluation?

Today, however, there is a new generation of compression devices coming in to the market that offer the possibilities of a safe and effective addition to our treatment arsenal.

My hat is off to two companies in this regard.

First, Tactile Systems for their Flexitouch Device and BioCompression for its development of pneumatic compression therapy that uses the Reid Sleeve Optiflow insert which has been demonstrated to not damage the superficial lymphatics.

Factors for Consideration in Using a Compression Pump

The question about compression pumps is not whether they are effective in the movement of fluid. This has been clearly demonstrated and without a doubt they are extremely effective. The central problems are the possible complications. The clinically demonstrated complications as mentioned above are (1) genital lymphedema because devices have not cleared the abdominal lymphatics before use of the pump and (2) damage to the superficial lymphatics. It is also my personal opinion that the use of pneumatic compression devices must not be marketed as a replacement for manual decongestive therapy by a certified lymphedema therapist or for a substitution in the use of compression bandaging… Rather, it should be used as adjunct for maintenance and should be included in the overall patient self-care program.

It is also important to understand the difference between treatment for arm lymphedema versus leg lymphedema. It is my utmost desire to provide important and independent information for patients as they decide whether or not to use a compression device.

Compression Pumps for Arm Lymphedema

It has been substantially demonstrated through various studies that the best treatment for arm lymphedema is actually a combination of manual decongestive therapy, compression bandages and the use of a compression pump.

In my personal opinion, I have no problem recommending this treatment modality.

Compression Pumps for Leg Lymphedema

The complications listed above have centered around the use of compression pumps for the leg lymphedema. Hopefully, the two new devices manufactured by Tactile and by BioCompression will resolve these issues.

Those of us with leg lymphedema desperately need some time of additional treatment option that not only helps but that we can feel totally safe using.

Contraindications for the use of a compression pump

A compression pump should not be used if:

You have an active infection
You have a blood clot or deep venous thrombosis
You have kidney or renal failure
You have congestive heart failure
You have body-wide edema
You have plueral effusions (lung fluid)
You have episodes of pulmonary embolism
You have Thrombophlibitis

Should I use a Sequential Pump?

Opinion Article - From a Certified Lymphedema Treatment Therapist

While there have been clinicians, therapists, and patients who have not had good results with pumps and do not recommend their use, hundreds of people have experienced great results with the proper use of the right pumps. Pumps are not for everyone, and success does depend on which pump is used, and the proper application of pumps. Pumps, like prescription drugs, or even like driving a car, if not used properly can cause damage, or will not achieve results. In providing lymphedema therapy for thirteen years, helping hundreds of people, I have never seen some of the problems some people are reporting. Many of the people I have worked with have successfully used their pump for five to ten years with no complications.

THE KEY IS USING THE RIGHT PUMP, THE RIGHT WAY.

Some therapists may tell you that pumps are a waste of money, that they do not work, that they do not help in opening up lymphatic flow, or that pumps make edema worse. Only part of this is true. When any clinician gives you information on clinical treatment, ask to see scientific clinic studies. Many “opinions” have been published, but no scientific clinical studies have been conducted or published that will back up these statements. There are however, many many scientific, clinical, published studies that prove the efficacy of pumps. Pumps also do not assist in opening up the lymphatics, nor were they designed to, nor are the recommended as such. Pumps are to be used as an alternative for bandaging, and MLD is applied to open up the lymphatic system. It is not appropriate for any clinician or patient to deprive you of any treatment that may really help you, by providing you with misinformation. If your disease is not properly treated and managed, serious health complications can occur. If a pump will assist you in accomplishing effective disease management, and your are given misinformation regarding their effectiveness, this is call for serious concern. Pumps have been clinically proven, beyond opinion, to help hundreds of thousands of people worldwide, but it is important to make sure you are a candidate, make sure you use the right pump, and make sure you use your pump correctly. It is not complicated, and I will review pump information below.

When reviewing pumps, look for a pump that contains ten or more chambers, operates on a short thirty-second cycle time, and applies graduated compression. The body operates on a pressure gradient system, so it is essential to obtain a gradient or graduated compression pump. Gradient or graduated means the pressure at the feet or hand is greater than the thigh or shoulder. Pressure starts at 60mmHg, and is about 1.5% less each chamber as compression moves proximal or towards the thigh or shoulder. Pumps that contain more chambers, and operate on a thirty second cycle versus sixty second cycle more closely mimics massage, and do not over compress the superficial lymphatics. Pumps that are not gradient, operate on a sixty second cycle and contain less than ten chambers can cause a reflux of fluid in the distal veins, and damage the superficial lymphatics. This has been proven upon review of pump compression during Doppler Ultrasonography. The result of this is pain, and edema that does not reduce but actually gets worse. Also, pressures should not be set higher than 60mmHg.

Doppler Ultrasonography shows that when external pressures are applied above 60mmHg, venous flow decreases rather than increases. The goal is to increase venous return in order to remove excess edema causing fluid. When venous return decreases, so does lymphatic flow.

Unless you have no other alternative, do not accept a pump from a supplier who is going to ship it to you or drop it off at your door step. Pumps should be set up in your home, and the provider should properly educate you on the proper use of the pump. If your health insurance company requires you to use an in-network provider who will not provide home set-up, have your physician include “home-set-up and patient education”, in his written prescription for your pump.

Pumps should not be applied over compression bandaging or compression stockings. They should be applied for about two hours in the morning, and two hours at night during treatment, and then as needed for continued edema reduction. Pumps should not be used during sleep over night, unless you are hospitalized, and your physician is directly monitoring treatment. I recommend the use of a Reid Optiflow, Jovi-Pak or Tribute for use with sequential pumps. These foam compression binders can be very effective in protecting the superficial lymphatics, and assisting the direction of lymphatic flow. Manual lymph drainage should also be applied either before and after pump therapy, or during pump therapy. If you have genital edema, or edema in the hips waist and abdomen, the LymphaPress pump has a bodysuit appliance that applies compression from the feet to the chest area. This has assisted my patients in significant abdominal reduction of edema.

You should not use a pump if you have edema throughout your entire body, if you have a blood clot, if you have an active infection, if you have (kidney)renal failure, if you have active cancer, if you have congestive heart failure, or if you are not applying manual lymph drainage. Pumps are also not normally recommended for babies, or children under age six.

For further study, information and lists of manufacturers please see:

Compression Pumps for Lymphedema Treatment