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Gay Lee Gulbrandson CLT-LANA
LY M P H E D E M A
Wellness Manual
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For Patients and Therapists
PUBLISHER’S
ONLINE
PREVIEW
MAKE A TREATMENT PLAN
CONTROL RISK FACTORS
GO FOR WELLNESS
Copyright © 2014 Gay Lee Gulbrandson – voddermld.com. All rights reserved.
This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or
by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any
information storage and retrieval system without written permission from the copyright owner, except for
brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by
individuals as part of their official duties as U.S. government employees are not covered by the abovementioned copyright. VodderMLD.com is a website of Gay Lee Gulbrandson. Content has been
included in this manual by permission of the respective copyright holders as shown in reference
footnotes and endnotes throughout the text. No claim of ownership or control or exclusivity of such
permitted uses is made hereby.
To request permission, or other information contact:
Gay Lee Gulbrandson 1791 Solano Ave. Suite A8, Berkeley, CA 94707
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info@voddermld.com, www.voddermld.com.
Research Assistant and Collaborator: Evan Meyer
Contributing Artist: Leif Meyer
Editors: Marilyn Miller, Vanessa Ta
Printed in USA
All illustrations used by permission of copyright holders.
All extensive quotes and reproductions used by permission of copyright holder.
ISBN-10: 0985866403
ISBN-13: 978-0-9858664-0-2
Title: Lymphedema Wellness Manual
Sub-Title: Interactive Lymphedema Management for Patients and Therapists
Includes: Lymphedema Wellness Manual Patient Handbook (separate cover)
Contents
ASSESSMENT & PROTOCOL
INTRODUCTION, GUIDE to USES
i
Tab Color
Section 1
LYMPHEDEMA OVERVIEW
1
Section 2
ASSESSMENT
15
Section 3
INDIVIDUAL TREATMENT PROTOCOL
45
Section 4
RISK FACTORS, PREVENTION
57
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TREATMENT & SELF CARE
Tab Color
Section 5
CDT COMBINED DECONGESTIVE THERAPY
81
Section 6
OTHER TREATMENTS
115
Section 7
EXERCISES
133
Section 8
QUALITY of LIFE
145
REFERENCES & RESOURCES
Tab Color
Section 9
RESOURCES
159
Section 10
MLD TOPIC CARDS
179
___ A_ _ APPENDIX A: SOURCES
APPENDIX B: GLOSSARY
211
__ APPENDIX C: REFERENCES
223
__ B _
__ C
__
_
D _ _ APPENDIX D: BLANK FORMS
___ E_
195
__
___ F_ _
_
228
APPENDIX E: CE EXAM QUESTIONS
229
APPENDIX F: INDEX
319
Attached: LYMPHEDEMA Wellness Manual Patient HANDBOOK
Contents IN Detail
INTRODUCTION
Contents
Contents Detail
List of Illustrations
List of Charts
Foreword by Dr. Paula Stewart
i
About This Book
ii
Acknowledgements
iii
Preface
iv
Action Guide
v
Legend
vi
Best Practices Effectiveness Ratings
vii
Abbreviations
viii
x
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Lymphatic System Illustration
Section 1: THE LYMPHATIC SYSTEM & LYMPHEDEMA
1
Lymph System, Lymphedema Overview
Lymphedema Symptoms, Signs
Diagnosis, Treatment & Diagnosis
Interventions for Lymphedema and Evaluations Overview
Lymphedema Treatment Best Practices Consensus Documents
Lymphedema Patient Outlook
Lymph Node Groups, Lymph Drainage, BCRL
Primary vs. Secondary Lymphedema Treatment
Lymph Drainage in Axilla and Breast Areas
Genesis of BCRL (Breast Cancer Related Lymphedema)
Lymphedema Risk After Cancer, Lymphedema Signs
Lymphedema Statistics Prevalence, Incidence, Prophylactic MLD
Lymphedema Statistics Incidence, Epidemiology
Pathophysiology — Causes of Secondary LE
Summary: Treatment & Diagnosis of Lymphedema
2
3
4
5
5
6
7
7
8
8
9
10
11
12
12
Section 2: ASSESSMENT & AUTHORIZATION
15
Intake Process Forms
Health Information & Consent Patient Auth. 1
Notice of Privacy Practices Patient Auth. 2
Photo Release Patient Auth. 3
HIPAA Notice of Privacy Practices Patient Disclosure 4
Patient History & Authorization Patient Entry Option 5
Lymphedema Assessment & Intake Therapist Entry 1
Limb Measurement Forms, Procedures, Calculations Guide
Limb Volume Measurements Therapist Entry 2
Arm Measurement Form Therapist Entry 3
Leg Measurement Form Therapist Entry 4
Letters of Medical Necessity Therapist Entry 5-6
Medicare Codes; Modifiers; Measurements for Progress
16
17
18
19
20
21
23
24
25
26
27
28
29
Contents in Detail
Patient Continuing Report 7
Physician Referral for MLD/CDT 8
Patient Information Handout Tell Me About Lymphedema
Benefits of Documentation, Photographic Documentation
Recognizing Lymphedema, Assessment, NLN Position
Ultrasound (US) Sonogram
Near Infrared Fluorescence Imaging (NIRF)
Tissue Dielectric Constant (TDC)
Bioimpedance (BIA), Bioelectrical Impedance (BIS)
Available Methods to Recognize Lymphedema
LBCQ Assessment Tool
Therapist Assessment Guide for Lymphedema
Patients at Risk for Lymphedema
Classification of Causes of Secondary Lymphedema
Section 3: INDIVIDUAL TREATMENT PROTOCOL (WAP)
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45
48
Action
55
Action
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Wellness Action Plan (WAP), Self-Care, Therapies, & Practices Plan
Patient Questions “My Turn”
30
31
Section 4: RISK FACTORS, PREVENTION
Risk Factors / Risk Reduction & Safe Practices Checklist
NLN Paper: Lymphedema Risk Reduction Practices
Lymphedema After Cancer Treatment
Lymphedema After Cancer Treatment; Factors & Myths
Treatment of LE Related Infections,
Prophylactic Antibiotics for Recurrent Infections
Blood Pressure Cuff, Injections & Venipuncture
Acupuncture
NCI General Precautions List
Air Travel Precautions
Obesity, Weight, Diet and Foods
Lymphedema Stimulating Massage Caution, Contraindicated
Preventing Cellulitis — A personal story
Prevention of Lymphedema: A Study Using MLD
Section 5: CDT Combined Decongestive Therapy
Combined Decongestive Therapy (CDT)
57
61
Action
64
Expert Opinion
64
Expert Opinion
66
Expert Opinion
67
Recommend
70
Some benefits/risks
71
Expert Opinion
71
Expert Opinion
71
Expert Opinion
72
Expert Opinion
73
Expert Opinion
75
Expert Opinion
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78
81
82
Recommend
Safety and Effectiveness of CDT, Benefits
84
Expert Opinion
Head and Neck Lymphedema
84
Expert Opinion
85
Recommend
86
Expert Opinion
87
Recommend
Contraindications
88
Expert Opinion
Modifications
90
Expert Opinion
Deep Tissue Massage Risk
91
Expert Opinion
The Pressure (Intensity) of MLD
92
Expert Opinion
Effects of MLD, Benefits of CDT for BCRL
92
Expert Opinion
95
Recommend
97
Expert Opinion
Skin Care
Wounds and Ulcers
Manual Lymph Drainage (MLD)
Compression Bandaging (CB)
Treatment Standards Guide
Contents in Detail
Compression Garments
101
Recommend
103
Expert Opinion
104
Recommend
Elevation while sleeping
106
Expert Opinion
Diaphragmatic Breathing
107
Recommend
Hydrotherapy
108
Recommend
109
Recommend
Construction
Exercise / Movement And Elevation
Patient Education Ongoing Checklist for LE
Outcomes of CDT
Therapist Competency, and Quality
Therapist Training, Certification, CLT-LANA, NALEA
110
111
112
Section 6: OTHER TREATMENTS (FOR LE)
115
Alternative Practices, Sleep And Relaxation, Yoga
Hyperbaric Oxygen (HBOT)
Low-Level Laser Therapy (LLLT)
Nanocrystalline Silver Dressing
Ultrasound (US)
Hivamat
Surgical Intervention
Drug Therapy
Lymphedema Taping
Intermittent Pneumatic Compression (IPC)
Myth vs. Fact Does MLD Conflict?
116
Section 7: EXERCISES
133
Hydrotherapy Orientation; and Hydrotherapy Exercise
Simple/Self Lymphatic Drainage (SLD)
The Lebed Method / Healthy-Steps
Marnitz Therapy
NLN Position Paper: Exercise
NCI PDQ Document Resource
PAL Study and a Clarification: Weight-lifting with LE
134
Expert Opinion
136
Some benefits/risks
138
Expert Opinion
139
Expert Opinion
139
Expert Opinion
140
Expert Opinion
141
Expert Opinion
Section 8: QUALITY of LIFE (QOL)
145
Psychosocial Support, Considerations
Coping with LE — Patient Support Website
Selected LE Patient Website Resources List
A Positive Approach For Living With Lymphedema
A QOL Psychology of Resiliency and Caring that Works
Standard QOL Survey Choices (Rand I-36)
146
Expert Opinion
147
Expert Opinion
149
Expert Opinion
150
Expert Opinion
154
Expert Opinion
155
Expert Opinion
Section 9: RESOURCES Services & Information
159
Locate a Certified MLD Therapist or Clinic
Selected Lymphedema Patient Information Websites
Selected Lymphedema Medical Information
Selected Lymphedema Research Organizations
Exercise Links, Warm Pools List
Selected LE Supplies Sources
Personal-wear Sources Article
160
Expert Opinion
Effective Unknown
118
Effective Unknown
119
Effective Unknown
119
Effective Unknown
120
Effective Unknown
121
Effective Unknown
124
Not Recommend
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Expert Opinion
127
Effective Unknown
129
161
162
163
163
164
165
Viewpoint
Contents in Detail
Compression Bandaging Comparison Chart
Compression Garment Standards Guide
Compression Garment Safe Use Monitoring — Leg
Compression Garments, Laplace’s Law
Compression Garment Vendor List
Compression Garment & Accessories Web Links
Stages of Lymphedema (LE Staging)
Compare: Obesity, LE, Lipedema, Lipolymphedema
Additional Applications of CDT or MLD
Nutrition Information, Natural Supplements
167
Section 10: MLD TOPIC CARDS Quick Reference
179
168
169
169
170
171
172
173
175
176
Topic Card I. Pathways of the Lymph System
Topic Card II. Fluid Movement in Loose Connective Tissue
Topic Card III. Structure & Function of the Lymph System
Topic Card IV. Loose Connective Tissue
Topic Card V. Effects of MLD
Topic Card VI. Edemas: Applications of MLD
How To Download Next 6 Topic Cards (TCVII through XII)
181
APPENDIX A: SOURCES & SUPPORTING DATA
195
Bibliography
Recommended / Complementary Books Therapists / Clinics
National Lymphedema Network (NLN) Position Papers
National Lymphedema Network (NLN) Publication
American Lymphedema Framework Project (ALFP) Papers
Organizations linked to CDT Best Practices
National Accreditation Program for Breast Centers (NAPBC)
Oncology Nursing Society (ONS): Putting Evidence
Oncology Nursing Society (ONS): PEP Effectiveness Ratings
Oncology Nursing Society (ONS): PEP Quick View for LE
LE Clinic Record-keeping Software
LE Clinic Improvement Model: Performance Audit Tools
Primary Sources: Consensus Documents & Meta-Studies List
196
209
211
Selected Lymphedema-related Terms
Selected Research Statistical Terms
Selected Online Lymphedema Glossaries
211
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185
187
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200
202
203
204
205
206
207
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APPENDIX C: REFERENCES
223
APPENDIX D: BLANK FORMS
229
APPENDIX E: CONTINUING EDUCATION COURSE
310
CE Course Credit Examination for 8 NCBTMB CEs
APPENDIX F: INDEX
312
319
ATTACHED: LYMPHEDEMA Wellness Manual Patient HANDBOOK
40 pg.
List of Illustrations
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Lymphatic System Major Vessels & Trunks
68
Lymph Node Groups and Veins in Chest Area
68
Lymph Drainage in Axilla and Chest Area
Understanding LE: Lymph Drainage of the Upper Body
Understanding LE: Healthy Fluid Balance in Tissue
Understanding LE: Manual Lymph Drainage
Understanding LE: Lymph Vessels and Structures of the Skin
Understanding LE: The Initial Lymph Vessel
Understanding LE: Net Force and Fluid Balance
Understanding LE: Filtration
Understanding LE: Filtration & Lymph Drainage
Understanding LE: Safety Valve Insufficiency Graph
Understanding LE: Mechanical Insufficiency Graph
Understanding LE: Collector Vessel
Understanding LE: Normal Capacity, Functional Reserve
Understanding LE: Initial Lymph Vessel to Collectors to Node (LVS)
Understanding LE: Safety Valve Function Graph
Understanding LE: High Protein Edema in Tissue
Understanding LE: Lymph Vessel System
Understanding LE: Diffusion
Understanding LE: Lymph Node
Understanding LE: Loose Connective Tissue Detail
Understanding LE: Drainage of Breast
x
7
8
14
35
39
47
59
80
88
93
94
96
103
108
114
120
123
132
138
139
158
173
List of Charts
Legend
Best Practices Effectiveness Ratings
Abbreviations
Pathophysiology - the Causes of Secondary LE
Patients at Risk of Lymphedema
Therapist Assessment Guide
Contraindications
Specific Contraindications
The Pressure (Intensity) of MLD
Treatment Standards Guide
Patient Daily Checklist
Myth vs. Fact About MLD
Selected Patient Information Websites
Personal-wear Sources List
Compression Comparison Chart
Compression Garments Classifications
Compression Garments Monitoring Leg Applications
Compression Garment Supplement
Lymphedema Garments Web List
Differential Diagnosis (Obesity, LE, Lipedema, Lipolymphedema)
Additional Applications of CDT/MLD
Foods and Nutrition and Supplements
MLD Topic Cards Quick Reference Sheets content
®
ONS-PEP Weight of Evidence Chart
®
Oncology Nursing Society: PEP Quick View for Lymphedema
Lymphedema Clinic Performance Rating Tool – Sample Audit
Consensus Documents List
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viii
12
42
43
41
88
90
92
97
109
129
160
161
162
163
164
165
167
168
169
170
171
173
175
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180
204
205
207
209
FOREWORD
At the heart of the treatment of lymphedema is the relationship between the therapist and
their client with lymphedema. Gay Lee's book is the first to focus so thoroughly upon this
relationship. Ms. Gulbrandson has successfully distilled her years of experience in the field into
a manual that is designed to foster this all-important therapeutic relationship.
The book is a practical how-to manual for this critical relationship. The manual is also a
complete resource for those seeking an encompassing survey of issues related to the treatment
of lymphedema, yet does not belabor anatomy and physiology. The complementary Patient
Handbook provides patients with much of the needed practical support one hopes to impart.
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At each stage of CDT this manual offers information, guidance and suggestions for both the
therapist and the client. All of which if utilized fully, build a collaborative interaction that
eventually leads to the ultimate goal of independence of the client in the management of their
lymphedema.
The author has provided painstaking assessments of the evidence available for common
practices in the field. Her presentation of resources is exhaustive and up to date. Even the most
naive therapist will gain confidence by having this manual to rely upon for navigating the
sometimes confusing world of lymphedema treatment.
The manual does not stop with treatment alone. In addition, all of the organizations that
support the certification of therapists in the field, research, patient advocacy, legislative support
and universal metrics are presented, giving an opportunity for both the therapist and client to
join the growing community of those who support the field of lymphedema. The manual is an
invaluable resource for both the therapist and client and will help foster excellence in the
delivery of lymphedema care.
I plan to incorporate the use of this manual into my practice.
Paula J. Stewart MD, MS, CLT-LANA
i
INTERACTIVE LE Wellness MANUAL
Action Guide
Action
Patient
Patient
&
Therapist
Review Contents and Introduction for use of the book.
Complete Section 2 Consent, Assessment & Intake with your
therapist. Add photos and measurements as needed.
[Therapist keep a copy of the signed forms]
Discuss Section 3 Individual Treatment Protocol with your
therapist. Be candid about what self-care you can handle!
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Read Section 1 Lymph System and Lymphedema.
[Therapist keep a copy of the Wellness Action Plan]
Discuss Section 4 Risk Factors with your therapist, noting
actions you will take to protect yourself.
TREATMENT
[Therapist keep a copy of the Risk Factors Form]
Review Section 5 CDT (combined decongestive therapy)
Lymphedema Best Practices Treatments for questions about
the management practices you will use. Review with therapist if
possible.
Review Section 6 Other Treatments for info on treatments not
included in CDT. Review with your therapist if possible.
Review Section 7 Exercises for details on cautions and how to
perform various self-care exercise techniques or guided activity.
REFERENCE
Consult Section 8 Quality of Life and review your social
outlook with your therapist as desired.
See Section 9 Resources for additional information and
products resources (See Table of Contents).
See Section 10 Topic Cards for illustrated full color quick
reference sheets on physiology of the lymph system / edema /
etc.
See Appendix for supporting data and information with more
resources (See Table of Contents).
Reference and Resources
Access
As Desired
Patient: Manage your lymphedema on your own terms. Live fully. Consult your physician at each
stage of LE treatment. If any new symptoms arise, consult your physician immediately.
v
BEST PRACTICES RATINGS
A unique effectiveness rating system is used throughout this book for LE therapies.
Recommended
Likely to Be Beneficial
Some Benefits & Risks
Effectiveness Unknown
Effectiveness Not Likely
Not Recommended
Ratings DEFINITIONS:
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This defines the effectiveness ratings used in this manual. These apply to the treatments and modalities rated in the book. Various meta-‐studies and consensus documents, including the Oncology Nursing Society (ONS) Putting Evidence Into Practice (PEP®) for Lymphedema, inform the ratings applied in this book, but the final ratings were chosen by the author. Author’s effectiveness ratings of interventions used in treating secondary lymphedema.
Recommended
Recommend
Effectiveness has been shown by strong evidence from rigorous studies, meta-analyses, or
systematic reviews and for which expectation of harms is minimal compared with the benefits
Likely to Be Beneficial
Likely Benefit
Effectiveness has been demonstrated by evidence from a single rigorous controlled trial, consistent
evidence from well-designed trials using small samples, or guidelines from evidence supported by
expert opinion
Some benefits/risks
Practices that therapists and patients should contrast for benefits and harmful effects regarding
individual status
Effective Unknown
Conflicting or insufficient data, or studies of inadequate rigor, with no documented proof of harm
Effectiveness Not Likely
Effective Unlikely
Practices for which lack of effectiveness has been demonstrated by negative evidence from a
single rigorously conducted controlled trial, consistent negative evidence from well-designed
controlled trials using small samples, or guidelines developed from evidence and supported by
expert opinion (None in this text.)
Not Recommended
Not Recommend
Practices that lack effectiveness or are harmful as shown by strong evidence from rigorous studies,
analyses, or systematic reviews and for which expectation of harms is significant or where the
costs, or harms associated with the practice exceed expected benefits
♦ Expert Opinion
Expert Opinion
Opinion based on sound clinical practice, authored by a researcher or an expert in a journal or book
chapter, and for which specific confirming studies may or may not exist.
Also see Oncology Nursing Society (ONS) PEP® ratings schema in Appendix A page 204.
vii
- - - - - - - - ASSESSMENT & PROTOCOL- - - - - - - -
SECTION 1: The Lymph System & LYMPHEDEMA
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3
4
5
5
6
7
7
8
8
9
10
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Lymph System, Lymphedema Overview
Lymphedema Symptoms, Signs
Diagnosis, Treatment & Diagnosis
Interventions for Lymphedema and Evaluations Overview
Lymphedema Treatment Best Practices Consensus Documents
Lymphedema Patient Outlook
Lymph Node Groups, Lymph Drainage, BCRL
Primary vs. Secondary Lymphedema Treatment
Lymph Drainage in Axilla and Breast Areas
Genesis of BCRL (Breast Cancer Related Lymphedema)
Lymphedema Risk After Cancer, Lymphedema Signs
Lymphedema Statistics Prevalence, Incidence, Prophylactic MLD
Lymphedema Statistics Incidence, Epidemiology
Pathophysiology — Causes of Secondary LE
Summary: Treatment & Diagnosis of Lymphedema
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12
12
Objective: Provide introduction to physiology of the lymph system, lymphedema
(LE) causes, symptoms and diagnosis, interventions, and outlook.
LYMPHEDEMA WELLNESS Manual
Patient: Read for overview of
secondary LE causes, risks and
clinical outlook prior to or after first
appointment.
1. The Lymph System and Lymphedema
The lymphatic system major lymph vessels, nodes, and ducts (green).
(For more physiology of lymph system, see Sec. 10, Topic Cards.)
1. The Lymph System and Lymphedema
Classification of Causes of Secondary Lymphedema:
!
Expert Opinion
Patient: If your condition or general history is listed on the left side, it does not mean you have
or will necessarily develop secondary lymphedema (LE), It does mean you have a risk of
developing LE. Therefore, if you do not already have LE, you should investigate measures to
minimize the likely development of LE, by consulting with your trained MLD clinician, using this
Medical Illustration Copyright © 2012 Nucleus Medical Media, All Rights Reserved.book,
www.nucleusinc.com
Used
by permission.
researching
other
measures, and consulting a physician lymphologist.
List below is not exhaustive, but rather includes representative examples on right.
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3
!
Classification
Representative Example(s)
Trauma and tissue damage
lymph node excision
radiotherapy
burns
varicose vein surgery/harvesting
large/circumferential wounds
scarring
Malignant disease
lymph node metastases
infiltrative carcinoma
lymphoma
pressure from large tumors
Venous disease
chronic venous insufficiency
venous ulceration
post-thrombotic syndrome
intravenous drug use
Infection
cellulitis/erysipelas
lymphadenitis
tuberculosis
filariasis
Inflammation
rheumatoid arthritis
dermatitis
psoriasis
sarcoidosis
dermatosis with epidermal involvement
Endocrine disease
Therapist: Discuss patient
questions on LE etiology and
outlook.
pretibial myxedema
Immobility and dependency
dependency edema
paralysis
Factitious
self harm
SOURCE #2: Best Practice For The Management of Lymphedema International Consensus © MEP
Ltd., 2006 ISBN 0-9547669-4-6 Published by Medical Education Partnership Pg 4 Table 1 By
permission of copyright holder Wounds International A division of Schofield Healthcare Media Ltd (UK).
See Sec. 4 Risk Factors, applicable to all LE or at-risk patients on Pg 33.
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Purchase includes a LYMPHEDEMA Wellness Manual Patient HANDBOOK
to place forms & facts into patient hands. Does not include Section 2 Assessment &
Authorization forms. To order more Patient HANDBOOKS see inside back cover.
1
The Lymph System
Lymph System Overview
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The lymph system is a transport (vascular) system made up of vessels that originate in the dermis (second layer) of the skin and all the tissues where there are capillaries. Unlike the circulatory system, where the heart pumps the blood away from the heart via arteries and back again through veins, the initial lymph vessels originate in the skin and organs, where the lymph is transported to the heart through lymph vessels [via the autonomous contractions of the lymphangions -‐ lymph vessel segments] with the assistance of muscle activity, skin resistance, breathing, and thoracic pressure changes. The lymph system helps the cells by removing excess water, proteins, dead cells, fatty acids, and metabolic waste from tissue spaces around the cells. Maintaining protein and fat circulation and fluid balance in the tissues is the task of the lymph vessel system. The lymph system, especially the lymph nodes, plays a role in immune response. Physical trauma of any type (including surgery) [and radiation] can injure the lymph system, resulting in short-‐term and/or long-‐term damage. RESOURCE: Poage E, et al. (Oncology Nursing Society) 2008.
Lymph System Knowledge
♦ Expert Opinion
“Until 50 years ago, lymph drainage was a ‘stepchild’ of medicine although the first descriptions and findings on
the lymph vessel system already existed before the 16th century. In the 17th century, the lymph vessel system
was rediscovered and described again. Even today, in many cases, lymphology is strongly neglected at university
and in medical continuing education.”
SOURCE: Kettenhuber G, et al. n.d.
Lymphedema
3
Lymphedema Overview
♦ Expert Opinion
When the transport capacity of the lymph vessel system is reduced, lymphedema can develop. Secondary
lymphedema is swelling resulting from damage to lymphatic vessels and/or lymph nodes. This can lead to the
accumulation of excess water, protein, and other substances in the tissue that may result in chronic inflammation
and swelling.
Patients at risk for lymphedema include those who have had lymph nodes removed or radiation therapy as part of
their cancer treatment.
Although breast cancer treatment is the most common cause of secondary lymphedema in the developed world,
lymphedema also can be the result of burns, trauma, venous disease, infection, inflammation, parasites, or
immobility.
Patients at risk should be aware of ways to lower risks and watch for signs and symptoms of complications from
lymphedema. Complications include infection, wounds, pain, fungus, and loss of function.
REFERENCE: Poage E, et al. (Oncology Nursing Society) 2008.
1
For more information on lymph vessel system physiology see Section 10 Topic Cards.
For more information on diagnosis of lymphedema see Appendix A page 195.
2
Section 1 The Lymph System and Lymphedema
Lymphedema Risk After Cancer
National Cancer Institute’s PDQ cancer information summary about lymphedema states:
“Cancer and its treatment are risk factors for lymphedema.
Lymphedema can occur after any cancer or treatment that affects the flow of lymph through the lymph
nodes, such as removal of lymph nodes. It may develop within days or many years after treatment.
Most lymphedema develops within three years of surgery. Risk factors for lymphedema include the
following:
• Removal and/or radiation of lymph nodes in the underarm, groin, pelvis, or neck. The risk of
lymphedema increases with the number of lymph nodes affected. There is less risk with the removal of
only the sentinel lymph node (the first lymph node to receive lymphatic drainage from a tumor).
•
Being overweight or obese.
•
Slow healing of the skin after surgery.
•
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• A tumor that affects or blocks the left lymph duct or lymph nodes or vessels in the neck, chest,
underarm, pelvis, or abdomen.
Scar tissue in the lymph ducts under the collarbones, caused by surgery or radiation therapy.
Lymphedema often occurs in breast cancer patients who had all or part of their breast removed and
axillary (underarm) lymph nodes removed. Lymphedema in the legs may occur after surgery for uterine
cancer, prostate cancer, lymphoma, or melanoma. It may also occur with vulvar cancer or ovarian
cancer.”
SOURCE: National Cancer Institute PDQ®. 2011.12
Lymphedema Signs
National Cancer Institute’s PDQ cancer information summary about lymphedema states:
Possible signs of lymphedema include swelling of the arms or legs.
Other conditions may cause the same symptoms. A doctor should be consulted if any of the following
problems occur:
• Swelling of an arm or leg, which may include fingers and toes.
• A full or heavy feeling in an arm or leg.
• A tight feeling in the skin.
• Trouble moving a joint in the arm or leg.
• Thickening of the skin, with or without skin changes such as blisters or warts.
• A feeling of tightness when wearing clothing, shoes, bracelets, watches, or rings.
• Itching of the legs or toes.
• A burning feeling in the legs.
• Trouble sleeping.
• Loss of hair.
Daily activities and the ability to work or enjoy hobbies may be affected by lymphedema.
These symptoms may occur very slowly over time or more quickly if there is an infection or injury to the
arm or leg.”
9
Lymphedema Statistics: By the Numbers and Prevention
Lymphedema Prevalence Estimates
♦ Expert Opinion
Lymphedema is a chronic condition that is not curable at present, but may be alleviated by appropriate
management; if ignored, it can progress and become difficult to manage. At birth, about one person in 6000 will
develop primary lymphedema; the overall prevalence of lymphedema/chronic edema has been estimated as
0.13–2%. In developed countries, the main cause of lymphedema is widely assumed to be treatment for cancer.
Indeed, prevalence of 12–60% has been reported in breast cancer patients and of 28–47% in patients treated for
gynecological cancer. However, it appears that about a quarter to a half of affected patients suffer from other
forms of lymphedema, e.g. primary lymphedema and lymphedema associated with poor venous function, trauma,
limb dependency or cardiac disease.
SOURCE: Moffatt C, et al. 2006.
28
Incidence of Lymphedema
♦ Expert Opinion
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Cancer treatment is the leading cause of lymphedema in developed countries. Development and severity of
lymphedema have a significant impact on comfort, psychological distress, and overall quality of life. Incidence
statistics have ranged from 5%–60%, with onset of symptoms ranging from immediately after treatment to 30
years after treatment.
REFERENCE: Poage E, et al. (Oncology Nursing Society) 2008.
1
Study Shows Prophylactic MLD May Prevent Lymphedema
♦ Expert Opinion
At this time, there was no statistically significant increase in the volume of the upper limb on the operated side in
women who underwent MLD. This study demonstrates that regardless of the surgery type and the number of the
lymph nodes removed, MLD effectively prevented lymphedema of the arm on the operated side.
MLD was demonstrated to be effective against arm volume increase. Even though confirmatory studies are
needed, this study demonstrates that MLD administered early after operation for breast cancer should be
considered for the prevention of lymphedema…
…among the 33 randomly chosen women, MLD was applied five times a week during the first 2 weeks, and twice
a week from day 14 to 6 months after surgery. The control group comprised 34 women without MLD, but with
applied self-drainage…
[MLD] strokes were applied to the side of the edematous limb, starting at the base of the neck and then
progressing to the affected limb. The [MLD] was always directed proximally from the upper arm to the axilla, and
then from the hand to the elbow. Finally, the whole limb was [treated with MLD] from the distal to the proximal
extremity.
The results presented in this study emphasize the significant influence of MLD in preventing secondary
lymphedema of the arm on the operated side irrespective of the number of excised lymph nodes (ALND/ SLND)
and applied radiotherapy. The results showed that although radiotherapy is one of the highest risk factors for
lymphedema of the arm after breast cancer surgery, prophylactic application of MLD helped the women escape or
considerably alleviate this negative effect. This result is much stronger when the higher number of the removed
lymph nodes in the group with MLD was taken into consideration.
13(p103,105,111)
SOURCE: Zimmerman A, et al. ILS. 2012.
In the group of women who received MLD, mean arm volumes on the operated side increased on the second
post-operative day and resolved by day 7 after surgery. At 6 months following breast cancer surgery, no increase
in volume was evident and lymphedema of the arm on the operated side did not occur. This study demonstrates
the effectiveness of MLD in preventing the onset of secondary lymphedema irrespective of the type of surgery
performed, the number of lymph nodes removed (ALND/SLND), and if radiation was applied. Furthermore… this
study shows that MLD applied directly following surgery for breast cancer and over a certain time, should be
considered for the prevention of the onset of secondary lymphedema.
SOURCE: Zuther J. 2013.
14
Patient and Therapist: For more about Prevention of Lymphedema see page 78.
10
Lymph Drainage of the Upper Body
Understanding Lymphedema
Terminus
Right
Lymphatic
Duct
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Axillary
Lymph
Nodes
Thoracic
Duct
Cisterna Chyli
Ly m p h D r a i n a g e o f t h e U p p e r B o d y
area to regional lymph nodes.
and the left axillary lymph nodes.
lymph vessels join together
leading to the heart
14
- - - - - - - - ASSESSMENT & PROTOCOL- - - - - - - -
SECTION 2: ASSESSMENT & AUTHORIZATION
16
17
18
19
20
21
23
24
25
26
27
28
29
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Intake Process Forms
Health Information & Consent Patient Auth. 1
Notice of Privacy Practices Patient Auth. 2
Photo Release Patient Auth. 3
HIPAA Notice of Privacy Practices Patient Disclosure
Patient History & Authorization Patient Entry Option
Lymphedema Assessment & Intake Therapist Entry 1
Limb Measurement Forms, Procedures, Calculations Guide
Limb Volume Measurements Therapist Entry 2
Arm Measurement Form Therapist Entry 3
Leg Measurement Form Therapist Entry 4
Letters of Medical Necessity Therapist Entry 5-6
Medicare Codes; Modifiers; Measurements for Progress
Patient Continuing Report 7
Physician Referral for MLD/CDT 8
Patient Information Handout Tell Me About Lymphedema
Benefits of Documentation, Photographic Documentation
Recognizing Lymphedema, Assessment, NLN Position
Ultrasound (US) Sonogram
Near Infrared Fluorescence Imaging (NIRF)
Tissue Dielectric Constant (TDC)
Bioimpedance (BIA), Bioelectrical Impedance (BIS)
Available Methods to Recognize Lymphedema
LBCQ Assessment Tool
Therapist Assessment Guide for Lymphedema
Patients at Risk for Lymphedema
30
31
32
33
34
35
36
36
37
38
40
41
42
43
Objective: Gather patient history, make clinical observations, complete the
authorization forms, and take measurements and/or photos. Discuss needs.
*COPY ANY NEEDED FORM(S) IN BACK OF BOOK BEFORE STARTING THIS SECTION
CLINIC / PRACTICE __________________________________________________
Patient: If possible, fill out 2-page History
before first appointment. Intake is with
your therapist or clinician, interview style.
Be as candid and complete as
possible for best results.
Patient: If possible, fill out first 2 pages before the initial appointment. Be as candid and complete as possible.
Patient History & Authorization
Which extremity(s) has/have lymphedema?
Patient Entry Pg 1
! Left Arm
! Right Arm
! Left Leg
Axillary Dissection (ALND) !
Sentinel Node (SLND) !
! Right Leg
Mastectomy !
What operations / surgery have you had? List all and dates including:
! Trunk
Lumpectomy !
Other ! Explain:
Reconstruction !
______________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
When and why did your first and/or subsequent episodes of lymphedema occur ? Please include surgeries
and dates (cause of the lymphedema if known):
_______________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Did your lymphedema appear suddenly ?
! No ! Yes
Do you know the cause of the lymphedema ?
! No ! Yes
What:
_________________________________________________________________
Do you know the type of lymphedema ?
! No ! Yes
Or Gradually? ! No ! Yes
What:
_________________________________________________________________
Have you had prior triggers or treatment for lymphedema? ! No
! Yes
If Yes, Circle all applicable.
Cancer / Malignancy
Recurrent Cancer/Malignancy
Surgery
Reconstructive Surgery
Diuretics
Reid Sleeve
Benzopyrones
Other?
Compression Garment
Antibiotics
Bandaging
Radiation
Pneumatic Pump
Tribute
CircAid
____________________________________________________________________________________________________________________________________________________________________________
CLINIC
/ PRACTICE
__________________________________________________
!
No
!
Yes
How many
times?
! No
! Yes
Lymphedema
& Intake
Clinician Entry 1
! No
! Yes
How Assessment
many times?
Have you ever had lymph fluid leakage (lymphorrhea)?
Have you ever had cellulitis or erysipelas?
! No
! Yes
How many times?
Does anyone in your family have lymphedema?
! No
! Yes
Who:
! No
! Yes
Do you have bronchial asthma?
Do you have hypertension?
! No
! Yes
Do you have diabetes?
! No
! Yes
! No
! Yes
Do you have any allergies?
Do you have any cardiac (heart) problems?
! No
! Yes
Do you have any kidney problems?
! No
! Yes
! No
! Yes
Do you have any circulatory problems?
Have you had radiation therapy?
! No
! Yes
Have you received / are receiving chemotherapy?
! No
! Yes
! No
! Yes
Are you taking or have taken prophylactic antibiotics?
Are you taking or have you taken benzopyrones?
! No
! Yes
Have you had any major accidents or illnesses?
! No
! Yes
Do you smoke?
! No
! Yes Are you pregnant or trying to get pregnant?
! No
! Yes
Have you ever had an infection in your affected limb?
_____________________
Did you take antibiotics for the infection?
_____________________________________________________
_______________________
_______________________
____________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
! No
Do you wear?
! Yes:
! Glasses
! Contacts
! Hearing Aid
Have you recently noticed any changes in your skin?
! No
! Yes
In the nails? ! No
! Yes
If you currently or within the past two years had any of the following, enter 1-10 severity scale in box (10 = worst).
Arthritis !
Contagious Condition !
Dislocation ! Muscle Strain or Tear !
Asthma !
Sciatica !
Sleep Problems !
www.voddermld.com/b
Cancer !
Constipation !
Headaches !
Back Pain !
Diabetes !
Fatigue !
Phlebitis !
Broken Bones !
Herniated Disc !
Skin Condition/Rash !
High Blood Pressure !
Varicose Veins !
177
Menstrual Pain !
Blood Clots !
Bursitis !
Heart Conditions !
Chronic Pain !
HIV +AIDS/ARC !
Infected Tooth !
Thrombosis !
Lymphedema (in green)
Radiation (in red)
Fibrosis (in blue hatch) Pitting (in gray) Scars (in black)
CLINICIAN EXAMINATION ! HISTORY & OBSERVATIONS
1. General medical history review
2. Edema-specific medical history:
a. Familial edema, congenital
__ No
__ Yes
__ No
__ Yes
__ No
__ Yes
b. Duration of the edema
c. Edema-triggering events
d. Edema progression
__ No
__ No
__ Yes
__ Yes
e. Appearance at the time of intake
f. Edema pre-treatment
__ No
__ No
__ Yes
__ Yes
g. Current edema therapy
__ No
__ Yes
h. Edema symptoms
i. Appearance of edema complications
__ No
__ No
__ Yes
__ Yes
j. Current medications
__ No
__ Yes
! INSPECTION
Std. Abbreviations: Right: Rt
Left: Lt
Medial: Med
__ Yes
__ Yes
__ Yes
o. Stemmer's sign
__ No
__ No
__ No
u. Edema color
r. Skin changes
__ No
__ No
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
s. Vascular delineation
__ No
__ Yes
t. Scarring
u. Radiation borders
__ No
__ No
__ Yes
__ Yes
w. Volume measurement
Lateral: Lat
__ No
__ No
p. Edema on one or both sides
q. Edema symmetry
v. Palpation and Pitting
k. Effect of therapy on the edema __ No
__ Yes
Use letter codes to enter explanations below:
! NOTES
l. View extremity from all aspects __ No
m. Estimation of edema extent
n. Estimation of edema severity
Bilateral: BiL
Cervical: C
Lumbar: L
__ No
__ Yes
__ No
__ Yes
Thoracic: T
Patient: Pt
______________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________
www.voddermld.com/b
Therapist: Answer patient
questions on LE etiology and
outlook. Be thorough and
sensitive. Copy all completed
forms for the file.
191
15
The forms in Section 2 support patient intake, assessment, and documentation.
Blank forms are single sided to copy from back of book, or download (fee), customize, print, fill out on
computer, and save to computer. Section 2 forms are NOT in Patient Handbook.
Blank Form on page:
Patient Authorization 1 231
Notice of Privacy Practices
Photo Release
HIPAA Notice of Privacy Practices
Patient Disclosure 4
239
Patient Entry Option 5
251
Lymphedema Assessment & Intake
Therapist Entry 1
255
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Health Information & Consent
Limb Circumference/Volume
Therapist Entry 2
257
Arm Measurement Form
Therapist Entry 3
259
Leg Measurement Form
Therapist Entry 4
261
Letter of Medical Necessity - Garment
Therapist Entry 5
263
Letter of Medical Necessity - CDT/MLD
Therapist Entry 6
265
Patient Continuing Report
Therapist Entry 7
267
Physician Referral for MLD/CDT
Therapist Entry 8-9
267
Tell Me About Lymphedema - Brochure
Patient Information
273
How To Find & Use Blank Forms
Copy: Remove from back of book, write clinic name at top, then make copies for patient records.
Print: Use black & white or color printer as preferred. (Retain file copies of all filled-in patient forms.)
Online: Register Wellness Manual online at www.VodderMLD.com/b for assorted eForms –
download and customize the computer fillable forms and add clinic/practitioner name (fee).
16
EXAMPLE – SEE BLANK FORMS IN BACK of BOOK
The full HIPAA Disclosure is 6 pages of text, and is not required in all cases. See back of book.
East-West Lymphedema Clinic, LLC
CLINIC / PRACTICE __________________________________________________
Page 6 is the Patient Receipt, that shall be retained by the clinic.
File Number: _______________
ACKNOWLEDGEMENT OF
RECEIPT NOTICE OF PRIVACY PRACTICES
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By signing below, I acknowledge receiving a copy of the
Notice of Privacy Practices, dated April 14, 2003, HIPAA
Disclosure consisting of 6 pages including this receipt.
Angelica Doubtfree
Signature of Patient or Personal Representative: X _______________________________________
Angelica Doubtfree
Printed Name of Patient or Personal Representative: _____________________________________
EXAMPLE
01/01/2013
Date: _______________________________________
Description of Personal Representative’s Authority to Act on Behalf of the Patient:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
(Enter Clinic Name. Privacy Officer, clinic address, phones, email, website - here:)
_____________________________________________________
123
Center Street
_____________________________________________________
_____________________________________________________
Centerville, CA 97979
_____________________________________________________
_____________________________________________________
712-555-9191
PLEASE PROVIDE A COPY OF THIS HIPAA DISCLOSURE TO THE PATIENT AT TIME OF SIGNING.
CLINIC NEED ONLY RETAIN THE SIGNED RECEIPT
Notice of Privacy Practices with Acknowledgement of Receipt April 2003 Page 6 of 6
www.voddermld.com/b
20
200
Section 2 Assessment and Authorization
CLINIC / PRACTICE __________________________________________________
Patient: If possible, fill out first 2 pages before the initial appointment. Be as candid and complete as possible.
Patient Entry Pg 1
x
Which extremity(s) has/have lymphedema? ! Left Arm ! Right Arm ! Left Leg ! Right Leg ! Trunk
x
Lumpectomy !
What operations / surgery have you had? List all and dates including: Mastectomy !
Axillary Dissection (ALND) !
Sentinel Node (SLND) !
x
Reconstruction !
Other ! Explain:
______________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
When and why did your first and/or subsequent episodes of lymphedema occur? Please include surgeries
and dates (cause of the lymphedema if known):
_______________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
x
!
x
x
_________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
! No ! Yes Or Gradually? ! No
Did your lymphedema appear suddenly ?
! No !
x Yes What: Cancer surgery
Do you know the type of lymphedema ?
! No ! Yes What:
Have you had prior treatment for lymphedema?
! No ! Yes
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EXAMPLE
Do you know the cause of the lymphedema ?
x
Yes
_________________________________________________________________
If Yes, Circle all applicable:
Surgery
Reconstructive Surgery
Radiation
Pneumatic Pump
Antibiotics
Other?
Compression Garment
Night Garment
Diuretics
Reid Sleeve
Bandaging
______________________________________________________________________________________________________________________________________________________________________
Have you ever had an infection in your affected limb?
Did you take antibiotics for the infection?
Have you ever had lymph fluid leakage (lymphorrhea)?
Have you ever had cellulitis or erysipelas?
Does anyone in your family have lymphedema?
Do you have bronchial asthma?
Do you have hypertension?
Do you have diabetes?
Do you have any allergies?
Do you have any cardiac (heart) problems?
Do you have any kidney problems?
Do you have any circulatory problems?
Have you had radiation therapy?
Have you received / are receiving chemotherapy?
Are you taking or have taken prophylactic antibiotics?
Are you taking or have you taken benzopyrones?
Have you had any major accidents or illnesses?
x
x
Do you smoke?
! No ! Yes
Do you wear?
! Glasses
x No
x No
x No
x No
x No
x No
x No
x No
x No
x No
x No
x No
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
x
x
x
No
No
No
No
No
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
x
x
Yes
How many times?
Yes
_____________________________________________________
Yes
How many times?
_______________________
Yes
How many times?
_______________________
Yes
Who:
Yes
_____________________________________________________
Yes
_____________________________________________________
Yes
_____________________________________________________
Yes
_____________________________________________________
Yes
_____________________________________________________
Yes
_____________________________________________________
Yes
Yes
Yes
_____________________
____________________________________________
_____________________________________________________
6 radiation treatments
3 series - very hard
_____________________________________________________
_____________________________________________________
Yes
_____________________________________________________
Yes
_____________________________________________________
Yes
_____________________________________________________
x
Are you pregnant or trying to get pregnant? ! No ! Yes
! Contacts
! Hearing Aid
! No ! Yes
x
x
Have you recently noticed any changes in your skin?
In your nails? ! No ! Yes
If you currently or within the past two years had any of the following, enter 1-10 severity scale in box (10 = worst).
Arthritis !
Contagious Condition !
5
Dislocation ! Muscle Strain or Tear ! Broken Bones !
Asthma !
Sciatica !
5
Sleep Problems !
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Cancer !
Constipation !
5
Fatigue 5
!
Headaches ! Back Pain ! Diabetes !
Herniated Disc !
Phlebitis !
Skin Condition/Rash !
High Blood Pressure !
Menstrual Pain !
5
Varicose Veins !
Bursitis !
Blood Clots !
Heart Conditions !
Chronic Pain ! HIV +AIDS/ARC !
Infected Tooth !
Thrombosis !
203
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EXAMPLE
This form is a downloadable PDF calculator. Enter measurements, all totals then display in black.
25
Arm Measurements Chart
Arm Measurements Record
Patient Name: _________________________________________
Date: ___________
Angelica Doubtfree
1/1/2013
Position of Patient:
Variation: _____________________________________________________________
Variation: _____________________________________________________________
Board Levels: R / L
R/L
Hand Dominance
Sitting
Abd. 90º
rd
Tip of 3 finger:
rd
Tip of 3 finger:
R/L ambidextrous:
A
Date
Weight/Height BMI
Side (Diff)
MCP (mid-point)
Ulnar styloid (distal) 0 cm
10 cm
20 cm
30 cm
40 cm
50 cm
60 cm
70 cm
:
Sum
% Difference
:
Thumb 1.
2.
3.
4.
5.
:
Measured by
Time AM/PM
Mid-point MCP ulnar – radial:
Mid-point MCP ulnar – radial:
Left Dom.
B
C
Mid Ulnar styloid:
Mid Ulnar styloid:
Normal limb (left) prior
D
E
F
G
measurement entered to compare.
H
I
J
K
1/1/2013
29
6
8.5
18
20
22
22
30
30
34
20
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Fingers
EXAMPLE
Therapist Entry 3
206
20%
7.5 x 7.5
8.5 x 8.0
7.5 x 8.5
7.5 x 7.5
6.5 x 6.5
JS
3 pm
Remember to enter the normal limb in one column for comparison and calculate % Difference entry.
Notes: _____________________________________________________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________________________________
REFERENCE: The Australasian Lymphology Association Ltd. Please go to their website to download forms and more. ALA Measurement Standards Form 3-2004
16
REFERENCE: The Australasian Lymphology Association Ltd.
The Arm Measurement --Therapist Entry 3 form is available for download as a PDF fillable form in Acrobat that
will record and save the measurements you enter on your computer (fee).
Download at www.VodderMLD.com/b
Label and fill all columns for dated entries of the swollen limb – plus contralateral (normal) limb in any column.
Therapist: Tracking Software. Computer programs can assist in standardizing assessments,
measurements, patient recordkeeping, claims and communications. See Appendix page 206.
26
30
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EXAMPLE
Therapist: This form is for chronic condition reporting per the Patient Protection and Affordable Care Act.
Assessment & Authorization: Physician Referral and Information
Therapist: This form is for patient referrals. Offer to patients and physicians.
LYMPHEDEMA TREATMENT REFERRAL FORM
Date:____________________________
(mm/dd/yyyy)
Client Name:______________________________
Phone Number:_______________________
Date of Birth:___________________________ (mm/dd/ yyyy) City:___________________________
Insurance Contact: __________________________________________________________________________________________
Past Medical History:__________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Past Treatment for Breast Cancer or: ____________________________________________
Radiation:________________________________________________________________
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Physician’s Guide: Combined Decongestive Therapy, Manual Lymph Drainage
Chemotherapy:____________________________________________________________
EXAMPLE
Herceptin: ________________________________________________________________
Hormone treatment:________________________________________________________
Combined / Complete / Complex Decongestive Therapy (CDT) is the gold standard of care for
lymphedema and related disorders, and includes these components:
Medications:_______________________________________________________________
1) Manual lymph drainage (MLD)
Diagnosis: _________________________________________________________________
2) Compression therapy (bandaging, garments)
Referral for (Imaging, X-ray results, etc.)
3) Exercise
_____________________________________________________________________________
4) Skin care
_____________________________________________________________________________
5) Patient education
The following are contraindications to MLD/CDT:
Uncontrolled CHF, infection, recent
DVT,
untreated
malignancy,
kidney or liver malfunction.
There are
two phases
in CDT:
Phase I - Intensive: MLD and bandaging is administered daily for 10 consecutive days. Custom
Area to be treated: _____________________________________________________________
compression garments are fitted at the end of Phase I.
___ Treatment: Manual Lymph Drainage, Duration: ________________________________
Phase II - Maintenance: The patient applies the practices and principles learned in Phase I. Specific
___ Treatment: Combined Decongestive Therapy,
__________________________
exercisesDuration:
are learned
that decongest the tissue. Skin care is taught to prevent skin breakdown.
Custom
garments
are
worn daily and bandages or night compression garments are worn at night.
___ Treatment: Compression Bandaging: __________________________________________
The intent
of CDT is to manage lymphedema
and
prevent progression of swelling over time. CDT has
___ Treatment: Compression Garment:
_________________________________
mmHg:
___
been shown to improve the quality of life for lymphedema patients.
Physician Name:_____________________________ Signature_________________________
Indications: Lymphedema, primary and secondary. Modified CDT is indicated for non-healing ulcers,
Physician Phone Number:______________________
lipedema, mixedDate:____________________________
edemas such as phlebo-lymphedema.
Physician ID Stamp Here / Comments:Contraindications: See below.
Referral to:
Manual lymph drainage (MLD) is a safe, gentle, rhythmic manual technique that has a profound effect on
the lymphatic system.
Manual lymph drainage increases the flow of lymph fluid, it also directs the flow around
obstructions by activating collateral pathways.
MLD can be used to treat swellings associated with injury or surgery and promotes wound
healing. Successful reduction of swelling leads to faster healing.
MLD is most commonly used as a component of Combined Decongestive Therapy (CDT) to treat
lymphedema. However, it is a powerful and profound stand-alone hands-on technique.
Indications: Lymphedema (primary or secondary), swelling due to trauma, promotion of wound healing,
obstructive edema, fractures, strains, joint inflammation, complex regional pain syndrome (CRPS), facial
nerve paralysis (Bell’s), fibromyalgia, paralysis, stroke, venous insufficiency, lipedema, skin conditions.
Contraindications: Uncontrolled CHF, renal failure, pulmonary failure, DVT, and acute infections.
Modified MLD or CDT: bronchial asthma, chronic inflammation, thyroid disorder, hyperthyroidism, low
blood pressure, menstruation (no deep work), nevus, pregnancy, treated cancer, recent asthma attack,
certain comorbidities.
For more information regarding these therapies or for an appointment please call:
31
Assessment & Authorization: Patient Information Handout
Therapist: This 2 page brochure may be printed and given to patients (original in back of book).
Information for our patients about Secondary Lymphedema.
Tell Me About Lymphedema
Patient Info
Tell me about Lymphedema!
Lymphedema is the swelling of a part of the body,
typically an extremity (limb). Lymphedema
sometimes occurs in the trunk, abdomen, face or
genital area. The swelling is typified by an
accumulation of protein-rich fluid in the layers of the
skin, which has pathological and clinical
consequences if left untreated. Once lymphedema
develops, it will not disappear, and must be
regarded as a lifelong condition.
Lymphedema, whether primary or secondary,
usually affects just one extremity; if both extremities
(example, both legs), are involved, the swelling will
be asymmetrical.
Treatment
EXAMPLE
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Medications: Diuretics are frequently prescribed in
an effort to control lymphedema. These often have
very poor long-term effect in the treatment of
lymphedema. Diuretics reduce the water content of
Causes
the edema, however the protein remains in the
tissue. When the diuretic loses effectiveness, the
Lymphedema has two major types: primary or
proteins continue to attract water to the swollen
secondary. Primary lymphedema develops from
Information
for our patients about Secondary Lymphedema.
area.
congenital malformations of the lymphatic system
that may be present at birth or may develop Page
in later2
Surgery: Several surgical procedures for
life, often during puberty or pregnancy. Primary Tell Me About
lymphedema
are described. Studies show none
of
Mosquito
risk – if outside, wear insect repellent. A
Lymphedema
lymphedema usually affects the lower extremities
the surgeries showed consistent results.
sole mosquito bite can initiate an infection.
Compression
(continued):
(legs) but may also occur in upper extremities and
Pneumatic Compression Pumps (IPC): These
Exertion risk - discuss exercises and activities with
In the phase I of CDT, compression therapy uses
other locations.
machines use inflatable sleeves, applied to the
your therapist before doing movements that cause
special
short-stretch
bandages. These materials are
Secondary lymphedema is far more frequent in the
swollen extremity. Improper use of these pumps
strain
or fatigue.
the MLD treatments to prevent the
population and often follows surgery or radio-applied between
often causes complications in lymphedema. Heat
Pumps
risk - hot bath or shower, sunbathing, sauna,
reaccumulation
of
interstitial
fluid,
which
has
been
therapy for treatment of cancer. Surgery including
may be used under the guidance of speciallyhot
trained
packs on the extremity could aggravate your
encouraged out of the extremity by MLD.
the removal of lymph nodes, such as mastectomies
therapists in combination with prescribed elements
lymphedema. Avoid major changes in temperature
After
decongestion,
the
patient
applies
compression
or lumpectomies along with the removal and/or
of CDT.
(hot/cold),
massages ("Swedish or deep tissue") on
garments during the day. Sometimes it is necessary
radiation treatment of the axillary (armpit) lymph
Complete Decongestive Therapy (CDT): The
your extremity or cosmetics that irritate the skin. Let
nodes, are a frequent cause of secondary to apply bandages at night. To obtain optimum
objective of CDT is to reduce the degree of swelling
your health care team know that you have
effects,
specially trained therapists should record
lymphedema in most countries. Other causes
of
and to maintain such reduction. For many the
lymphedema - avoid injections or acupuncture in
measurements for compression garments; poorly
lymphedema include trauma or infections involving
patients this can be accomplished by properly
your affected extremity. Blood pressure or blood
of the lymph system. Venous insufficiencies fitted
may sleeves or stockings have injurious effects.
trained practitioners. CDT is safe and non-invasive.
draws/injections should be performed on the
also contribute to the onset of lymphedema Compression garments are made in round or flatCDT has excellent results; involving two main
unaffected limb.
(phlebolymphostatic edema or phlebedema).knit types; and the correct amount of compression
phases of treatment including the following methods.
Nutrition - there is no known diet for lymphedema.
depends on factors including patient's age, skin
Either primary and secondary lymphedema may
Manual Lymph Drainage (MLD): a light andNutritionists
gentle
recommend a low salt, low fats diet.
condition,
affect upper or lower extremities. Generally the
legs and amount of swelling.
manual modality that stimulates the activity of
lymph may effect on your swelling negatively.
Obesity
For maximum effect, it is necessary to wear
are involved more often with primary lymphedema,
vessels and helps moves interstitial fluid. Done
Travel - avoid endemic Filariasis zones; if traveling
garments
and secondary lymphedema is involved more
often daily, and be replaced every six months.
correctly, MLD decreases the size of the swollen
by airplane wear your garment, and apply an
with the arms.
Exercises: a trained
CDT
therapist
will
work
with
extremity to normal or nearly normal size. Performed
additional bandage on top.
the physician to
recommend
an exercise
Symptoms
daily
in the phase
I of CDT.program
Attire - garments that are too tight may restrict the
the
for
each
patient.
Decongestive
exercises
assist
In the early stages of lymphedema (stage I) swelling
Compression (Bandaging and/or Garments):
Theflow of lymph. Avoid tight bra straps, panties
normal
jointlimb.
and muscle lymph pump action, and are most
may be temporarily reduced by elevation of the
skin is damaged in lymphedema. To avoid the
or
socks and always be sure your jewelry is loose.
while wearing a compression
However, the protein-rich edema causes a effective if performed
reaccumulation of interstitial fluid after MLD, skilled
bandage
Movements are modest and
See your physician - if you observe signs of an
progressive thickening of the edematous tissue;
this or garment.
application of compression on the affected extremity
and should not cause pain.
infection (fever, chills, red or hot skin), fungal
is known as lymphostatic fibrosis and occursneed
in not be aerobic,
produces sustained benefits.
Exercises
are
done
slowly
including
affected
and
uninfections, or if you observe any other changes that
stage II lymphedema. Additional complications such
Compression also assists the normal effectsmay
of the
affected
relate to your lymphedema.
as fungal infections, continued hardening and
often limbs.muscle activity on lymph flow, assists in reduction
of
care: with lymphedema the skin is highly
General
Suggestions - wear your compression
a severe increase in swelling of the extremitySkin
occur
fibrotic tissue and encourages venous circulation.
susceptible to infections, and is usually dry. Low-pH
garments daily; if necessary wear your bandages at
in stage III lymphedema.
lotions containing no alcohol or fragrance should be
night; use elevation as often as possible during
pageday; perform prescribed exercises daily; and
used to moisturize of the skin and to avoidContinued
cracks on next the
that lead to infections. Immediately consult your
consult your doctor or therapist whenever you
physician if fungal infections appear in the affected
have questions about your lymphedema.
limb.
What To Do and Not Do
A trained lymphedema therapist will explain how to
avoid skin infections and minimize related risks that
may aggravate lymphedema. Here is a list of the
common precautions:
Avoid injuries to the skin – use caution doing
gardening, playing with pets, doing housework. Cut
your nails with clippers, don't cut cuticles. Injuries,
even small ones, frequently cause infections.
32
REFERENCE: Zuther J. 2008.
14(p243-244)
For further information, please contact us with
your request. We are happy to assist.
Assessment: Benefits
Role of Documentation and Methods in Lymphedema Treatment
♦ Expert Opinion
Documentation supports the following benefits:
- proves the effectiveness of the therapy
- indicates patient progress
19
19
- reimbursement/billing requirements
19
- tracks patient therapeutic needs to determine appropriate treatment
19
Documentation types suggested:
- photos (visual evidence of progress, wound healing, skin color)
19
- simple circumference measurements (include both sides for comparison)
19
(Always use the same 7 measuring points)
- volume measurements (include both sides for comparison)
- measurements are performed weekly at minimum
19
19
19
- duration of each treatment and therapist name/ID (entire record of treatments)
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- range of motion measurements
18
18
- bandaging description
18
- garment details logged
Ancillary benefits:
- documents increased quality of therapy (to patient, physician, payers, management)
- basis for marketing approach
18
18
- knowledge base for promotion (supports performance standards)
- enhances therapist’s self-confidence and conviction
18
18
Please consult the original sources for greater detail than can be examined here.
SOURCE: Weissleder H, et al. 2008.
SOURCE: Zuther J. 2008.
18(p495-)
19(p137-139)
Assessment: Documentation
Photographic Documentation Guide for Lymphedema
♦ Expert Opinion
Photographic record guidelines:
18
- use uniform lighting
18
- place lens at same height as center of subject area
18
- use same distance from subject in all comparison photos
18
- provide a glare-free background/backdrop
18
- remove distracting objects from frame and subject (jewelry, etc.)
18
- consistent subject position
- use close-ups of specific details
- document date – time – name – location – purpose – release and file location or custodian
REFERENCE: Weissleder H, et al. 2008.
18
Therapist: Photo Documentation. Complete the intake with dated digital photos. Show the same
details in each picture; distance, light, and exposure time should remain the same. A room without
natural light is preferable. Close-ups of fungal infections or ulcers provide an objective measure of
treatment progress. Place measuring tape or ruler near wounds. The pictures must show the date.
33
Assessment: Therapist Tool - Assessment Guide
♦ Expert Opinion
CERTIFIED THERAPIST ASSESSMENT OF CHRONIC EDEMA
Symptoms in limb/body part
(One or more of the following, AND is of chronic duration, i.e. > 3 months)
•
Pain
or
tension
•
Swelling
•
Heaviness
•
Tightness
and
fullness
No History of Cancer
History of Cancer
Details of:
•
Surgery
•
Lymph
node
removal
•
Radiotherapy
•
Other
surgery
•
Complications
(e.g.
post-operative
infection, etc)
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Exclude other causes of edema:
•
Cardiac,
renal
or
hepatic
failure
•
Thyroid
disease
•
Medication
side-effects
•
Venous
insufficiency
(including
past
DVT,
chronic ulcers)
•
Mass
(pelvic,
abdominal,
lymphadenopathy)
•
Immobility
•
Chronic
neurological
disorders
•
Obesity
•
Other
surgery
Consider:
•
Tumor
recurrence
•
Cellulitis
•
DVT
ABSENT
Secondary
Lymphedema
Investigate
triggers:
Is there a
recent exacerbation of
the edema?
Advise
pt.
of need to
verify
safety
of
CDT/MLD.
In medical history,
exclude
the
above
and
also
inquire
about:
•
Travel
history
•
Trauma
to
limb
•
Past
cellulitis,
infection,
ulcers
•
Family
history
of
limb
swelling
PRESENT
Investigate
as
appropriate,
and
refer
back
to
patient’s
own
medical
specialist. (Require Rx)
Examination:
Perform
a
full
physical
exam
Plus
assess
skin
condition,
degree
of
pitting,
presence
of
Stemmer’s
sign,
and
record bilateral limb circumferences
Investigations: Full
Blood
Exam;;
Urea
&
Electrolytes;;
Controlled
Respiration
Test,
Creatinine;;
Thyroid
Function;;
Liver
Function;;
Chest
X-Ray (exclude
cardiac/pulmonary
causes);;
Erythrocyte
Sedimentation
Rate;;
Glucose
Tolerence
if
BMI
>35;;
LEGS:
Venous
Doppler
Scan
(exclude
venous
insuff/
DVT),
or
CT
scan
(abdomen,
pelvis
-
to
exclude
mass/tumor).
Differential: Consider
lymphedema
as
differential
diagnosis
(either
primary,
secondary
or
mixed)
Refer to trained lymphedema practitioner
or
clinic
for
comprehensive
assessment
and
management
(CDT/MLD).
To
find
the
nearest
specialist
practitioner
or
clinic
visit:
National
Lymphedema
Network
www.Lymphnet.org.
Based upon a chart developed by representatives from the Lymphoedema Association of Victoria, National Breast Cancer Centre, Lymphoedema Practitioners’ Education Group of Victoria, Royal Australasian College of
Surgeons, Australian Practice Nurses Association, and General Practice Divisions – Victoria, with funding from the Department of Human Services, Victoria. Extensively revised by Gay Lee Gulbrandson, 2012.
27
REFERENCE: Lymphoedema Association of Queensland.
(Edited for this manual.)
41
Assessment: Patients at Risk of Developing Lymphedema
IDENTIFYING A PATIENT AT RISK
Effective identification of patients at risk of
lymphedema relies on awareness of the causes
of lymphedema and associated risk factors,
implementation of preventive strategies, and selfmonitoring.
Patients, care givers and healthcare
professionals should be aware that there may be
a considerable delay of several years from a
causative event to the appearance of
lymphedema.
RISK FACTORS FOR DEVELOPING LE
The true risk factor profile for lymphedema is
not known. There may be many factors that
predispose an individual to developing
lymphedema or that predict the progression,
severity and outcome of the condition. Further
epidemiology is required to identify these
factors, and research is needed to establish
how risk factors themselves can be modified to
reduce the likelihood or severity of consequent
lymphedema.
Lower limb lymphedema
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Upper limb / trunk lymphedema
♦ Expert Opinion
■ Surgery with axillary lymph node dissection,
particularly if extensive breast or lymph node surgery
■ Surgery with inguinal lymph node dissection
■ Postoperative pelvic radiotherapy
■ Scar formation, fibrosis and radiodermatitis from
postoperative axillary radiotherapy
■ Recurrent soft tissue infection at the same site
■ Radiotherapy to the breast, or to the axillary, internal
mammary or subclavicular lymph nodes
■ Varicose vein stripping and vein harvesting
■ Drain/wound complications or infection
■ Cording (axillary web syndrome - AWS)
■ Seroma formation
■ Advanced cancer
■ Obesity
■ Obesity
■ Genetic predisposition/family history of chronic
edema
■ Advanced cancer
■ Intrapelvic or intra-abdominal tumors that involve or
directly compress lymphatic vessels
■ Orthopedic surgery
■ Congenital predisposition
■ Poor nutritional status
■ Trauma in an 'at risk' arm (venipuncture, blood
pressure measurement, injection)
■ Thrombophlebitis and chronic venous insufficiency,
particularly post-thrombotic syndrome
■ Chronic skin disorders and inflammation
■ Any unresolved asymmetrical edema
■ Hypertension
■ Chronic skin disorders and inflammation
■ Taxane chemotherapy
■ Insertion of pacemaker
■ Concurrent illnesses such as phlebitis,
hyperthyroidism, kidney or cardiac disease
■ Arteriovenous shunt for dialysis
■ Immobilization and prolonged limb dependency
■ Air travel
■ Air travel
■ Living / visiting a lymphatic filariasis endemic area
■ Living / visiting a lymphatic filariasis endemic area
28(p3 Box 4)
"People at risk of lymphedema should be identified early during routine assessment, monitored and
taught self care."
28
For more information about risks and exposures see Section 4 Risk Factors page 57.
42
- - - - - - - - ASSESSMENT & PROTOCOL - - - - - - - -
SECTION 3: Individual treatment protocol
Wellness Action Plan (WAP), Self-Care, Therapies, & Practices Plan
Choose “Long Form” or “Short Form” to copy and save.*
Patient Questions “My Turn”
48
Action
55
Action
Objective: This interactive section creates a treatment plan appropriate to the
patient at time of interview.
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*COPY ANY NEEDED FORM(S) IN BACK OF BOOK BEFORE STARTING THIS SECTION
CLINIC / PRACTICE __________________________________________________
Wellness Action Plan (WAP)
Patient Entry
With your clinician, each recommended LE management technique is reviewed; clinician suggests
actions appropriate to your needs. Enter plans in appropriate spaces below.
Lymphedema (LE): Left Arm
_________________________
Right Arm
_________________________
Left Leg
Self Care / Therapies 1
_________________________
Right Leg
_________________________
Other
___________________________________________
Self Care / Therapies 2
Early signs or symptoms of lymphedema:
Clothing or jewelry, e.g. sleeve, shoe or ring,
becoming tighter
Feeling of heaviness, tightness, fullness or stiffness
Aching
Observable swelling
Care, Check-up and Exams: Maintain frequent
contact with your physician(s). Review all symptoms,
both old and new at each visit.
_______________________________________________________________________________________
Medications: Review all new medications with
your physicians and pharmacists, and read all
information sheets provided before taking any new
medicine or combinations of medicine.
__________________________________________________________________________________________________________
______________________________________________________________________________
Preventive Measures (See Sec. 4 Risk Factors)
Take good care of skin and nails
Maintain optimal body weight
Eat a balanced diet
Avoid injury to area at risk
Avoid tight underwear, clothing, watches and jewelry
Avoid exposure to extreme cold or heat
Use high factor sunscreen and insect repellent
Wear prophylactic compression garments, if
prescribed
Undertake exercise/movement and limb elevation
Wear comfortable, supportive shoes
Prescriptions: Review all available care options
and coverage. Ask for prescriptions for all reasonable
forms of care and supplies, even if not covered by
insurance (may be deductible from taxes).
MLD / Therapeutic Care / Physical Therapy
Compression Garments and stockings
Bandaging and taping supplies
Personal care supplies
Vitamins & prescription supplements
Massage therapy / MLD treatment
Other
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
Post Surgery LE patients have an expectancy of
50% developing a skin infection, Of those, 20% or
more will develop repeated skin infections over time.
CDT Treatment Overview (Combined
Decongestive Therapy): CDT is the recognized
treatment for LE. CDT includes • Skin Care, • Manual
Lymph Drainage, • Compression, • Exercise, •
Education. These techniques are addressed each in
turn below.
___________________________________________________________________________________________________________________________________
Individual Treatment Protocol: In consultation
with physician & certified lymphedema therapist,
determine action plan in Wellness Book using
appropriate therapies and related health modalities.
Write overall goal HERE:
____________________________________________________________________________________________________________________________
Skin Self-Care Minimum Guidelines
• Use neutral soaps to avoid excessive drying.
• Use moisturizing cream.
• Use sunscreen and insect repellents.
• Inspect skin folds and keep them clean and dry.
• Inspect for cuts, scrapes, abrasions, and insect bites.
• Wear protective gloves & garments when working
outdoors (like knee pads), or when doing cleaning or
washing dishes.
• If injury occurs, wash with soap and water, apply
topical antibiotics, and monitor for redness, pain, or
swelling.
If swelling occurs, contact a clinician immediately.
• Avoid blood pressure and blood draws or
venipuncture on affected limbs if possible.
• Avoid manicure / pedicure. Do not push cuticles back
or trim them. Cut nails square across. Avoid hangnails
and ingrown nails.
• Avoid wearing tight garments, underwear, or jewelry
on affected areas of the body.
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
Checking in and maintenance plan: (More later)
Routine and frequent monitoring of results measured
against plans and goals is important as we set
objectives.
__________________________________________________________________________________________________________________________________
Wound / ulcer / fungus-care guidelines: Action
plan for immediate intensive treatment. Manual Lymph
Drainage (MLD) should be used to enhance care and
speed-up healing of wounds, scars, venous ulcers, etc.
Consult a Lymphedema or Wound Care clinic locator.
See NLN Clinic Locator in Sec. 9 Resources or visit
www.VodderMLD.com/b How To Locate a Clinic.
___________________________________________________________________________________________________________________________________
CLINIC / PRACTICE __________________________________________________
___________________________________________________________________________________________________________________________________
INTERACTIVE LE CONTROL Wellness Book
See Sec. 4 Risk Factors for more info.
NOTES: ___________________________________________________________________________
_______________________________________________________________________________________
___________________________________________________________________________________________________________________________________
_______________________________________________________________________________________
NOTES: ___________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
www.voddermld.com/b
Patient: With your therapist, each LE
therapy or management technique is
considered; therapist suggests
treatments appropriate to you and your
preferences. Be candid about what you
are willing and able to do.
to manage your LE.
Therapist: Be sure to involve the
patient’s physician in treatment plan.
The patient may keep these forms,
so make copies for clinic file.
My Turn
181
Clinician: Help patient prepare this worksheet after completing the Treatment Protocol. Ask patient to make the
entries. It may provoke adjustments to the Treatment Protocol as other considerations are brought to the fore.
Things to know about my Lymphedema – A review of my progress so far:
My turn to interview the Practitioner!
• What type of lymphedema do I have (primary or secondary)?
______________________________________________________
• What other conditions / symptoms do you suspect need further diagnosis by a physician?
___________________________________________________________________________________________________________________________________________________________________________
• How can you be sure that my swelling is due to lymphedema and not another underlying
medical condition?
______________________________________________________________________________________________________________________________________
• What further investigation might be needed or recommended to establish the diagnosis?
___________________________________________________________________________________________________________________________________________________________________________
• What is the stage of my lymphedema (Stage 0, 1, 2, or 3)? See Appendix A
__
___________________________
• What are the treatment options for my lymphedema? See Section 3, and Section 5 CDT
__
_
___________________________________________________________________________________________________________________________________________________________________________
• Who else will be involved in my treatment and how will I put a team together?
_______________________
___________________________________________________________________________________________________________________________________________________________________________
• What are the advantages and disadvantages of each of the treatments? See Section 5 CDT
_
• What monitoring will be appropriate to measure the effectiveness of my treatment plan?
___________________________________________________________________________________________________________________________________________________________________________
• How long will I have to continue treatment?
• Who should I contact with questions?
________________________________________________________________________________________
___________________________________________________________________________________________________
• What types of activities should I avoid during and after treatment? See Section 4 Risks
__
• What other types of support do you offer or suggest for patients with lymphedema?
________
____________
__________________________________________________________________________________________________________________________________________________________________________
I agree to work with my physician and dietician in conjunction with my MLD practitioner.
___________________________________________________________________________________________________________________________________________________________________________
I am still wondering about:
________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________________________
Name:
www.voddermld.com/b
___________________________________________________________________________
Date:
______________________
189
45
The forms in Section 3 support LE patient care protocols.
Blank forms are single sided to copy from back of book, or download (fee), customize, print, fill out on
computer, and save to computer. Forms are also in Patient Handbook.
Blank Form on page:
Wellness Action Plan (Long Form)
Patient Entry
277
Wellness Action Plan (Short Form)
Patient Entry
289
Choose Short Form (example on page 48) or,
Choose Long Form (start on page 49) print or give Patient HANDBOOK to
patient before proceeding.
Short Form is condensed for use when appropriate.
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Long Form includes therapist notes and protocol suggestions.
Therapist: Author recommends Long Form for recently diagnosed patients. The Long Form in
this Section is blank so therapist can enter general notes applicable to multiple patients.
My Turn
Blank Form on page:
Patient Entry
295
download and customize the computer fillable forms and add clinic/practitioner name, etc. (fee)
Hand out: Give patient a LYMPHEDEMA Wellness Manual Patient HANDBOOK.
Patient: In support of managing your lymphedema, we follow a process to explore all your needs
and concerns. The therapist strives to make this process as easy and understandable as possible.
Thank you for your participation.
The following is an interactive review of suggested strategies to support your individual secondary
lymphedema management needs including self-care, treatments, and more.
Use a blank form from back of book, or your LYMPHEDEMA Wellness Manual
Patient HANDBOOK to make notes as you work with the therapist on the protocol.
Therapist: Author recommends Long Form for first few interviews, thereafter consider use Short
Form. The Long Form in this Section is blank so therapist can enter general notes applicable to
multiple patients in future interviews.
Therapist: The care recommendations of a lymphedema therapist do NOT replace a needed
comprehensive clinic-based program of Phase I CDT (inpatient / intensive CDT) with physician
monitoring. It is the intent of this Manual to primarily support a Phase II CDT (outpatient or followup treatment plan) for ongoing LE maintenance.
46
Section 3 Individual Treatment Protocol
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The lymph vessels and structures of the skin.
47
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Individual Treatment Protocol: Wellness Action Plan (WAP Short Form)
48
Section 3 Individual Treatment Protocol
Individual Treatment Protocol: Wellness Action Plan (WAP Long Form)
Patient Name ______________________________________ Date: ___________________
Lymphedema (LE): Left Arm
_________________________
Right Arm
_________________________
Left Leg
_________________________
Right Leg
_________________________
Other
___________________________________________
Therapist: Prepare an Individual Treatment Protocol in consultation with the patient. Give patient a
Wellness Action Plan (WAP) 6 pg. or 3 pg., in session to mark up and retain. (Always keep a file copy).
Use Therapist Notes on long form as a guide. Adapt and adjust the Wellness Action Plan as appropriate.
A thorough intake is necessary to select LE care recommendations. Regular follow-up is essential.
Scale 1 - 3

♦

♦
Therapist Notes
How will I know if secondary LE is
developing, either post-surgery or for anyone
at risk?
What are the early signs of LE?
There is a better chance of limiting the effects of
LE through early detection / diagnosis.
Pt. Self Care /Therapies 1
 Early signs or symptoms of lymphedema:
■ Clothing or jewelry, e.g. sleeve, shoe or ring,
becoming tighter
■ Feeling of heaviness, tightness, fullness or stiffness
■ Aching
■ Observable swelling
_____________________________________________________________________________________________
u
________________________________________________________________________________________________________________
____________________________________________________________________________________
Post surgery and all patients LE prevention.
What should I do before I actually develop LE?
 Preventive Measures (See Section 4 Risk
Factors)
■ Take good care of skin and nails
■ Maintain optimal body weight
■ Eat a balanced diet
■ Avoid injury to area at risk
■ Avoid tight underwear, clothing, watches and jewelry
■ Avoid exposure to extreme cold or heat
■ Use high factor sunscreen and insect repellent
■ Wear prophylactic compression garments, if prescribed
■ Undertake exercise/movement and limb elevation
■ Wear comfortable, supportive shoes
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Priority
What should I do if I suspect latent LE?
What are the risks of aggravating my existing
lymphedema?
u
Therapist: Perform assessment. If LE is present,
continue through the entire checklist.
See Section 5 Patient Education for information.
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________

♦

♦
Post surgery patients (secondary LE)
What are the risks of aggravating my existing
lymphedema?
u
___________________________________________________________________________________________________________________________________________
Health Goal & Wellness Manual
Patient evaluates own health status, decides on
desired outcome, and sets goals to achieve the
outcome, while working with therapist.
Set goals for each portion of the Wellness Action
Plan HERE:
u
♦

♦
 Individual Treatment Protocol: In consultation
with physician & lymphedema therapist, determine
action plan in Wellness Manual using appropriate
therapies and related health modalities. Enter overall
goal HERE:
________________________________________________________________________________________________________
_________________________________________________________________________________________

 Secondary LE: Breast cancer patients have an
expectancy of 50% developing a skin infection. Of
those, 20% or more will develop repeated skin
infections over time.
_________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
Self monitoring & therapist monitoring
needed for improving wellness and achieving
goals
Monitoring your LE care should be scheduled.
u
 Checking in and maintenance plan: (More later)
Routine and frequent monitoring of results measured
against plans and goals is important as we set
objectives.
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
Wound, Ulcer, or Fungus present?
If present, consultation with wound care clinic /
physician / specialist is needed. MLD often will
greatly assist in wound healing, scars, etc.
 Wound / ulcer / fungus-care guidelines: Action
plan for immediate intensive treatment. Manual lymph
drainage (MLD) may be used to enhance care and
speed-up healing of wounds, scars, venous ulcers, etc.
Consult a Lymphedema or Wound Care clinic now.
See Section 9 Resources for more information.
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
u
See NLN Clinic Locator in Section 9 Resources or visit
www.VodderMLD.com/b How To Locate a Clinic.
________________________________________________________________________________________________________________________________________
49
- - - - - - - - ASSESSMENT & PROTOCOL - - - - - - - -
SECTION 4: RISK FACTORS
61
Action
64
Expert Opinion
64
Expert Opinion
66
Expert Opinion
67
Recommend
70
Some benefits/risks
71
Expert Opinion
71
Expert Opinion
71
Expert Opinion
72
Expert Opinion
73
Likely Benefit
75
Not Recommend
76
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Risk Factors / Risk Reduction & Safe Practices Checklist
NLN Paper: Lymphedema Risk Reduction Practices
Lymphedema After Cancer Treatment
Lymphedema After Cancer Treatment; Factors & Myths
Treatment of LE Related Infections,
Prophylactic Antibiotics for Recurrent Infections
Blood Pressure & Venipuncture
Acupuncture
NCI General Precautions List
Air Travel Precautions
Obesity, Weight, Diet and Foods
Lymphedema Stimulating Massage Caution, Contraindicated
Preventing Cellulitis — A personal story
Prevention of Lymphedema: A Study Using MLD
78
Objective: Review risk factors for triggering LE or aggravating existing LE; includes
cautions for skin infections and rating certain other risks.
*COPY NEEDED FORM(S) IN BACK OF BOOK BEFORE STARTING THIS SECTION
CLINIC / PRACTICE __________________________________________________
Risk Factors
restrictive jewelry i.e. knee highs, girdle, tight bra, elastic cuffs,
garter, tight jewelry or rings; use soft pads under bra straps for
arm edema.
_________________________________________________________________________________________________________________________________________________________
! Acupuncture: Skin infection is a possibility. A needle opens
a pathway for bacteria. For patients who insist on acupuncture,
sterilized needles may be used in areas remote from the edema.
If acupuncture is used, inform the provider of your lymphedema and
request maximum infection control precautions.
_________________________________________________________________________________________________________________________________________________________
! Deep Tissue Massage: Avoid deep tissue massage / deep
treatments on the affected limb that cause redness of the skin, as
this increases blood flow (filtration) and probable swelling.
_________________________________________________________________________________________________________________________________________________________
_
! Injections / Blood draws:
Never allow injections or blood
! General skin care:
Use oven mitts.
- You may immerse hands in water only up to 102° F.
- Keep skin clean and dry at all times, always wear gloves,
- Use Lymphoderm™ lotion to prevent chapping, cracking,
- Avoid Pedicure or Manicure in affected limb,
- All nail care done only by informed & trained specialist,
- Never cut cuticles, tell Manicurist before service,
- Use sunscreen (SPF30), non-drying insect repellent.
_________________________________________________________________________________________________________________________________________________________
! Cellulitis (includes erysipelas / lymphangitis):
A lethal,
fast-moving skin infection affecting many lymphedema patients
repeatedly. Can occur from any wound/chafing/break to the skin
in affected limb; from ill-fitting or overuse / sleeping in day
compression garments, and from unidentified causes.
TIP: If redness, itching, pain, rash, swelling, increased skin
temperature, fungus, fever, or if flu-like symptoms occur, contact
your physician immediately (NO DELAY, SERIOUS DANGER).
________________________________________________________________________________________________________________________________________________________
! First Aid: If cut, scratched, pricked, or hangnail, etc., wash
draws in affected limb(s).
_________________________________________________________________________________________________________________________________________________________
! Blood Pressure Test:
Never allow blood pressure cuff on
affected limb(s). Do not allow automatic BP tests. Limit inflation
of manual cuff to 20 mmHg. above baseline BP.
_________________________________________________________________________________________________________________________________________________________
! Razor Cuts:
Use only safe type electric razor, maintained in
top condition (to prevent safety razor cuts).
_________________________________________________________________________________________________________________________________________________________
! Triggers: Use all possible precautions to prevent any
abrasion, burn, sunburn, bruise, insect bite (mosquito, bee, flea,
etc.), animal bite, cat or thorn scratch, puncture, infection, etc.
Blood loss also aggravates edema.
Wear gloves for gardening, dish washing. Do not cut cuticles
during manicure. See physician immediately if signs of infection
exist, or any rash or hot skin feeling, suggesting cellulitis, etc.
Such infections can go systemic rapidly, resulting in death.
_________________________________________________________________________________________________________________________________________________________
! Heavy Lifting:
Do not do any heavy lifting. Observe a
maximum weight limit of 12 pounds. Do not carry heavy purses
on either shoulder.
_________________________________________________________________________________________________________________________________________________________
!
Temperature Extremes: High temperature situations must
be avoided including hot showers, baths, sauna, hot tub, tanning
salon, hot packs, direct sunlight, infrared, peloids, paraffin bath,
mud bath, hair dryer (beauty parlor ), and cosmetic heat facials.
Low temperature extremes must be avoided, as rebound
swelling and chapping can occur.
_________________________________________________________________________________________________________________________________________________________
! Exercise Plan: Extreme weight training or rigorous work the
to point of fatigue or pain is not OK (Max 12 lb. lift). Use light
aerobics, bicycle, swimming, walking. No extreme stress in
affected limb(s) such as heavy repetitive use (scrubbing, pulling).
_________________________________________________________________________________________________________________________________________________________
! Pregnancy Avoid MLD during the first months of pregnancy
or when there are complications. In uncomplicated pregnancies
MLD can be used until the very end particularly on legs / breasts.
thoroughly with soap and water, apply antibiotic ointment,
protect wound, watch for infection; seek medical care at first
sign of redness/heat/tenderness/swelling, etc.
_________________________________________________________________________________________________________________________________________________________
! Elective Surgery:
Elective (and especially cosmetic)
surgery decisions should always include prior consultations with
your physician and MLD therapist, as complications may result
that cause or complicate lymphedema.
_________________________________________________________________________________________________________________________________________________________
_
! Other Surgery: Surgery decisions should include joint
consultations with your physician, oncologist, and surgeon, as
removal of lymph nodes and other tissues may result in
complications in lymphedema patients.
_________________________________________________________________________________________________________________________________________________________
! Eat Safely & Properly: Eat a low sodium, high fiber,
balanced, fresh live food diet. Maintain your optimal weight.
Avoid alcohol and smoking. Tell physician and caregivers of all
medications, reactions, conditions, questions, and skin changes.
_________________________________________________________________________________________________________________________________________________________
! Dieting or diuretics can aggravate lymphedema or overall
health. Do not use diuretics for LE, or try radical diets. Consult
physician / nutritionist for proper dietary guidelines and
alternatives to using diuretics to control lymphedema swelling.
_________________________________________________________________________________________________________________________________________________________
WELLNESS Manual
! Air Travel: Avoid flying. If you must travel by air,LYMPHEDEMA
or drive to /
live at high altitudes (over 5,000’), wear appropriate well-fitting
compression garments and/or bandages.
It is advisable for Risk
patientsFactors:
who wear arm-sleeves
to also wear
a
Treatment
of Infections
hand-piece when travelling by airplane.
Lymphedema patients have a greatly
_________________________________________________________________________________________________________________________________________________________
increased
risk
infection.
Immediate
! Leg Edema
Precautions:
Avoidof
prolonged
standing or
sitting; avoid hospitalization
crossing legs; wear proper,
well-fitting shoes
with
is indicated
if symptoms
good toe protection. Buy special electric razor. Wear all
include: garments and night garments.
prescribed compression
!"
Fever,
confusion,
vomiting,
hypotension, or tachycardia,
! #ymptoms continue despite oral
antibiotics for 48 hours
!" Unresolved local symptoms despite
first- and second-line oral antibiotics.
Approximately 20% of lymphedema
patients have recurrent skin infections.
The greatest cause of these recurrent skin
infections (cellulitis usually includes
erysipelas / lymphangitis / lymphadenitis
or related infections) is failure to comply
with the prescribed drug treatment plan.
The risk of failure to recognize early the
presence of an infection in a limb is that
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
www.voddermld.com/b
Patient: Review risks with your therapist
using a risks checklist from back of book.
Read and ask questions. Be cautious,
appropriate to your susceptibility to risks,
while still engaging fully in life.
Patient Safe Practice Guidelines
The risk factors for triggering or aggravating LE or skin infections.
! Constrictive Apparel: Do not wear restrictive clothing or
187
Recommended
the infection could become systemic and
result in death. Basic penicillin class
drugs should be administered as soon as
possible and continue for at least two
weeks or until signs of the infection have
completely resolved. An alternative for
patients
allergic
to
penicillin
is
clindamycin.
Acute infection with fever is a
contraindication for manual lymph
drainage. Generally a compression
garment is avoided during the active
phase
of
an
infection;
however
excessively long periods without use of
compression are also not recommended,
so light compression may be indicated.
An increase in post infection CDT to
reduce limb volume is supported in the
literature.
Erysipelas
Therapist: Guide patient through
LE risks and cautions.
(Defined)
Erysipelas is a painful skin infection that affects the skin plus the subcutaneous tissues and lymphatic structures that are
located just under the skin. (Cellulitis affects the deeper tissues.) Erysipelas also requires prompt treatment with antibiotics, is
caused by the bacteria streptococci, invades rapidly, and spreads through the lymphatic vessels, damaging the lymph vessels
and increasing the formation of fibrosis in the affected tissues. It also is one of the most common complications of lymphedema,
tends to recur, and is correlated with stage of lymphedema.
SOURCE: Poage E, et al. 2008.
1
NLN Position Statement
Skin and Nail Care
Meticulous hygiene is recommended to decrease the amount of fungus and bacteria on the skin. Low pH
moisturizers should be applied to keep skin from drying and cracking. Cracks and dry areas of the skin are entry
points for bacteria and fungus, which can result in infections and wounds. Skin infections are known as cellulitis
(or erysipelas). Cellulitis is a serious infection of the skin that requires antibiotic treatment in people with
lymphedema.
SOURCE: NLN Position Statement. 2011.5
Essential Self Care
Since lymphedema is a life long condition, patient education in self management is very important. To reduce the
risk of developing lymphedema or having lymphedema worsen, all patients with lymphedema or at risk for
lymphedema should be instructed in essential self care. The important areas of education include risk reduction
practices, self lymph drainage, skin care, signs and symptoms of infection, proper fit and care of garments, and the
importance of good nutrition, exercise and weight control.
SOURCE: NLN Position Statement. 2011.5
72
57
The forms in Section 4 support patient education about LE risks.
Blank forms are single sided for copying from back of book, or download (fee), customize, print, fill out
on computer, and save to computer. Forms are also in Patient Handbook.
Blank Form on page:
Patient Risk Factors (Long Form)
Patient Entry
297
Patient Risk Factors (Short Form)
Patient Entry
303
Choose Short Form (example on page 60) or,
Choose Long Form (start on page 61) print or give Patient HANDBOOK to
patient before proceeding.
Short Form is condensed for easy patient reference.
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Long Form includes a more complete discussion of risks.
Therapist: Author recommends Long Form for recently diagnosed patients. The Long Form in this
Section is blank so therapist can enter general notes applicable to multiple patients.
download and customize the computer fillable forms and add clinic/practitioner name (fee).
Hand out: Give patient a LYMPHEDEMA Wellness Manual Patient HANDBOOK.
Patient and Therapist: This section covers the known or suspected risks for triggering secondary
lymphedema or aggravating an existing lymphedema. Note those risks that apply to the part of the
body affected by your lymphedema.
There is little evidence-based literature regarding many of these risk reduction practices. These
recommendations are based on knowledge of pathophysiology and clinical experience of experts.
Infections: Many risk factors are based on the fact that any opening in the skin, no matter how
small, is a pathway for pathogens that can initiate an infection of the skin in at-risk or LE patients.
Such infections are extremely risky and could result in death. Some precautions are listed in order to
increase awareness of such risks, and are NOT always based on documented medical incidents.
Skin infections known collectively as cellulitis or erysipelas are mentioned here. Cellulitis is not a
risk factor for lymphedema: it is a complication; prophylactic antibiotics are for prevention of
infection.
However, due the lack of another section more appropriate to the subject, these frequent and
recurring complications of lymphedema, and its prophylaxis, are discussed in this section.
Use a blank form from back of book, or your LYMPHEDEMA Wellness Manual Patient
HANDBOOK to make notes as you work with the therapist on the protocol.
58
Section 4 Risk Factors
The initial lymph vessel (ILV) structure cross-section.
Understanding
Lymphedema
INITIAL
LYMPH VESSEL
Anchoring Filament
(Collogen)
LCT
Cells
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Reticular Fibers
Endothelial
Cells
Lumen
(Space)
Initial Lymph Vessel (ILV)
The smallest lymph vessel is the Initial Lymph Vessel (ILV), starting blind in the LCT. The endothelial
ILV: Initial lymph vessel
LCT: Loose Connective Tissue
ILLUSTRATION COURTESY OF: Leif B. Meyer
59
Risk Factors: Risk Reduction & Safe Practices Worksheet (Short Form)
CLINIC / PRACTICE __________________________________________________
Risk Factors
Patient Safe Practice Guidelines
Patient: Suspected risk factors for triggering LE, aggravating existing LE; or causing skin infections. Sec. 4.
✔ Constrictive Apparel: Do not wear restrictive clothing or

✔ General skin care: Use oven mitts.

restrictive jewelry i.e. knee highs, girdle, tight bra, elastic cuffs,
garter, tight jewelry or rings; use soft pads under bra straps for
arm edema. Use cotton socks and clothes.
- Immerse hands in water only up to 102° F.
- Keep skin clean and dry at all times, always wear gloves,
- Use Lymphoderm™ lotion to prevent chapping, cracking,
- Avoid Pedicure or Manicure in affected limb,
- All nail care done only by informed & trained specialist,
- Never cut cuticles, tell manicurist before service,
- Use sunscreen (SPF30 +), non-drying insect repellent.
OK
_________________________________________________________________________________________________________________________________________________________
✔ Acupuncture: Skin infection is a possibility. A needle opens

a pathway for bacteria. For patients who insist on acupuncture,
sterilized needles may be used in areas remote from the edema.
If acupuncture is used, inform the provider of your lymphedema and
request maximum infection prevention precautions.
OK
_________________________________________________________________________________________________________________________________________________________
✔ Deep Tissue Massage: Avoid deep tissue massage / deep

__________________________________________________________________________________________________________________________________________________________
✔ Injections / Blood draws: Never allow injections, IVs,

or
blood draws in affected limb(s).
Yes
_________________________________________________________________________________________________________________________________________________________
✔ Blood Pressure Test: Never allow blood pressure cuff on

affected limb(s). Do not allow automatic BP tests. Limit inflation
of manual cuff to 20 mmHg above baseline BP.
Yes
_________________________________________________________________________________________________________________________________________________________
✔ Razor Cuts: Use only safe type electric razor, maintained in

top condition (to prevent safety razor cuts).
OK
_________________________________________________________________________________________________________________________________________________________
✔ Triggers: Use all possible precautions to prevent any

abrasion, burn, sunburn (30 SPF apply often), bruise, insect bite
(mosquito, bee, flea, etc.), animal bite, cat or thorn scratch,
puncture, infection, etc. Blood loss also aggravates edema.
Wear gloves for gardening, dish washing. Do not cut cuticles
during manicure. See physician immediately if signs of infection
exist, or any rash or hot skin feeling, suggesting cellulitis, etc.
Such infections can go systemic rapidly, resulting in death.
Yes
_________________________________________________________________________________________________________________________________________________________
✔ Heavy Lifting: Do not do any heavy lifting or repetitive lifting.

Observe a maximum weight limit of 12 pounds. Do not carry
heavy purse on either shoulder. Use strap pad for purse, luggage
OK
_________________________________________________________________________________________________________________________________________________________
✔ Temperature Extremes: High temperature situations must

be avoided including hot showers, baths, sauna, hot tub, tanning
salon, hot packs, direct sunlight, infrared, peloids, paraffin bath,
mud bath, hair dryer (beauty parlor), and cosmetic heat facials.
Low temperature extremes must be avoided, as rebound
swelling and chapping can occur. No cold showers.
OK
_________________________________________________________________________________________________________________________________________________________
✔ Exercise Plan: Heavy weight training or rigorous work the to

point of fatigue or pain is not OK (Max 12 lb. lift). Use light
aerobics, bicycle, swimming, walking. No extreme stress in
affected limb(s) such as heavy repetitive use (scrubbing, pulling).
Shower after swimming, dry completely, especially all skin folds.
OK
_________________________________________________________________________________________________________________________________________________________
✔ Pregnancy Avoid MLD during the first months of pregnancy

or when there are complications. In uncomplicated pregnancies
MLD can be used until the very end particularly on legs / breasts.
Not for me!
_________________________________________________________________________________________________________________________________________________________
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60
_________________________________________________________________________________________________________________________________________________________
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EXAMPLE
treatments on the affected limb that cause redness of the skin, as
this increases blood flow (filtration) and probable swelling.
Yes
]
]
]
]
]
]
]
✔ Cellulitis (includes erysipelas / lymphangitis, etc.): A

lethal, fast-moving skin infection affecting many lymphedema
]
patients repeatedly. Can occur from any wound/chafing/break to
]
the skin in affected limb; from ill-fitting or overuse / sleeping in
]
day compression garments, and from unidentified causes.
]
TIP: If redness, itching, pain, rash, swelling, increased skin
temperature, fungus, fever, or if flu-like symptoms occur, contact ]
your physician immediately (NO DELAY, SERIOUS DANGER).
]
✔ First Aid: If cut, scratched, pricked, or hangnail, etc., wash ]

thoroughly with soap and water, apply antibiotic ointment,
]
protect wound, watch for infection; seek medical care at first
sign of redness/heat/tenderness/swelling/pain (infection), etc.
]
OK - Yes
]
]
✔ Elective Surgery: Elective (and especially cosmetic)

surgery decisions should always include prior consultations with ]
your physician and MLD therapist, as complications may result
]
that can lead to, cause, or complicate lymphedema.
]
Yes
]
✔ Other Surgery: Surgery decisions should include joint

consultations with your physician, oncologist, and surgeon, as ]
removal of lymph nodes and other tissues may result in
]
complications in lymphedema patients.
]
Yes
]
✔ Eat Safely & Properly: Eat low sodium, high fiber, fresh live

]
food balanced diet. Maintain your optimal weight. Avoid alcohol
and smoking. Tell physician and caregivers of all medications, ]
reactions, conditions, questions, and skin changes. Drink water. ]
OK
]
✔ Dieting or diuretics can aggravate lymphedema or overall ]

health. Do not use diuretics for LE, or try radical diets. Consult
]
physician / nutritionist for proper dietary guidelines and safer
]
alternatives to diuretics to control lymphedema swelling.
OK
]
✔ Air Travel: Avoid flying. If you must travel by air, or drive to / ]

live at high altitudes (over 5,000’), wear appropriate well-fitting ]
compression garments and/or bandages.
It is advisable for patients who wear arm-sleeves to also wear a ]
]
hand-piece/glove/gauntlet when travelling by airplane.
OK
]
]
✔ Leg Edema Precautions: Avoid prolonged standing or

sitting; avoid crossing legs; wear proper, well-fitting shoes with ]
good toe protection. Buy special electric razor. Wear all
]
prescribed compression and night garments. Replace worn
compression garments. Above all, stay physically active. Wear ]
closed-toe shoes that don’t constrict the feet when outside.
]
Prevent. treat ingrown nails immediately.
]
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
___________________________________________________
215
Section 4 Risk Factors
Risk Factors: Treatment of Infections
Cellulitis/Erysipelas
♦ Expert Opinion
Patients with lymphedema are at increased risk of acute cellulitis/erysipelas, an infection of the skin and
subcutaneous tissues. The cause of most episodes is believed to be Group A â-haemolytic streptococci.
Staphylococci or other bacteria may also cause it…
Good skin care reduces the likelihood of cellulitis/erysipelas, and consequently the need for antibiotics.
Symptoms are variable. Episodes may come on over minutes, remain subacute over several weeks or be
preceded by systemic upset. Symptoms include pain, swelling, warmth, redness, lymphangitis, lymphadenitis and
sometimes blistering of the affected part. More severe cases have a greater degree of systemic upset, e.g. chills,
rigor, high fever, headache and vomiting. In rare cases, these symptoms may be indicative of necrotizing fasciitis.
The focus of the infection may be tinea pedis (athlete's foot), venous eczema, ulceration, ingrowing toe nails,
scratches from plants or pets, or insect bites…
Prompt treatment of cellulitis/erysipelas is essential to prevent further damage that can predispose to recurrent
attacks.
Criteria for Hospital Admission
♦ Expert Opinion
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The patient should be admitted to hospital if they show:
■ signs of septicemia (hypotension, tachycardia, severe pyrexia, confusion or vomiting)
■ continuing or deteriorating systemic signs, with or without deteriorating local signs, after 48 hours of oral
antibiotics
■ unresolving or deteriorating local signs, with or without systemic signs, despite trials of first and second line oral
antibiotics. It is essential that patients with cellulitis/erysipelas, who are managed at home, are monitored closely,
ideally by the general therapist.
Exclude:
■ other infections, e.g. those with a systemic component
■ venous eczema, contact dermatitis, intertrigo (chafing), microtrauma and fungal infection
■ acute deep vein thrombosis
■ thrombophlebitis
■ acute lipodermatosclerosis
■ lymphangiosarcoma (Stewart-Treves syndrome)
Swab any exudate or likely source of infection, e.g. cuts or breaks in the skin.
Before commencing antibiotics establish:
■ extent and severity of the rash–mark and date the edge of the erythema
■ presence and location of any swollen and painful regional lymph nodes
■ degree of systemic upset
■ erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) and white cell count.
Commence antibiotics as soon as possible, taking into account swab results and bacterial sensitivities when
appropriate. During bed rest, elevate the limb, administer appropriate analgesia (e.g. paracetamol or NSAID), and
increase fluid intake.
Avoid: SLD and MLD. If tolerated, continue compression at a reduced level or switch from compression garments
to reduced pressure MLLB. Avoid long periods without compression.
Recommence usual compression and levels of activity once pain and inflammation are sufficiently reduced for the
patient to tolerate. Educate patient/carer – [about] symptoms, when to seek medical attention, risk factors,
antibiotics 'in case', prophylaxis if indicated.
Antibiotic regimens:
Antibiotic regimens for cellulitis/erysipelas in lymphedema vary according to the clinical situation. Antibiotics should
be continued for at least 14 days after an acute episode has responded clinically to treatment. It may take one to
two months of antibiotic treatment to achieve complete resolution.
28
69
Risk Factors: Recurrent Infections
Lymphedema patients who have an initial cellulitis are likely to experience repeat infections (cellulitis / erysipelas and other infections). Patients who have a history of two or more infections per year should consult competent medical experts for evaluation of the prophylactic use of antibiotics. Such patients should also carry an emergency or backup supply of an appropriate prescribed antibiotic to be taken when symptoms of an infection first appear. If you have persistent symptoms such as fevers, chills, or if general constitutional symptoms of infection develop, immediate hospital admission is recommended, in the literature. (See above) The selection of suggested antibiotics have been published in various consensus documents and articles. These recommendations should be taken into consideration when making a decision regarding the antibiotic used to treat an infection, or the choice for prophylaxis. The suggested medications usually include penicillin (or clindamycin or erythromycin if the patient has a penicillin allergy) in the literature. ♦ Expert Opinion
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Recurrent Infections
Recurrent infections, especially cellulitis (a skin infection) and/or lymphangitis (infection of the lymph vessels):
Cellulitis occurs in up to 50% of patients with lymphedema and is caused by a common pathogen called betahemolytic streptococcus [or other pathogens]. Patients are highly prone to reinfection since there is an inadequate
response of the immune system, which affects prevention as well as overcoming infection. Signs of infection of the
skin and subcutaneous tissue include:
• redness
• elevated skin temperature
• pain
• swelling
• fever, chills
It is critical that treatment for any infection be initiated immediately since, if left untreated, localized infection can
result in abscess, tissue degeneration, and/or sepsis (generalized infection) which is much more difficult to treat.
SOURCE: Medifocus.com, Inc. 2010.
10
ISL International Consensus Document
Drugs
c. Antimicrobials:
. . . If repeated limb “sepsis” recurs despite optimal CPT [CDT], the administration of a prophylactic
penicillin or broad spectrum antibiotic is recommended. Fungal infection, a common complication of
extremity lymphedema, can be treated with antimycotic drugs (e.g., flucanozole, terbinafine). In most
instances, washing the skin using a mild disinfectant followed by antibiotic-antifungal cream is helpful.
SOURCE: International Society of Lymphology. 2013.2(p57)
Please consult the original sources of the many quotations and studies for the full meaning in
context. See Appendix C References. Many studies and articles are available online, often at no
charge.
70
Section 5 CDT - Combined Decongestive Therapy
CDT: Compression Bandaging - Treatment Standards Guide
Standard Treatment Criteria
Moderate to severe lymphedema
Distorted shape
Lymphorrhea / broken skin
Subcutaneous tissue thickening
Tissue swelling (moderate to severe)
Factors affecting psychosocial morbidity
Commitment to treatment
Patient requires
lymphedema
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bandaging
DOES THE PATIENT HAVE
Neurological
Defi
cit
Lipedema
Palliative Needs
Fraility/reduced mobility
Arterial disease
Chronic venous
insuffi
ciency
and lymphedema
Venous ulceration and
lymphedema
YES ?
YES ?
YES ?
NO ?
YES ?
Is the patient obese/
elderly?
Does the patient have
reduced mobility?
NO ?
MODIFIED INTENSIVE
THERAPY WITH
REDUCED PRESSURE
STANDARD INTENSIVE
THERAPY WITH
HIGH PRESSURE
STANDARD INTENSIVE
THERAPY
INTENSIVE THERAPY
FOR VENOUS DISEASE
40(p6c1)
REFERENCE: Moffatt CJ, et al. 2005.
Therapist: For definitions of the INTENSIVE THERAPIES in chart above see prior page.
97
CDT: Compression Bandaging
Contraindications
Risks
■ Severe arterial insufficiency (ABPI <0.5), although modified MLLB with reduced pressures
can be used under close supervision
■ Uncontrolled heart failure
■ Severe peripheral neuropathy
Caution required: cellulitis/erysipelas: CB can be continued, if tolerated, at reduced pressure); diabetes mellitus,
paralysis, sensory deficit, controlled congestive heart failure: application of CB to one limb at a time may be
advisable.
28(p32)
Compression Bandaging (CB) Terms and Definitions
♦ Expert Opinion
Recoil force: Force within the bandage that returns the bandage to its initial length from a stretched state. The
greater the amount of rubber (elastic), the greater the recoil force.
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Resting pressure: Pressure exerted by the bandage on the extremity without movement.
Working pressure: Pressure exerted by the bandage on the extremity with movement.
®
Long-stretch material– rubber-elastic:
• High resting pressure
• Minimal working pressure
[ACE -Type]
Short-stretch material– textile-elastic:
• Minimal resting pressure
• High working pressure
[desirable for lymphedema]
When to Use CB
73(p13)
♦ Expert Opinion
• During the intensive drainage phase (must be adjusted daily to the changing extremity volume)
• If the garment is not yet available
• If the garment alone is not sufficient In case of skin wounds (weeping eczema, fistulas, ulcer)
Types of bandages used:
• Short-stretch bandage: low resting pressure, high working pressure for all lymphedemas.
• Long-stretch bandage: high resting pressure, low working pressure
1. Phlebedema
2. Paralysis (no active movement possible)
Major Cautions: • Arterial occlusive disease; • Neuropathy; • Paralysis
73
National Cancer Institute’s PDQ cancer information summary about lymphedema states the issue succinctly:
“Bandages:
Once the lymph fluid is moved out of a swollen limb, bandaging (wrapping) can help prevent the area from
refilling with fluid. Bandages also increase the ability of the lymph vessels to move lymph along.
Lymphedema that has not improved with other treatments is sometimes helped with bandaging.”
98
CDT: Compression Bandaging - ILF Best Practices Report
Best Practice for the Management of Lymphedema - 2nd ed. (2012)
♦ Expert Opinion
Compression Therapy: A position document on compression bandaging
About this document
‘Best Practice for the Management of Lymphoedema - Compression Therapy: A position document’, represents an
international multidisciplinary initiative led by the International Lymphoedema Framework (ILF) in association with the
American Lymphedema Framework Project (ALFP) and the Canadian Lymphedema Framework (CLF). For clarity
and simplicity, this document pertains to compression bandaging only; other compression methods such as
Intermittent Pneumatic Compression (IPC) and hosiery will be the topic of a later document.
The ILF … believes that a large, bulky document which attempts to cover all aspects of decongestive lymphatic
therapy (DLT) would not do justice to the needs of patients and practitioners world-wide. Therefore, it was decided to
build [12] individual, in-depth documents on topics that fall under the DLT ‘umbrella’. Each discreet section…
provides a model for best practice in the assessment, treatment and continuing management of lymphedema.
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The document contains broad practice standards applicable to the international lymphedema community for future
review, consensus building, and translation. Naturally, it is expected that practitioners will have undertaken the
relevant training and educational requirements before using the guidance here.
Summary Statements
[Entire summary is included here for clarity]
Summary of recommendations for compression bandaging in lymphedema management Level B evidence
(based on RCT and systematic review evidence) [randomized controlled clinical trials]
Findings from a recent Cochrane systematic review have shown that bandaging and compression hosiery
are more effective at reducing and maintaining limb volume over 6 months than using compression hosiery
alone.
àBandaging is used throughout the management of lymphedema
• Within a period of intensive DLT [CDT]
• In combination with compression hosiery/devices in long term management
• In palliative care to aid symptom control
àSpecialist knowledge and skills are required for safe and effective application
Compression affects the venous, arterial, lymphatic and microcirculation
àCompression is only contraindicated in critical ischemia (ABPI < 0.5 or ankle systolic 50mmHg)
àCompression enhances arterial circulation in patients with mixed disease (ABPI 0.4-0.8) by removal of edema
àCompression removes edema by:
• Reduction in capillary filtration
• Increased lymphatic drainage
• Shift of fluid to non-compressed areas
• Breakdown of fibrosclerotic tissue
Criteria for an ideal compression system
àHigh stiffness, tolerable resting pressures to enhance patient adherence
àOptimal leg compression levels (40- 60mmHg at rest - 60 -90mmHg on standing)
àOptimal arm compression level (30mmHg at rest)
àDifferent levels of compression for lower and upper limbs are influenced by the effects of gravity and capillary
filtration rates
àHigher levels of pressure may impede lymphatic drainage and damage initial lymphatics
àCompression bandage profiles change over wear time due to edema reduction (50% pressure drop in 2 hours, two
thirds loss after 24 hours)
General recommendations for compression
àChronic edema/lymphedema requires constant compression, if discontinued edema [will] recur rapidly
Continued
99
CDT: Compression Garments
Recommended
As a component of CDT
CDT: Compression garments are generally used after the appropriate Phase I CDT has been completed and the desired limb volume reduction has been accomplished. Fitting a compression garment is critical and requires a specially trained therapist. There are specific contraindications for the use of compression garments listed below. The type of garment is critical and the construction and type of fabric is important. Proper care for the garment affects its term of use. Garments should be worn consistently, each day. Compression garment cannot be worn at night. There are many types of garments. Garments can be replaced after new measurements, when edema has been reduced, or at least 2 to 3 times each year. Some patients may be able to wear a night garment only. Garments are available in both off-‐the-‐shelf, and custom fitted. LE patients should consult their therapist to choose the appropriate compression garment. Compression Garment
(Defined)
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A compression garment is a knit two-way stretch sleeve or stocking that is worn to assist in controlling swelling and
to aid in moving lymph fluid from the affected area. It should be worn only while the patient is awake and active
(LymphNotes.com, 2006) and should be custom fitted for each patient.
SOURCE: Poage E, et al. (Oncology Nursing Society) 2008.
1
Compression Garment Indications
Indications
Compression garments can be used as initial management in patients who have mild upper limb
lymphedema (ISL stage I) with minimal subcutaneous tissue changes and shape distortion. Where there is
considerable soft pitting edema, MLLB (inelastic bandaging) will be required to reduce and stabilize the
swelling prior to the application of compression garments. In general, the level of compression used to
treat lymphedema of the upper limb is lower than that required for lower limb lymphedema. Lower
pressure compression garments also have a role to play in managing symptoms in a palliative context.
28(p10)
Criteria Indicating Patient Suitability For Compression Garments
■ Good dexterity
♦ Expert Opinion
■ Intact, resilient skin
■ No or minimal shape distortion
■ Absent or minimal pitting edema
■ Concordant and motivated
■ Ability to tolerate and manage hosiery (+/- carer support)
■ Swelling that can be contained by compression garments
■ Ability to monitor skin condition and engage in prevention strategies
■ Symptom-based management/palliative needs
28(p39)
Therapist: Compression garment use must be monitored carefully to avoid potential health risks.
For information on Intermittent Pneumatic Compression (IPC) see Section 6 Other on page 127.
101
CDT: Compression Garments
Contraindications to Compression Garments
Risks
■ Arterial insufficiency – ABPI <0.5 in the lower limb [incl. Arterial occlusive disease]
■ Acute cardiac failure
■ Extreme [limb] shape distortion
■ Very deep skin folds
■ Lymphorrhea, or other weeping skin condition
■ Extensive [skin] ulceration
■ Severe peripheral neuropathy
Caution required: cellulitis / erysipelas: if tolerated, patients can continue garment use or switch to reduced
pressure MLLB [CB]; also for sensory deficit, paralysis, fragile or damaged skin.
28(p39)
Types of Therapeutic Failure In Compression Garments
Risks
- incorrect fit
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“Incorrect treatment with compression stockings can impair the entire therapy. Most common mistakes are:
- incorrect grade of compression
- incorrect stocking quality
- incorrect type of treatment”
SOURCE: Weissleder H, et al. 2008.
18(p454)
Points To Include In A Compression Garment Prescription
■
Quantity of garments (at least two – one for wearing, one for washing)
■
Color
■
Manufacturer, style and garment code
■
Level of compression required
■
Knitted texture, i.e. circular knit or flat knit
■
Length
■
Fixation and attachment, if needed, e.g. silicone top, waist attachment
■
Sex of the patient
■
For ready to wear garments, state size
■
For custom garments, provide all measurements required by the mfr.
♦ Expert Opinion
28(p40)
Lymphedema Arm Sleeves, Gauntlets, and Gloves
Patient Information
These garments are designed to help control the swelling and should be utilized after you have undergone treatment
to reduce to the size of your arm. They are also used in conjunction with compression bandage.
A compression garment [may be] considered an alternative to bandaging. There are night garments now available
along with the more familiar day garments. The various garments and styles have different wearing and care
methods, as well as different methods and aids for donning or doffing.
REFERENCE: Moffatt CJ, et al. 2005.
40
For garment standards and garment vendor lists, Laplace’s Law, see Section 9 Resources page 170.
102
CDT: Compression Garments - Construction
Compression Garment Construction
Patient Information
The garment should completely cover the edema.
The type and compression class of the garment are determined by a physician. In addition, different variations and
combinations can be utilized, e.g. doubling the stocking on the lower leg with a single stocking on the upper leg. The
pressure of compression should only be as high as the patient can tolerate for an entire day of wear.
Circular-knit garments: the mesh count is the same in all areas of the garment, the mesh width changes according
to the dimensions of the body.
Advantages: affordable, visually pleasing.
Disadvantages: compression is suboptimal where there are large variations in the dimensions of the extremity;
tendency to roll up at the ends; abrasion in skin folds and joints
Flat-knit garments: an even mesh width but differing mesh counts
Advantages: exact fit for extreme variations in limb size, indispensable for large edemas.
Disadvantages: relatively expensive, visually un-pleasing.
73(p14)
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National Cancer Institute’s PDQ® cancer information summary about lymphedema states the issue succinctly:
“Pressure garments:
Pressure garments are made of fabric that puts a controlled amount of pressure on different parts of the
arm or leg to help move fluid and keep it from building up. Some patients may need to have these
garments custom-made for a correct fit. Wearing a pressure garment during exercise may help prevent
more swelling in an affected limb. It is important to use pressure garments during air travel, because
lymphedema can become worse at high altitudes. Pressure garments are also called compression sleeves
and lymphedema sleeves or stockings.”
For garment standards, leg garment monitoring, and vendors see Section 9 Resources page 170.
103
CDT: Exercise, Movement and Elevation
Recommended
CDT Exercise, movement and elevation includes a variety of low impact/low intensity exercises and therapies. The benefits include improved cardiovascular function, muscle strengthening, and improved range of motion/functional capacity. Exercise are designed for the individual patient. Exercise should be initiated slowly and build up over time. Exercise and should not be stopped suddenly but taper off if mild concerns intrude. Some of the benefits of exercise, movement, and elevation, have been found to include a return to normal levels of activity and upper limb volume reduction. Related benefits include a likely contribution towards weight reduction efforts and increase in limb strength. In some cases the need to wear the compression garment during exercise is reduced or eliminated at times. The competent therapist must work closely with the patient to develop an appropriate exercise plan, with professional guidance before doing heavy resistance training. Exercise (low intensity)
(Defined)
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Exercise may be beneficial for all patients. Although activity and exercise may temporarily increase lymph fluid
load, appropriate exercise may enable the patient with lymphedema to resume regular exercise and activity while
minimizing the risk of exacerbation of the swelling. Compression garments or compression bandages must be
utilized during exercise to counterbalance the excessive formation and stasis of interstitial fluid. Exercise plans
must be individualized for each patient. See NLN guidelines for specific guidelines. Lymphedema exercises
(decongestive exercises) are a standard and integral part of phase I and phase II complete decongestive therapy
programs for individuals with lymphedema.
SOURCE: Poage E, et al. (Oncology Nursing Society) 2008.
1
General Guidelines on Exercise
♦ Expert Opinion
■ Patients should be encouraged to maintain normal functioning, mobility and activity
■ Exercise /movement should be tailored to the patient's needs, ability and disease status
■ Patients should be encouraged to include appropriate warming up and cooling down phases as part
of exercise to avoid exacerbation of swelling
■ Compression should be worn during exercise [in most cases]
■ Experienced patients can help to demonstrate, teach and monitor exercise, and provide information
on access to local exercise programs
28(p41)
Types of Exercise
♦ Expert Opinion
■ start with low to moderate intensity exercise
■ paralyzed limbs can be moved passively
■ walking, swimming, cycling and low impact aerobics are recommended
■ heavy lifting and repetitive motion should be avoided [See PAL study and commentary page 142]
■ flexibility exercises maintain range of movement
28(p41)
For exercise procedures, guidelines, and opportunities see Section 7 Exercise page 133-on.
104
CDT: Exercise, Movement and Elevation
Exercise / Movement and Elevation
♦ Expert Opinion
Exercise /movement are common rehabilitative interventions used to reduce edema. At present, there is little
evidence to indicate which types, intensities and frequencies of exercise may be safely used in the management of
lymphedema.
Effects Of Exercise / Movement
Exercise improves muscular strength, cardiovascular function, psychological wellbeing and functional capacity.
Gentle resistance exercise stimulates muscle pumps and increases lymph flow; aerobic exercise increases intraabdominal pressure, which facilitates pumping of the thoracic duct.
Tailored Exercise / Movement Programs
Combinations of flexibility, resistance and aerobic exercise may be beneficial in controlling lymphedema, and should
be tailored to the individual patient. Physiotherapy referral is required for patients who have difficulty with mobility,
joint function or joint movement.
Elevation
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Elevation of the affected limb, ideally to just above the level of the heart, is often advised to reduce swelling. It is
thought that elevation acts by maximizing venous drainage and by decreasing capillary pressure and lymph
production.
Anecdotal evidence suggests that limb elevation when the patient is sitting or in bed may be a useful adjunct to
active treatment, but should not be allowed to impede function or activity. Patients should be encouraged not to sleep
in a chair and to go to bed at night to avoid the development of 'arm chair' legs or exacerbation of lower limb
lymphedema.
28(p47)
Exercise With Lymphedema After Breast Cancer
♦ Expert Opinion
The findings of this review support the growing body of evidence from the literature purporting that participation in an
exercise program does not exacerbate existing lymphedema in breast cancer survivors. Moreover, exercise was
found to reduce the severity of symptoms associated with lymphedema. This is an important finding, as lymphedema
31
and its symptoms may serve as deterrents to participation in regular physical activity and exercise. Research
evidence has demonstrated benefit from exercise in improving physical fitness, functioning, and quality of life in
40
breast cancer survivors. Moreover, observational data have shown a protective association between increased
41
physical activity after breast cancer diagnosis and recurrence, cancer-related mortality, and overall mortality.
Therefore, the evidence suggests that breast cancer survivors can safely follow a graduated exercise program to
achieve health and fitness without fear of worsening existing lymphedema.
SOURCE: McNeely ML, et al. ACS. 2010.
32(p11)
[Footnote numbers in quote above are not supported in this document. Please consult the original publication.]
Therapist: Exercise is shown to be effective when used in tandem with a regular program of MLD.
Patient: For more information about exercise, weight lifting study (PAL), and misconceptions clarified
see Section 7 Exercise page 142.
105
CDT: Exercise, Movement and Elevation – Hydrotherapy
Hydrotherapy - Aquatherapy Exercises
Patient Information
Note To Therapists and Patients:
The hydrotherapy exercises described in Section 7 should not be attempted without supervised instruction
from a qualified instructor. Key cautions include:
Ø Exercises should be performed in neutral temperature pool (90 - 91°F, i.e. skin temperature).
Ø Ideally water level should be above the heart.
Ø The exercises should be stopped when you become tired. Do not become exhausted.
Ø If patient has any cardiovascular concerns, patient should be observed more closely and only perform the
exercises under the prescription of a physician.
Ø When patients with lymphedema have open wounds, cellulitis or CHF, they should not perform these exercises.
Follow all guidelines and cautions carefully.
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US Agency for Healthcare Research and Quality, Technology Assessment Report
Aquatherapy
Aquatherapy [hydrotherapy], which consists of slow water based exercises, has been tried as a therapy
for lymphedema.51 The physiological rationale for the use of aquatherapy is based on the concepts of
hydrostatic pressure, water temperature, and water viscosity. Hydrostatic pressure increases with the
depth of water and lymphedematous limbs are thought to benefit from this pressure gradient through the
direction of interstitial fluid toward the trunk.51 Aquatherapy is performed in warm water to prevent capillary
vasodilatation and decreased flow that can occur at lower temperatures. Water viscosity provides
resistance to movement, which is believed to assist lymph flow via the muscle pump effect and promotes
muscle strengthening. At present there is very little literature examining the use or efficacy of aquatherapy
for lymphedema management.
SOURCE: Centers for Medicare & Medicaid Services (CMS). 2010.15(p13)
[Footnote numbers in quote above are not supported in this document. Please consult the original publication.]
For hydrotherapy exercise information see Section 7 Exercises page 135.
108
CDT: Patient Education
Recommended
Patient education as a component of CDT includes the necessary information that should be shared with all LE patients. This training includes not only information covered earlier in the book but adds any additional instruction regarding risks and exposures that are specific to the individual patient. This includes further information about clothing, footwear, garments, skin care, nail care, exercise, body weight, diet, nutrition, travel, environmental exposures, including the many concerns listed below. Ongoing Checklist
Patient Information
A copy of the checklist shown below should be given to all patients for frequent regular review.
Blank Form page:
Ongoing Checklist – LE Patient
Section 5
305
Patient Entry
CLINIC / PRACTICE __________________________________________________
Patient Action
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EXAMPLE
Ongoing Checklist – Lymphedema Patient
A) Skin Care to Prevent Injury or Infection
• Use neutral pH soaps to avoid excessive drying (ask pharmacist).
• Use moisturizing cream.
• Inspect skin folds and keep them clean and dry.
• Inspect for cuts, scrapes, abrasions, and insect bites.
• Wear protective gloves and garments when working outdoors, washing dishes.
• Use sunscreen and insect repellents.
• In hot climates, vegetable-based products are preferable to mineral oil- or petroleum-based products.
• Avoid extremes of temperature, both hot and cold.
• Avoid using scented products.
• If injury occurs, wash with soap and water, apply topical antibiotics, and monitor for redness, pain, or
swelling. If swelling, redness, fever, pain, occurs, contact a physician immediately.
• Avoid blood pressure, blood draws, IV, injections, or venipuncture on affected limbs.
• Avoid manicure, pedicure, cuticle trimming or push-back, ingrown nails.
• No chemical peels, no intense facials, scrubs, or chemical baths.
• Inspect the affected limb daily for any changes.
• Avoid scratches, cuts, abrasions, or other skin injuries.
• Avoid burns from cooking.
• Avoid prolonged exposure to heat, such as hot tubs or saunas.
• Use electric razor under arms.
• Wear comfortable, supportive shoes.
• Wear loose fitting jewelry and clothes.
• Wear light-weight breast prostheses.
• Avoid using the affected arm to lift or carry heavy objects.
• Elevate the affected limb daily or as needed.
B) MLD
• Use MLD as often as possible, as prescribed, appropriate to your lymphedema condition.
C) Compression
• Use compression garments & night garments as directed by physician or therapist.
• Use compression garments during air travel, or periods of inactivity as advised by physician or therapist.
• Wear well-fitting compression for stronger action.
• Use compression bandaging (CB) (lymphedema bandaging) as prescribed or directed by therapist.
• Wear compression stockings generally if advised.
D) Exercise / Movement & Elevation
• Exercise routine daily including diaphragmatic breathing exercise/aquatic exercise.
• Use SLD or hydrotherapy daily, with verification of proper technique.
• Wear well-fitted compression garment or bandaging for strenuous activities.
• Use lymphedema taping as appropriate, with verification of proper technique if self-applied.
• Monitor limbs after exercise; gradually build up duration and intensity of exercise, avoid heavy resistance; and
discuss embarking on exercise programs with therapist first.
E) General Advisory
• Maintain a healthy weight, and eat a balanced fresh food diet.
• Avoid wearing tight garments, underwear, or jewelry on affected areas of the body.
• Should swelling progress, seek early treatment from a trained therapist to prevent or minimize progression.
• Review the risks with your therapist and physician regularly.
• Never ignore your lymphedema.
NOTES: ______________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________
315
Patient: Refer to this list regularly as a reminder of general considerations in the management of
your lymphedema. Add your own particular notes. Keep a copy accessible in your home or business.
109
The sequence of lymph flow from ILV to lymph node.
Understanding Lymphedema
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1. INITIAL LYMPH VESSEL
1
2. PRECOLLECTOR
1-2-3-4 LYMPH FLOW
2
4. LYMPH NODE
3
4
3. COLLECTOR LYMPH VESSELS
Lymph Vessel System (LVS)
The gentle movements of MLD, and muscular motion, allow
then a collector vessel, then a lymph node.
After an approximately 50% reduction of lymph volume
in the lymph nodes, the remaining lymph
is returned to the circulatory system.
: Leif B. Meyer
114
- - - - - - - - TREATMENT & SELF CARE - - - - - - - -
SECTION 6: OTHER TREATMENTS
116
Expert Opinion
117
Effective Unknown
118
Effective Unknown
119
Effective Unknown
119
Effective Unknown
120
Effective Unknown
121
Effective Unknown
124
Not Recommend
125
Expert Opinion
127
Effective Unknown
129
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Alternative Practices, Sleep And Relaxation, Yoga
Hyperbaric Oxygen (HBOT)
Low-Level Laser Therapy (LLLT)
Nanocrystalline Silver Dressing
Ultrasound (US)
Hivamat
Surgical Intervention
Drug Therapy
Lymphedema Taping
Intermittent Pneumatic Compression (IPC)
Myth vs. Fact Does MLD Conflict?
Objective: Description of LE treatments other than CDT, with effectiveness ratings,
descriptions, comments. Always follow the advice of the physician.
6. Other Treatments
Other Treatments: Hyperbaric Oxygen
Patient: Read reviews and ratings
of other treatments. Be cautious if
considering alternative treatments,
research the risks first.
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Indications for Hyperbaric Oxygen (HBOT):
Indications
Hyperbaric oxygen therapy is known to promote healing in bone that has become ischaemic following radiotherapy.
In patients with upper limb lymphedema following radiotherapy, two small studies have indicated that hyperbaric
oxygen may improve lymph flow and reduce limb volume in the short-term. Further research is required to establish
whether benefits can be demonstrated in randomized trials and in the long-term.
SOURCE #2: Best Practice For The Management of Lymphedema International Consensus © MEP Ltd., 2006 ISBN 0-95476694-6 Published by Medical Education Partnership Pg 51. By permission of copyright holder Wounds International (UK).
Hyperbaric medicine, also known as hyperbaric oxygen therapy (HBOT), is the medical
use of oxygen at a level higher than atmospheric pressure.
! Expert Opinion
1
Several therapeutic principles are made use of in HBOT :
The increased overall pressure is of therapeutic value when HBOT is used in the treatment of decompression
2
sickness and air embolism .
For many other conditions, the therapeutic principle of HBOT lies in its ability to drastically increase partial pressure
of oxygen in the tissues of the body. The oxygen partial pressures achievable using HBOT is much higher than
those achievable while breathing pure oxygen at normobaric conditions (i.e. at normal atmospheric pressure);
A related effect is the increased oxygen transport capacity of the blood. Under normal atmospheric pressure,
oxygen transport is limited by the oxygen binding capacity of hemoglobin in red blood cells and very little oxygen is
transported by blood plasma. Because the hemoglobin of the red blood cells is almost saturated with oxygen under
atmospheric pressure, this route of transport cannot be exploited any further. Oxygen transport by plasma, however
is significantly increased using HBOT as the stimulus.
Recent evidence notes that exposure to hyperbaric oxygen (HBOT) mobilizes stem/progenitor cells from the bone
3
marrow by a nitric oxide (NO) -dependent mechanism . This mechanism may account for the patient cases that
suggest recovery of damaged organs and tissues with HBOT.
Applications:
6. Other Treatments
Enhancement of healing in selected problem wounds; Osteomyelitis (refractory); Delayed radiation injury (soft
Other treatments: Drug Therapy
tissue and bony necrosis);
'
SOURCE #26: Wikipedia http://en.wikipedia.org/wiki/Hyperbaric_oxygen Accessed 9-2-2011. Permission via terms of use.
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Gesell, Laurie B. (Chair and editor) (2008). Hyperbaric Oxygen Therapy Indications. The Hyperbaric Oxygen Therapy
/"$4%('ISBN
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Committee Report (12 ed.). Durham, NC: Undersea and Hyperbaric Medical Society.
0930406230.
2 Jørgensen TB, Sørensen AM, Jansen EC (April 2008). "Iatrogenic systemic .5+;$(%',),#"$&%('6%&%/$#,'/+5'48-.3%(%-"9'
air embolism treated with hyperbaric oxygen
therapy". Acta Anaesthesiol Scand 52 (4): 566–568. doi:10.1111/j.1399-6576.2008.01598.x. PMID 18339163.
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3 hom SR, Bhopale VM, Velazquez OC (April 2006). "Stem cell mobilization by
hyperbaric oxygen".
American
Journal
of
Physiology - Heart 290 (4): H1378-H1386. doi:10.1152/ajpheart.00888.2005. PMC 233328.
http://ajpheart.physiology.org/content/290/4/H1378.full.
Pharmacology:
Not Recommended
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Risks
There are currently no guidelines for pharmacological therapy of lymphatic illnesses.
Anticoagulant medications and leech treatments should not be used for lymphedema therapy.
Diuretics are also not indicated for lymphedema because they remove water but not protein.
www.voddermld.com/b
85
SOURCE #11 Manual Lymph Drainage the Dr Vodder method: Lecture Notes Therapy Course, Kettenhuber, G MD, et al. Dr
Vodder Akademie. (Undated) Pg 16 By permission of copyright holder.
Pharmacology:
! Expert Opinion
“Diuretics are not suitable for BCRL, as they only serve to increase protein concentrations in the interstitium and
encourage an increase in swelling, inflammation and fibrosis.” [BCRL - Breast Cancer Related Lymphedema]
SOURCE #30: Lymphoedema following surgery for breast cancer. Pain SJ, Purushotham AD. British Journal of
Surgery 2000;87(9):1128-41. Permitted use.
Drugs
a. Diuretics.
Therapist: Ask patient if other
modalities are being used that
may affect Best Practices – CDT
benefits.
Diuretic agents are of limited use during the initial treatment phase of CPT and should be reserved for patients with specific
co-morbid conditions or complications. Long-term administration of diuretics, however, is discouraged for it is of marginal
benefit in treatment of peripheral lymphedema and potentially may induce fluid and electrolyte imbalance. Diuretic drugs may
be helpful to treat effusions in body cavities (e.g., ascites, hydrothorax) and with protein-losing enteropathy. Patients with
peripheral lymphedema from malignant lymphatic blockage may also derive benefit from a short course of diuretic drug
treatment.
b. Benzopyrones.
Oral benzopyrones, which have been reported to hydrolyze tissue proteins and facilitate their absorption while stimulating
lymphatic collectors, are neither an alternative nor substitute for CPT. The exact role for benzopyrones (which include those
termed rutosides and bioflavonoids) as an adjunct in primary and secondary lymphedema treatment including filariasis is still
not definitively determined including appropriate formulations and dose regimens. Coumarin, one such benzopyrone, in higher
doses has been linked to liver toxicity. Recent research has linked this toxicity with poor CYP2A6 enzymatic activity in these
individuals.
c. Antimicrobials:
Antibiotics should be administered for bona fide superimposed acute lymph stasis-related inflammations
(cellulitis/lymphangitis or erysipelas). Typically, these episodes are characterized by erythema, pain, high fever and, less
commonly, even septic shock. Mild skin erythema without systemic signs and symptoms does not necessarily signify bacterial
infection. If repeated limb “sepsis” recurs despite optimal CPT, the administration of a prophylactic penicillin or broad
spectrum antibiotic is recommended. Fungal infection, a common complication of extremity lymphedema, can be treated with
antimycotic drugs (e.g., flucanozole, terbinafine). In most instances, washing the skin using a mild disinfectant followed by
antibiotic-antifungal cream is helpful.
SOURCE #4: The Diagnosis And Treatment of Peripheral Lymphedema 2009 Consensus Document of the International
Society of Lymphology, Lymphology 42 (2009) 51-60. P 53. Reprinted by permission of publisher.
www.voddermld.com/b
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- - - - - - - - TREATMENT & SELF CARE - - - - - - - -
SECTION 8: QUALITY OF LIFE
Psychosocial Support, Considerations
Coping with LE — Patient Support Website
Selected LE Patient Website Resources List
A Positive Approach For Living With Lymphedema
A QOL Psychology of Resiliency and Caring that Works
Standard QOL Survey Choices (Rand I-36)
146
Expert Opinion
147
149
150
154
Expert Opinion
155
Objective: This section briefly reviews psychosocial considerations, patient state
of mind, offers some accessible support ideas, and patient evaluation resources.
8. Quality of Life
Quality of Life: Psychosocial Support
Lymphedema Management:
! Expert Opinion
SOURCE #2: Best Practice For The Management of Lymphedema International Consensus © MEP Ltd., 2006 ISBN 0-9547669-4-6 Published by
Medical Education Partnership Pg 1. By permission of copyright holder Wounds International A division of Schofield Healthcare Media Ltd (UK).
Psychosocial support:
! Expert Opinion
Psychosocial support is an important element of the holistic treatment of lymphedema: it has the potential to have
considerable influence on outcome by enhancing concordance, encouraging self management and maximizing
quality of life. Intervention involves planning and implementing psychosocial care strategies that help patients and
their family/care givers to take a positive role in the management of their lymphedema and to achieve as good a
quality of life as possible.
If psychosocial problems are not resolved within three months, the patient should be referred for specialist
intervention.
SOURCE #2: Best Practice For The Management of Lymphedema International Consensus © MEP Ltd., 2006 ISBN 0-9547669-4-6 Published by
Medical Education Partnership Pg 48. By permission of copyright holder Wounds International A division of Schofield Healthcare Media Ltd (UK).
Social Engagement:
Patient Information
Research suggests that individuals with lymphedema limit social activities. Concerns about appearance and ability to
function in social environments may be reasons for these self-imposed limitations. Quality interactions with friends
and loved ones are critical to everyone’s mental health. If your lymphedema physically prevents you from engaging
in activities you formerly enjoyed, such as distance running, playing softball, etc., you should consider finding new
activities in which to participate. If you think lymphedema limits you, but haven’t really tested whether that thought is
true or not, you may want to try activities and see what happens. You can always stop if you run into difficulties!
Many lymphedema patients do find it helpful to start new hobbies or activities, or revive old ones. . .
SOURCE #16 Living with Lymphedema: A Guide for Healthy Living Sheila H. Ridner. Originally published in LymphLink, 9-2010,
Volume 22, Issue 3 Copyright 2010 National Lymphedema Network www.lymphnet.org. Reprinted by permission.
Psychosocial:
! Expert Opinion
The precise form of management program required will be determined by the site, stage, severity and complexity of
the lymphedema, and the patient's psychosocial situation. Patients may require referral to a lymphedema service, or
for assessment of coexisting medical, functional or psychosocial problems. Successful management of lymphedema
relies on patients and care givers playing an active role.
SOURCE #2: Best Practice For The Management of Lymphedema International Consensus © MEP Ltd., 2006 ISBN 0-95476694-6 Published by Medical Education Partnership Pg 15. By permission of copyright holder Wounds International (UK).
Patient: Read if you have low moods.
Practice accessing your strength and
positive outlook. If overwhelmed, call
your counselor, therapist, support
group members, or a mental health
hotline now.
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A progressive chronic condition that affects a significant number of people and can have deleterious effects on patients'
physical and psychosocial health. Even though it may be greatly ameliorated by appropriate management, many patients
receive inadequate treatment, are unaware that treatment is available or do not know where to seek help.
3. Psychosocial rehabilitation: Psychosocial support with a quality of life assessment-improvement program is an integral
component of any lymphedema treatment.
8. Quality of Life
Quality of Life: Selected LE Patient Support Websites
SOURCE #4: The Diagnosis And Treatment of Peripheral Lymphedema 2009 Consensus Document of the International Society
of Lymphology, Lymphology 42 (2009) 51-60. Pg 57. Reprinted by permission of publisher.
Online Lymphedema (LE) Patient Quality Of Life Resources Links
Patient Education
Since lymphedema is a life!long condition, patient educationNational
in self!management
is very important. Network:
To reduce the risk
Lymphedema
www.lymphnet.org
of developing lymphedema or having lymphedema worsen, all patients with lymphedema or at!risk for lymphedema should be instructed in
(NLN) Lymphnet is the publication name and the website title:
essential self care. The important areas of education include risk!reduction practices, self!lymph drainage, skin care, signs and symptoms of
Includes a toll-free recorded information line. Referrals to lymphedema treatment centers, health care
infection, proper fit and care of garments, and the importance of good nutrition, exercise
and weight control.
professionals,
training programs, and support groups.
quarterly&newsletter
a resource
and more. Educational materials. A biennial conference, a computer
SOURCE #5: Position Statement Of The National Lymphedema Network Topic: TheADiagnosis
Treatment of with
Lymphedema.
NLNguide
Medical
database, and more. Books: Child Apart, Juanita McDonald, A detailed account of the author’s experience growing
Advisory Committee Updated February 2011 Pg 10. Reprinted by permission of publisher.
www.voddermld.com/b
110
up with Milroy’s disease. Coping with Lymphedema, Joan Swirsky, RN & Diane Sackett Nannery. Practical guide to
understanding, treating and living with lymphedema, describes benefits of early intervention with professional help.
Lymphnotes:
www.lymphnotes.com
The online information resource and support group for those with lymphedema and family, friends, therapists. See
selected list below of very good resources by major topic.
Lymphedema Resources Pages: www.lymphnotes.com/resources.php
* Lymphedema Treatment, listing by state of facilities that provide lymphedema treatment.
* Lymphedema Professionals, listing of members who are licensed medical professionals.
* Lymphedema Garments, list vendors selling garments, bandages, and compression/LE.
* Other Resources, merchandise, i.e. pumps, or related interest to LE therapists, patients.
* Support Groups, listing lymphedema support groups with meeting dates and contacts.
* Therapist Training, listing of training programs for LE therapists that meet LANA standards.
* The Lymph Notes Contents; alphabetical listing of articles currently posted on this web site.
* The Lymphedema Glossary, listing and definitions of lymphedema medical terms.
Lymphedema People:
www.lymphedemapeople.com/
An excellent website dedicated to people who experience all types of lymphedema. The Forum has a lot of wonderful
sharing topics; online support groups, and a whole lot more. Takes extra familiarity to navigate these sites efficiently.
Lighthouse Lymphedema Network:
http://lighthouselymphedema.org/
An excellent website dedicated to people who experience all types of lymphedema, located in Georgia.
StepUp-SpeakOut:
www.stepup-speakout.org/
StepUp-SpeakOut Inc. (SU-SO) has a fine website. Located on the East Coast, with lymphologists on the staff.
Many other groups and websites provide great support including the ones you find and list here:
_________________________________________________________________________________________________________________________________________________________
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_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
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113
Therapist: LE patients often
have feelings that are hard to
handle at times. Please refer the
patient to competent mental
health counseling if you detect
feelings of depression. Then
follow-up as appropriate.
The survey form on Page 156 supports patient QOL measurements for
those clinics that also provide skilled QOL support services.
Blank forms are single sided for copying from back of book, or download (fee), customize, print, fill out
on computer, and save to computer. Forms are also in Patient Handbook.
Blank Form on page:
Patient QOL 36-Item Health Survey
Patient Entry
307
Therapist: Particular attention should be paid to indications of need for assistance in performing
activities of daily living, state of mind, emotional resiliency, and the special approaches useful in
treating advanced disease, for patients and family members.
145
- - - - - - - - REFERENCES & RESOURCES - - - - - - - -
SECTION 9: RESOURCES
160
161
162
163
163
164
165
167
168
169
169
170
171
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Selected Lymphedema Patient Information Websites
Exercise Links, Warm Pools List
Personal-wear Sources Article
Compression Bandaging Comparison Chart
Compression Garment Standards Guide
Compression Garment Safe Use Monitoring — Leg
Compression Garments, Laplace’s Law
Compression Garment Vendor List
Compression Garment & Accessories Web Links
Stages of Lymphedema (LE Staging)
Diagnosis Chart (LE, Lipedema, Obesity, Lipolymphedema)
Additional Applications of CDT or MLD
Nutrition Information, Natural Supplements
172
173
175
176
Objective: Lists of LE services and products, details of compression garment use,
risks, care, construction, staging, diagnosis, and other LE resources for patients.
9. Resources
Patient: Locate additional
information and resources as
needed.
Resources: Locate a Certified MLD Therapist or LE Clinic Patient Information
IMPORTANT: Complications of lymphedema and related conditions are frequent, dangerous, and may be life
threatening within hours. If patient has any symptoms including fever, pain, swelling, infection, redness of the skin,
etc. you should seek urgent medical care.
NOTE: The author cannot say if any listed therapist is properly trained, currently certified, or uses the recognized
CDT / Vodder MLD methods properly and effectively. You must verify this yourself by asking questions, and
comparing notes with others. However, both the DR VODDER SCHOOL INTERNATIONAL and NAVALT only list
therapists who meet the LANA training standards and are certified in Dr. Vodder MLD.
Use the sources below to seek MLD Therapists (Certified Manual Lymph Drainage therapists). Please specify their
training was in the Dr Vodder method of MLD, and the therapist is currently certified. In addition, many of the best
trained therapists possess a Certified Lymphedema Therapist certification ('CLT-LANA'). Look for that too.
ENTER or PASTE THE URLS BELOW IN YOUR BROWSER WINDOW
vodderschool.com
Dr Vodder School International (DVSI):
First Choice For Listings or http://www.vodderschool.com/therapist_search.cfm
On Home Page left side Menu Bar click on "Find a Therapist" or “Find an Esthetician”
% Choose the Country, then scroll to choose the state
CA = California, etc.
(Only currently certified graduates are listed)
navalt.org
On Home Page left Menu Bar click on "Therapist Directory"
% Choose “Click here”
% Select Therapist or Esthetician
Enter the name or location and click on "SEARCH". (Only current members are listed)
North American Vodder Association of Lymphatic Therapy (NAVALT):
clt-lana.org
On Home Page left side Menu Bar click on "LANA Certified
Therapists" at
top
LYMPHEDEMA
WELLNESS
Manual 9. Resources
Use SEARCH BY pull-down arrows to choose STATE, ZIP, or NAME
% Enter abbreviation, zip code or name in box to right
of pulldown,Lymphedema Garments on the Web
Resources:
% click SEARCH on right. (Only current LANA members are listed)
Lymphology Association of North America (LANA):
Patient Information
Patient: Once you are in the maintenance stage of controlling your lymphedema, you may have different needs for day
and night. Some garments are meant
primarily for day wear, and some primarily for night wear. Some garments are
lymphnet.org
interchangeable depending on your needs. Discuss what will be best for your particular needs with your therapist.
Click on blue "For Patients" on top bar,
(Only Associate members are listed)
images and menu
buttons below are hyperlinks if you use some electronic versions of this document. If not working as
% "Search For Treatment" or “Support Groups” The
on pull-down
hyperlinks, go to this site: 2011 http://www.stepup-speakout.org/Sigvaris_lympphedema_garments.htm
% Enter zip code or choose the state abbreviation
and click Submit
National Lymphedema Network (NLN):
www.lymphnotes.com
On Home Page top menu bar click on “Lymphedema Resources”
% Click on Lymphedema Professionals, alpha listing of members who are licensed
medical professionals who treat lymphedema. (Only members are listed)
% Click on Lymphedema Treatment, alpha listing of member facilities that
provide lymphedema treatment.
Lymphnotes:
Jobst
Sleeves/Gloves
Juzo Sleeves/Gloves
www.lymphedemapeople.com
List of physicians that accept lymphedema patients:
Lymphedemapeople.com:
Mediven (Medi)
http://www.lymphedemapeople.com/phpBB3/viewtopic.php?f=25&t=5&sid=dc173e704c1ca58dc5dcacb73a3888cc
www.voddermld.com/b
119
Lymphedivas
Gottfried Medical
Barton-Carey
BioConcepts
Sigvaris
Lymphedema Sleeve Company
Solaris/Tribute
Telesto-Medtech
JoviPak(Jovi)
1
Therapist: Best idea:
Prepare a local contacts list
and referrals list for your
area patients.
No Image
www.voddermld.com/b
126
159
Resources: Locate a Certified MLD/CDT Therapist or Clinic
Go to www.VodderMLD.com/b/wellness, for Wellness Manual registration, resources, links.
Look4LE Smartphone App - American Lymphedema Framework Project (ALFP): alfp.org
Download this free smartphone App has 900+ LANA qualified listings and much supporting information.
à Go to alfp.org, à Click on Look4LE. Or visit your App store. Search for Look4LE. Download.
(Current CLT-LANA are listed; Visit http://alfp.org/ to request listing.)
Dr. Vodder School International (DVSI):
vodderschool.com
On Home Page left side Menu Bar click on "Find a Therapist"
à Choose the Country, then scroll to choose the state (CA = California, etc.)
(Only current biennially recertified graduates of this school are listed)
National Lymphedema Network (NLN):
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Click on blue "For Patients" on top bar,
à "Search For Treatment" or “Support Groups” on pull-down menu
à Enter zip code or choose the state abbreviation and click Submit
lymphnet.org
(Only Associate members are listed)
Lymphology Association of North America (LANA):
clt-lana.org
On Home Page left side Menu Bar click on "LANA Certified Therapists" at top
Use SEARCH BY pull-down arrows to choose STATE, ZIP, or NAME
à Enter abbreviation, zip code or name in box to right of pull-down,
à click SEARCH on right.
(Only current LANA members are listed)
Lymph Notes:
www.lymphnotes.com
On Home Page top menu bar click on “Lymphedema Resources”
à Click on Lymphedema Professionals, alpha listing of members who are licensed medical professionals
who treat lymphedema.
à Click on Lymphedema Treatment, alpha listing of member facilities that provide lymphedema treatment.
Lymphedemapeople.com:
www.lymphedemapeople.com
List of physicians that accept lymphedema patients: Note: May not be updated regularly.
http://www.lymphedemapeople.com/phpBB3/viewtopic.php?f=25&t=5&sid=dc173e704c1ca58dc5dcacb73a3888
cc
North American Vodder Association of Lymphatic Therapy (NAVALT):
navalt.org
List of trained and currently certified lymphedema therapists that accept lymphedema patients, searchable.
160
- - - - - - - - REFERENCES & RESOURCES - - - - - - - -
SECTION 10: TOPIC CARDS
Topic Card I. Pathways of the Lymph System
Topic Card II. Fluid Movement in Loose Connective Tissue
Topic Card III. Structure & Function of the Lymph System
Topic Card IV. Loose Connective Tissue
Topic Card V. Effects of MLD
Topic Card VI. Edemas: Applications of MLD
How To Download Next 6 Topic Cards (TCVII through XII)
181
183
185
187
189
191
193
10. Topic Card Reference
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Objective: Review the theoretical basis of lymph system functions and faults.
III. Structure and Function of Lymph System (1 of 2)
Copyright ©2006-2011 Gay Lee Gulbrandson, Berkeley, CA, USA All rights reserved. www.vodderMLD.com
4.95 USD
s
s
s
s
s
s
s
s
s
s
2. PRECOLLECTOR
s
1
Precollectors collect Lymph from
several ILVs and transport it to Collector
Vessels.
Precollectors (and ILV) are found
everywhere in the body except the CNS.
Precollectors are vessels with some
non-functioning rudimentary valves.
Precollectors allow some transcytosis.
Precollectors rely on extrinsic forces to
move the lymph.
MOVEMENT OF LYMPH
3-10
s
The following Intrinsic forces effect the movement of lymph in the
COLLECTOR LYMPH VESSELS (FIGURE 3, LOWER LEFT):
In the walls of the smooth muscle of lymphangions:
Automyogenic cells generate random contractions of smooth muscle,
CAUSING CONTRACTION AT THE RATE OF TIMES PER MINUTE
Stretch receptors are activated when the lymphangion is full of fluid,
stimulating the nerve supply and causing a contraction.
These are both known as intrinsic forces.
s
s
s
s
2
s
s
Extrinsic forces (auxiliary pumps) work on lymph vessels from the outside:
s -OVEMENT OF THE SKELETAL MUSCLES
s 0ULSATION OF THE ARTERIES
s "REATHING
s 0ERISTALTIC MOVEMENT OF THE INTESTINES
s *OINT PUMPS
s 4HE FORCE OF GRAVITY s -OVEMENT OF THE SKIN -,$
Extrinsic forces increase lymphangion contraction up to 30x per minute.
3
4
3. COLLECTOR LYMPH VESSELS
Collector Lymph Vessels only transport lymph.
Lymph vessels or Collector Vessels are made
up of units called lymphangions.
lymphangions have One way valves that
prevent backflow.
Collector Vessels are composed of three major
layers:
Intima – the lymphangions structure.
Media – the smooth muscle surrounding
the lymphangions.
s Adventitia – the outer layer (NOT SHOWN),
connecting the Collector Vessel to the
surrounding tissue.
s
s
s
s
s
s
s
s
4. LYMPH NODE
10. Topic Card Reference
All Collector Vessels go to a Lymph Node.
s 4HERE ARE ABOUT LYMPH NODES IN THE BODY
about 1/3 in the face & neck region.
s Lymph nodes vary from the size of a pin head to a
kidney bean.
Lymph node structure:
A connective tissue capsule.
3 layers of sinuses with walls called trabecula.
EALTHY
Germinal Centers where lymphocytes activate.
s -ANY afferent lymph vessels bring lymph to the
lymph node.
s efferent lymph vessels remove the clean
concentrated lymph from the lymph node and
ultimately return it to the venous arches.
The hilum is where a small artery enters, and a
vein leaves the lymph node.
IV. Loose Connective Tissue
s
s
s
s
H
s
s
s
www.voddermld.com/b
Patient: Review Topic Cards to
learn theory of lymph system, fluids,
edemas, MLD, and much more.
™
Dr. Vodder MLD Topic Series 3A
1. INITIAL LYMPH VESSEL
Initial lymph vessels (ILV): valveless, single layer of
endothelial cells surrounded by a fibrous matrix of
reticular fibers.
Movement in dermis (LCT) via anchoring filaments
pull the endothelial cells open, allowing Lymph
Obligatory Load (LOL) to enter the ILV. Inside the ILV
these substances (LOL) are called Lymph.
Lymph is formed of:
s BLOOD PLASMA WATER
s PROTEINS
s LARGE MOLECULAR FATS
s CELL DEBRIS
The ILVs are the beginning of the lymphatic pathways.
The function of the ILV is to collect Lymph.
s
140
LCT
(1 of 2)
4.95 USD
™
3-10
CONGESTED LCT
Flow Flow
In Out
Flow
In
STRUCTURE OF LOOSE CONNECTIVE TISSUE
Loose connective tissue (LCT) fills all cavities, surrounds all organs and
comprises the dermis (the second layer of the skin).
LCT is made up of several substances:
s WATER
s .ONCELLULAR COMPONENTS
Protein, Mucopolysaccharides or glycogen, Nutrients.
s #ELLULAR ELEMENTS CONSIST OF
Fibroblasts, Resting migratory cells, Lymphocytes, Plasma cells, Mast cells,
Fat cells, Macrophages and microphages.
s "LOOD CAPILLARIES
s
)NITIAL LYMPH VESSELS
s
%ND FIBERS OF THE AUTONOMIC NERVOUS SYSTEM
s
#OLLAGEN AND %LASTIN &IBERS
LCT is the medium that our cells inhabit and the health of this tissue
determines the health of our body. The lymph system begins in the LCT.
Manual Lymph Drainage (MLD) helps to normalize the function and composition of connective tissue (LCT) by removing the excess substances.
Flow
Out
TRANSIT STRETCH
Transit stretch is the distance substances travel from the blood capillary to
the cell (also called “diffusion time”), accounting for time required.
When the LCT is healthy the transit stretch is short. When the LCT is
congested (edematous) the transit stretch is longer because the
substances have to travel farther, through more fluid.
The relationship described in transit stretch between time and distance is:
Time = Distance 2 [squared]
MLD reduces the amount of filtrate or fluid in the LCT, thus shortening the
transit stretch.
Therapist: Six more Topic Cards
are available free online for
reference, at
www.voddermld.com/b
COLLAGEN AND ELASTIN FIBERS
LCT contains cells that produce collagen and elastin fibers, polysaccaride proteins, and a ubiquitous half-gel binding mass (or ground substance).
THIXOTROPHY
Thixotrophy is the mechanical transformation of a substance (in this case
LCT) from a gel to a solution (sol) and back.
The LCT fluctuates between the gel and sol state all the time. The gel state
creates structure that keeps the nutrients close at hand. LCT is in a gel
STATE OF THE TIME
The sol state takes nutrients to the
cells and assists in cellular fluid
movement.
When the body is healthy there is a balance in the thixotrophic properties
of LCT. MLD promotes the LCT to fluctuate from a gel to a sol (solution)
state.
This normalizes the health of the LCT.
GEL
SOL
Collagen fibers – have high
tensile strength like steel - returning
to their original size after being
stretched (recoilability).
Collagen fibers stretch
proportionally with the amount of
added fluid (weight).
Elastin fibers – have low tensile
strength like elastic - and do not
return to their original size (lack of
ability to recoil, poor recoilability),
after a long period of distortion.
Elastin fibers stretch
non-proportionally, meaning that
their initial stretch is the largest.
MLD encourages fluid to leave the LCT. This helps prevent stretching of the
skin from excess fluid or swelling in the LCT.
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143
More MLD Topic Cards. See page 193 for guide to free downloads.
The remaining 6 Topic Cards (VII – XII – listed below) are free online.
VII. Indications
IX. Basic Principles of MLD
XI. Evidence Based Practice for Lymphedema
VIII. Contraindications
X. Glossary, References,
XII. Dr. Vodder MLD Strokes
Copyright Gay Lee Gulbrandson, Berkeley, CA 94707 All rights reserved.
All copyrighted watershed images used by permission of the copyright owners. Original illustrations and graphics by Leif B Meyer
Note: The following 6 Topic Cards are the first of 12 illustrated reference sheets available.
179
MLD Topic Cards: Contents and Detail Overview:
I. Pathways of the Lymph System
II. Fluid Movement of the Loose Connective Tissue
Filtration and absorption of proteins, fats, wastes, fluids, through circulatory system, tissues, and lymph
vessels; role of blood pressure, tissue pressure, osmotic & oncotic pressures, more.
III. Structure & Function of the Lymph System
Details hierarchy of lymph system elements from smallest vessels to largest vessels, angions, nodes, ducts;
functions of lymph nodes, fluid volumes and blood to tissue to lymph cycle, more.
Behavior of tissues, component cells, transit stretch and ground substance, inertia, congestion effects,
Starling's research, function and role of LCT, solution and gel states of interstitial mass.
V. Effects of MLD
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6 INCLUDED IN SECTION 10
Organization of the lymph system, nomenclature, direction of flows, terminus, drainage paths, location of nodes
and clusters, ducts, organ drainage, limbs, trunk, legs, head and neck, more.
Fluid transport role of MLD on lymph, analgesic effect, smooth muscle, capillary response, nervous system
effects, skin galvanic changes, humoral and cellular immune response, more.
VI. Applications of MLD
Types and causes of primary and secondary edemas, development of and stages of lymph-edema, venous
insufficiency, low and high protein edemas, blood pressure, thrombosis, more.
VII. Indications
SECOND 6 FREE ONLINE
Extensive list of conditions and situations that are known to benefit from use of MLD for typical clients with
healthy lymph system, scars, sprain, surgery, migrane; edema, lymphedema, more.
VIII. Contraindications
Conditions that pose potential risk of harm to clients with compromised lymph system, circulation, malignancies
that limit MLD; modifications of MLD to accommodate relative contraindications.
IX. Basic Principles of MLD
The guidelines for effective MLD technique, what to do and what not to do, amount of pressure, direction,
repetition, basic strokes types, where they are used, special strokes, anatomy, more.
X. Glossary, Reference
List of key terms and definitions; combined decongestive therapy (CDT/MLD) explained, survey of knowledge
for CLT-LANA professional independent certification exam, much more.
XI. Evidence Based Practice for Lymphedema (LE)
Evidence based best practices in LE treatment, LE statistics, applications list, Dr Vodder School Int'l programs
& training, MLD applications list, survey of organizations in LE research, more.
XII. Dr. Vodder MLD Strokes
The basic strokes illustrated and explained in plain language; correct locations for use of the strokes,
condensed basic principles, explanation of skin motion, direction of strokes, more.
Authored by Gay Lee Gulbrandson, CLT-LANA, NCTMB, CMT.Original illustrations and graphics by Leif B Meyer.
Copyright 2003 - 2013 by Gay Lee Gulbrandson, Berkeley, CA 94707. All rights reserved.
180
Section 10 Topic Cards Reference
I
I. Pathways of the Lymph System
4.95 USD
3-10
The territories of the head and face drain to the
s
s
s
s
s
s
The profundus, neck, and deltoid drain to the
terminus, a lymph vessel that empties into
terminus
the venous arches.
arches The left side drains to the
left terminus and the right side to the
right terminus.
s
s
Head Watersheds:
vertical watersheds divide head in half.
The
Over crown of head from ear to ear, like a
headset.
From bridge of nose to angle of jaw on each
side of face.
ss
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s
profundus, a cluster of lymph nodes at the
scorner
of the jaw. The left side drains to the left
and the right side to the right
s profundus
profundus.
sPosterior
head drains to the soccipital lymph
nodes and then to the respective s profundus.
s
Saddle of the Thigh
Watershed:
Sacrum to middle of
the back of thigh then
inferior to popliteal
fossa.
™
DIRECTION OF DRAINAGE OF THE SKIN OF THE HEAD
WATERSHEDS
Lymphatic watersheds are the borders between
areas of lymphatic drainage called territories.
The body is divided horizontally into upper and
lower halves by a great watershed called the
Navel-lumbar line. The other watersheds
are:
Horizontal Watersheds:
Around the neck, along the clavicle and
spine of scapula.
At tops of thighs crease to trunk.
Vertical Watersheds:
In front, from the jugular fossa to the pubic
symphysis.
In back, alongside the spinal column.
Shoulder Watershed:
At lateral upper arm fascicle around deltoid.
s
s
(1 of 2)
s
DIRECTION OF DRAINAGE OF THE SKIN OF THE ARM
s
The arm drains to the axillary lymph nodes, located at the armpit.
The skin of each side of the torso above the Navel-Lumbar line also drains to
the axillary lymph nodes on that side of the body (right to right and left to
left).
s
Lymph flow in territories is as
follows:
 Arms and trunk above Navel-lumbar line drain to the
axillary lymph nodes.
 Skin of trunk below Navel-lumbar line, buttocks and legs drains to the
inguinal lymph nodes.
 Skin above clavicle and spine of scapula drains directly to the
terminus.
 Head and neck drain directly to terminus.
There is one terminus on each side of the body (right and left). The
terminus empties the lymph into the subclavian vein at the venous arch.
Ultimately, all lymph drains to the terminus. The axillary lymph nodes
empty directly to terminus. The ingunal lymph nodes empty via other
lymph nodes, the Cisterna Chyli and the thoracic duct to terminus.
s
s
s
s
s
s
s
s
s
s
s
MLD is always done in the direction of flow of the lymph. With precisely
performed Manual Lymph Drainage, we can make the lymph vessels of the
skin drain more efficiently.
Anastomosis is the cross-connection
between the territories on each side
of a watershed, interlacing or weaving
the sides together.
The arm is subdivided by minor
watersheds into several territories, but
lymph vessels of the arm possess
numerous anastomoses that connect
the lymph pathways with each other.
The lymph flow in the arm can thus be
treated as a single pathway up the
arm to the axillary lymph nodes.
The deltoid, however, drains
directly to the terminus.
s
s
s
In some of the population, there is an
additional, alternative pathway for
the drainage of the arm called the
radial catchment: it follows
along the radius, thumb side of the
arm under the deltoid to the
terminus, bypassing the axillary
lymph nodes.
s
s
s
181
Section 10 Topic Cards Reference
IV
HEALTHY LCT
(1 of 2)
4.95 USD
™
3-10
CONGESTED LCT
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Flow Flow
In Out
Flow
In
STRUCTURE OF LOOSE CONNECTIVE TISSUE
Loose connective tissue (LCT) fills all cavities, surrounds all organs and
comprises the dermis (the second layer of the skin).
LCT is made up of several substances:
sWATER
s.ONCELLULARCOMPONENTS
Protein, Mucopolysaccharides or glycogen, Nutrients.
s#ELLULARELEMENTSCONSISTOF
Fibroblasts, Resting migratory cells, Lymphocytes, Plasma cells, Mast cells,
Fat cells, Macrophages and microphages.
s"LOODCAPILLARIES
s)NITIALLYMPHVESSELS
s%NDFIBERSOFTHEAUTONOMICNERVOUSSYSTEM
s#OLLAGENAND%LASTIN&IBERS
LCT is the medium that our cells inhabit and the health of this tissue
determines the health of our body. The lymph system begins in the LCT.
Manual Lymph Drainage (MLD) helps to normalize the function and composition of connective tissue (LCT) by removing the excess substances.
Flow
Out
TRANSIT STRETCH
Transit stretch is the distance substances travel from the blood capillary to
the cell (also called “diffusion time”), accounting for time required.
When the LCT is healthy the transit stretch is short. When the LCT is
congested (edematous) the transit stretch is longer because the
substances have to travel farther, through more fluid.
The relationship described in transit stretch between time and distance is:
Time = Distance 2 [squared]
MLD reduces the amount of filtrate or fluid in the LCT, thus shortening the
transit stretch.
COLLAGEN AND ELASTIN FIBERS
LCT contains cells that produce collagen and elastin fibers, polysaccaride proteins, and a ubiquitous half-gel binding mass (or ground substance).
THIXOTROPHY
Thixotrophy is the mechanical transformation of a substance (in this case
LCT) from a gel to a solution (sol) and back.
The LCT fluctuates between the gel and sol state all the time. The gel state
creates structure that keeps the nutrients close at hand. LCT is in a gel
STATEOFTHETIME
The sol state takes nutrients to the
cells and assists in cellular fluid
movement.
When the body is healthy there is a balance in the thixotrophic properties
of LCT. MLD promotes the LCT to fluctuate from a gel to a sol (solution)
state.
This normalizes the health of the LCT.
GEL
SOL
Collagen fibers – have high
tensile strength like steel - returning
to their original size after being
stretched (recoilability).
Collagen fibers stretch
proportionally with the amount of
added fluid (weight).
Elastin fibers – have low tensile
strength like elastic - and do not
return to their original size (lack of
ability to recoil, poor recoilability),
after a long period of distortion.
Elastin fibers stretch
non-proportionally, meaning that
their initial stretch is the largest.
MLD encourages fluid to leave the LCT. This helps prevent stretching of the
skin from excess fluid or swelling in the LCT.
187
APPENDICES
CONTENTS
195
211
APPENDIX C: REFERENCES
223
229
APPENDIX E: CONTINUING EDUCATION COURSE
310
CE Course Credit Examination for 8 NCBTMB CEs
319
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APPENDIX F: INDEX
312
APPENDIX A: Sources and Supporting Data
Bibliography
Recommended / Complementary Books Therapists / Clinics
National Lymphedema Network (NLN) Position Papers
National Lymphedema Network (NLN) Publication
American Lymphedema Framework Project (ALFP) Papers
Organizations linked to CDT Best Practices
National Accreditation Program for Breast Centers (NAPBC)
Oncology Nursing Society (ONS): Putting Evidence
Oncology Nursing Society (ONS): PEP Effectiveness Ratings
Oncology Nursing Society (ONS): PEP Quick View for LE
LE Clinic Record-keeping Software
LE Clinic Improvement Model: Performance Audit Tools
Primary Sources: Consensus Documents & Meta-Studies List
196
197
198
198
199
200
202
203
204
205
206
207
209
Objective: Find additional LE information, books, organizations working on LE, Best
Practices rating schema, patient records software, clinic self-improvement tips.
Therapist: Refer patients here for reference data and sources. Much more information is available on
the internet. However, there is a great deal of incorrect information on the web, so guide patients to
the links and sources listed in Section 9 Resources and in Appendix A as a first step to search for
accurate lymphedema information.
195
Appendix: LE Clinic Self Audit; A Sample Evaluation Form
Best Practices Standard:
(Sample headings below, suggest yours)
Delivery of services – quality, consistency,
process, etc.
New patient assessment/intake.
FIRST STEP: Create a performance checklist for each “standard”. See example below. Rating before
audit.
Date:
Rating after audit,
Improvement Objectives,
incl. future plans.
Implementation Plans, Methods,
Date:
Resources, and Assignments
__________________ SECOND STEP: Evaluate performance before changes. __________________
THIRD STEP: FOURTH STEP: Devise plans for improvement, in writing, allocate resources to accomplish goals over time. Evaluate per-‐
formance after change is complete. Therapist: The example above suggests ideas of how to approach the clinic self-audit subject matter.
Evaluation Process: Example of a performance plan detail (create for all processes):
Example of a process improvement: “New patient assessment/intake”. (Blank spaces for notes)
Second Benchmark:
Complete identification forms
Third Benchmark:
Shared review and create file
• Confirm pt. identity (ID card,
insurance card, copy)
_________________________
• Confirm patient appointment
_________________________
• Verbal checklist of qualifying
factors for clinic pt.
_________________________
• Written screening and ID form
_________________________
• Proceed with pt. intake forms if
apparently qualified
_________________________
• If pt. not qualified for care here
refer pt. to designated agency.
This means give a referral form
to pt. and check off the
recommended contacts
_________________________
• Give pt. the intake and billing
forms
_________________________
• When complete give pt. our
clinic information brochure and
our lymphedema brochure if
appropriate (physician diagnosed
LE)
_________________________
• Explain billing process to pt.
_________________________
• Assemble pt. folder for therapist
intake/assessment session
_________________________
• Inform clinic administrator of pt.
intake status and request /
approve
_________________________
_________________________
_________________________
• Dispatch pt. folder to therapist
for intake/assessment
_________________________
• Prepare treatment Rx letters as
needed
_________________________
• Prepare garment Rx letters as
needed
_________________________
• Enter all required billing and
EHR fields
_________________________
• Prepare pt. treatment plan
forms for verbal explanation to
pt. and mail confirmation copies
_________________________
• Refer folder to clinic
administrator for review and
treatment plan, billing, approvals
_________________________
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First Benchmark:
Qualify patient for intake.
Therapist: The example above suggests an approach for analysis of each process in a self-audit.
Clinic evaluation must be undertaken with the full support and participation of clinic staff and
management. A desirable consensus goal is identification and correction of any deficiencies in the
safe, accurate, documented, and effective delivery of LE services provided. An outside senior CDT
instructor, a lymphologist, and a patient representative should be included in an advisory role to help
guide the improvement process. The process should be well understood and include all concerned
staff and the goals are agreed upon before undertaking a performance audit and improvement plan.
Some topics in the Lymphedema Wellness Manual may be useful to support an audit process.
Actual audit forms are NOT included here due to the unique nature and operations of each clinic.
208
Appendix C: References
71. Fife CE, et al. Lipedema: A Frequently Misdiagnosed and Misunderstood Fatty Deposition Syndrome.
Advances in Skin Wound Care; 2010;23:81-92. Available: https://www.nursingcenter.com/pdf.asp?AID=965295
-or- https://www.nursingcenter.com/prodev/ce_article.asp?tid=967981. Accessed 11-5-2011
72. Kasseroller R. Compendium of Dr Vodder’s Manual Lymph Drainage. (trans. Fogg DM.) Heidelberg: Haug;
1998. ISBN 3-7760-1729-5.
73. Kettenhuber G, et al. Manual Lymph Drainage the Dr Vodder method: Lecture Notes Therapy Course. Dr
Vodder Akademie. (n.d.) Limited availability from Dr Vodder School International, www.vodderschool.com, -orDr Vodder Akademie, Austria. www.vodderschule.com.
74. Foldi M, Strosenreuther R, eds. Foundations of Manual Lymph Drainage. 3rd English Ed Elsevier, Inc; 2005.
ISBN 0-323-03064-5.
75. Werner R. Your Clients With Lyme Disease. In: Massage Today. 2009:9(10). Available:
http://www.massagetoday.com/mpacms/mt/article.php?id=14101&no_paginate=true&no_b=true.
76. Lymphedema Advise.com eBook. 2010. Hodges P. lymphedemaadvice.com Accessed 6-29-2011.
77. United States Department of Agriculture National Agricultural Library General Nutritional Information.
http://fnic.nal.usda.gov/nal_display/index.php?info_centers=4&tax_level=1. Accessed 10-12-2010.
78. Medical Advisory Committee, Position Statement of the National Lymphedema Network. San Francisco, CA.
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National Lymphedema Network. List of free Position Statement downloads:
http://lymphnet.org/lymphedemaFAQs/positionPapers.htm.
79. NLN Lymphlink Newsletter, National Lymphedema Network. San Francisco, CA. Accessed 10-30-2013
http://lymphnet.org/newsletter/newsletter.htm.
80. American Lymphedema Framework Project (ALFP), Publications; Systematic Reviews. Downloads
(abstracts): http://alfp.org/publications.php.
81. Breast Center Standards Manual. 2011. National Accreditation Program for Breast Centers (NAPBC).
www.napbc-breast.org. Accessed 9-27-2012.
82. North American Vodder Association of Lymphatic Therapy (NAVALT). www.navalt.org. LymVoPro.
http://www.navalt.org/ -orhttp://ssmith11.photobiz.com/cart/product_detail.cfm?productID=36510&categoryID=9114. Accessed 6-22-2011.
83. Academy of Lymphatic Studies. Academy Store, Educational Items; Limb Volume CD.
https://acols.com/Store.aspx. Accessed 11-05-11.
84. Haddenham Healthcare Ltd. 2012. LymCalc 4.0. http://www.lymcalc.com/. Accessed 3-20-2012.
85. Moffatt CJ, et al. Template for Management: Developing a Lymphedema Service. HealthComm UK Ltd; 2007.
Available: http://www.woundsinternational.com/clinical-guidelines/lang-ENG/page-2. Aberdeen, Wounds
International A division of Schofield Healthcare Media Ltd. Accessed 6-26-2011.
86. At Work, Issue 68, Spring 2012: Institute for Work & Health, Toronto, Canada. http://www.iwh.on.ca/whatresearchers-mean-by Accessed 3-28-2013.
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__________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________
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__________________________________________________________________________________________________________________________________________________________________________________
227
CONTENTS: BLANK FORMS
May remove blank forms from book with scissor or razor knife for copying.
Page
Section 2
Patient Authorization 1
231
Notice of Privacy Practices
Section 2
233
Photo Release
Section 2
235
HIPAA Notice of Privacy Practices
Section 2
Patient Disclosure 4
239
Section 2
Patient Entry Option 5
251
Lymphedema Assessment & Intake
Section 2
Therapist Entry 1
255
Limb Circumference/Volume
Section 2
Therapist Entry 2
257
Arm Measurement Form
Section 2
Therapist Entry 3
259
Leg Measurement Form
Section 2
Therapist Entry 4
261
Letter of Medical Necessity - Garment
Section 2
Therapist Entry 5
263
Section 2
Therapist Entry 6
265
Section 2
Therapist Entry 7
267
Physician Referral
Section 2
Therapist Entry 8
269
*Physician Guide to CDT/MLD
Section 2
Therapist Entry 9
271
Tell Me About Lymphedema - Brochure
Section 2
Patient Information
273
*Wellness Action Plan (Long Form)
Section 3
Patient Entry
277
Wellness Action Plan (Short Form)
Section 3
Patient Entry
289
*My Turn
Section 3
Patient Entry
295
*Patient Risk Factors (Long Form)
Section 4
Patient Entry
297
Patient Risk Factors (Short Form)
Section 4
Patient Entry
303
*LE Patient Ongoing Checklist
Section 5
Patient Action
305
Patient QOL 36-Item Health Survey
Section 8
Patient Entry
307
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Health Information & Consent
*These forms are included in the 40 page Patient Handbook, ready to use.
HOW TO USE INTERACTIVE BLANK FORMS
Blank forms in Manual are single sided for easy stream-feed copying.
Remove (or download eForms), enter clinic name at top, add address, etc. where shown.
Make copies in patient sets. Print in black & white or color as preferred. Save the original.
Retain file copies of all filled-in patient forms.
Therapist: Keep a copy of all completed forms in the patient file. To remove forms from book for
copying, gently tear out or use a scissor/razor knife. Use a plain white sheet to mask uneven edge.
229
Lym ph ed em a W elln ess M an u al
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Section 2
HIPAA Notice of
Privacy Practices P4
Page 5 of 6
1. HIPAA disclosure form only needed for electronic data filing / sharing.
2. Patient receives entire 6 pages.
3. Clinic must fill out spaces on pages 1, 5, 6.
4. Clinic retains a file copy only of last page with signatures.
DO NOT COPY THIS BLUE TEXT UNLESS NEEDED
246
Privacy Official at the office(s) where we have provided you with health care services, or to this clinic’s Privacy
Officer at the address listed below, and provide the reason or reasons that support your request.
We may deny any request that is not in writing or does not state a reason supporting the request.
We may deny your request for an amendment of any information that:
1. Was not created by us, unless the person that created the information is no longer available to amend the
information;
2. Is not part of the Protected Health Information kept by or for us;
3. Is not part of the information you would be permitted to inspect or copy; or
4.Is accurate and complete.
If we deny your request for amendment, we will do so in writing and explain the basis for the denial. You have
the right to file a written statement of disagreement with us. We may prepare a rebuttal to your statement and
will provide you with a copy of any such rebuttal. Please contact the Privacy Official at the office(s) where we
have provided you with health care services, or to the this clinic’s Privacy Officer at the address listed below.
Right to an Accounting of Disclosures
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This right only applies to disclosures for purposes other than treatment, payment or health care operations as
described in this Notice of Privacy Practices It also excludes disclosures: (1) to you; (2) to your family members,
relatives, friends or other persons who may be involved in your care, or for notification or disaster relief efforts;
(3) for national security or intelligence purposes; (4) to correctional institutions or law enforcement officials; (5)
that occurred prior to April 13, 2002; (6) made incident to a permitted or required use or disclosure, as described
in this Notice; and (7) made pursuant to an authorization. The right to receive an accounting of disclosures is
subject to certain other exceptions, restrictions and limitations. You must submit a written request for disclosures
in writing to the Privacy Official at the office(s) where we have provided you with health care services, or to this
clinic’s Privacy Officer at the address listed below. You must specify a time period, which may not be longer
than six years from the date of the request and cannot include any date before April 14, 2003. You may request a
shorter timeframe. Your request should indicate the form in which you want the list (i.e., on paper, etc.). You
have the right to one free request within any 12-month period, but we may charge you for any additional requests
in the same 12-month period. We will notify you about the charges you will be required to pay, and you are free
to withdraw or modify your request in writing before any charges are incurred.
Right to Obtain a Paper Copy of this Notice
You have the right to a paper copy of this Notice. Even if you have agreed to receive this Notice electronically,
you are still entitled to a paper copy of this Notice. You may obtain a paper copy of this Notice by asking your
practitioner for a copy at your next appointment, sending a written request for a paper copy to the clinic manager
at the address listed below, or sending a request for a paper copy via e-mail to ________________.
COMPLAINTS
You may complain to us or to the Secretary of the U. S. Department of Health and Human Services if you
believe your privacy rights have been violated by us.
You may file a complaint with us by writing or phoning this clinic’s Privacy Officer.
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
You may contact this clinic’s Privacy Officer for further information about the complaint process or for
additional information about any of the other matters identified in this Notice.
We will not retaliate against you in any way for filing a complaint, either with us or with the Secretary.
This Notice is effective in its entirety as of April 14, 2003.
Notice of Privacy Practices with Acknowledgement of Receipt April 2003 Page 5 of 6.
Page 6 is solely the Patient Receipt.
247
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Section 2
HIPAA Notice of
Privacy Practices P4
Receipt
Page 6 of 6
Clinic retains only this last page 6 of 6 when
complete with all signatures and dates, in patient
file. A copy of Pg 6 is given to patient.
1. HIPAA disclosure form only needed for electronic data filing / sharing.
2. Patient receives entire 6 pages.
3. Clinic must fill out spaces on pages 1, 5, 6.
4. Clinic retains original of last page with signatures. Patient receives
a copy of page 6.
248
Page 6 is the Patient Receipt, and shall be retained by the clinic.
File Number: _______________
ACKNOWLEDGEMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES
By signing below, I acknowledge receiving a copy of the Notice of Privacy Practices, dated April 14, 2003,
HIPAA Disclosure consisting of 6 pages including this receipt.
Signature of Patient or Personal Representative:
X _______________________________________
Printed Name of Patient or Personal Representative: _____________________________________
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Date: _______________________________________
Description of Personal Representative’s Authority to Act on Behalf of the Patient:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
PLEASE PROVIDE A COPY OF THIS HIPAA DISCLOSURE RECEIPT PAGE AND THE 5 PRECEEDING HIPAA
NOTICE PAGES TO THE PATIENT AT TIME OF SIGNING.
CLINIC NEED ONLY RETAIN THE SIGNED RECEIPT ORIGINAL.
Notice of Privacy Practices with Acknowledgement of Receipt
April 2003 Page 6 of 6
249
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Section 2
DRAFT
Letter of Medical Necessity
CDT/MLD T6
Page 1 of 1
1. This is a draft letter that must be tailored to each patient’s individual
situation, gender, and recommendations.
2. DO NOT use this form as a blank to be filled in. It will not be correct or
proper without modification.
264
Therapist Entry
6
Date: __________________________
RE: ___________________________ (Patient Name)
To Whom It May Concern:
I had the pleasure of seeing Mr./Ms. __________________________________________ on
___________________________.
He/she (choose) was found to have primary/secondary (choose) Lymphedema of the
______________________ (body area) following _________________________. (describe the
precipitating event)
I believe he/she (choose) will benefit from ____________ treatments of Complete Decongestive
Therapy, given daily for a total of ______________________ weeks.
Complete Decongestive Therapy: Each CDT treatment consists of four steps 1. Meticulous skin and nail care, including the eradication of any infection.
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2. Manual lymph drainage, a manual treatment technique that stimulates lymph vessels to contract
more frequently and that channels lymph and edema fluid toward adjacent, functioning lymph systems.
Manual lymph drainage begins with stimulation of the lymph vessels and nodes in adjacent basins
(neck, contralateral/ipsilateral axilla and/or groin) (choose), which is followed by manual decongestion,
in segmental order, of the involved trunk, upper part, lower part of the extremity, wrist (ankle) (choose)
or hand (foot) (choose). Edema fluid and obstructed lymphatics are made to drain toward the venous
angle, toward functioning lymph basins for example across the mid-line of the body, down toward the
groin, over the top of the shoulder, around the back and so forth.
3. Compression Bandaging is done immediately after manual lymph drainage. Bandages are applied
from the distal to the proximal aspect of the extremity with maximal pressure distally and minimal
pressure proximally. This is done by using several layers of cotton bandages or foam materials to
ensure uniform pressure distribution or to increase pressure in areas that are particularly fibrotic. The
bandages do not constrict blood flow but increase diminished skin and interstitial pressures. This
prevents any reaccumulation of excavated edema fluid and also prevents the ultrafiltration of
additional fluid into the interstitial space.
4. The bandaged patient is next guided through a series of decongestive exercises with the muscles
and joints functioning within closed space. The exercises increase lymph flow in all available lymph
channels and in collateral pathways that are used to make the passage to the venous angle.
This should reduce his/her (choose) swelling and stabilize his/her (choose) condition. Without this
therapy, his/her (choose) swelling can be expected to progress and lead to complications.
The patient will also be instructed in a home maintenance program so that he/she (choose) can
continue treatment on his/her (choose) own at home.
Sincerely,
Therapist: This letter should be typed in full, on a clinic letterhead.
265
Section 2 Patient Continuing Report: Medicare
T7 Page 1 of 1
In conformity with the Patient Protection and Affordable Care Act, and court decisions,
revised record-keeping measurements including "quality indicators", to track chronic
conditions such as lymphedema are mandated.
This requires a new approach to the traditional “progress and effectiveness of treatments”
standard for chronic conditions, where patient “progress” in treatment does not reflect the
reality of chronic illness care goals.
The Patient Continuing Report form supports this new requirement.
Note: If clinic does no Medicare or insurance billing, this form is not needed; however
for consistency, if you use this form for some patients, you should use it for all patients.
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Details: The Middle Class Tax Relief and Jobs Creation Act of 2012 (see MCTRJCA; Section 3005(g);
http://www.gpo.gov/fdsys/pkg/CRPT-112hrpt399/pdf/CRPT-112hrpt399.pdf) states that “The Secretary of
Health and Human Services shall implement, beginning on January 1, 2013, a claims-based data collection
strategy that is designed to assist in reforming the Medicare payment system for outpatient therapy services
subject to the limitations of section 1833(g) of the Social Security Act (42 U.S.C. 1395l(g)). Such strategy shall be
designed to provide for the collection of data on patient function during the course of therapy services in order to
better understand patient condition and outcomes.”
This claims-based data collection system is being implemented to include both 1) the reporting of data by therapy
providers and practitioners furnishing therapy services, and 2) the collection of data by the contractors. This
reporting and collection system requires claims for therapy services to include nonpayable G-codes and related
modifiers. These non-payable G-codes and severity/complexity modifiers provide information about the
beneficiary’s functional status at:
• The outset of the therapy episode of care,
• Specified points during treatment, and
• The time of discharge.
For Medicare these G-codes and related modifiers are required on specified claims for outpatient therapy
services – not just those over the therapy caps.
Specifically, functional reporting, using the G-codes and modifiers, is required on therapy claims for certain DOS as
described below:
• At the outset of a therapy episode of care, i.e., on the DOS for the initial therapy service;
• At least once every 10 treatment days -- which is the same as the newly-revised progress reporting period -the functional reporting is required on the claim for services on same DOS
HCPCS/CPT Codes requiring Functional G-code(s) and Corresponding Modifiers)
92506
92611
96125
92597
92612
97001
92607
92614
97002
92608
92616
97003
92610
96105
97004
SOURCE: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8005.pdf
Note: These codes are not generally used in massage therapy, however this system will become ubiquitous eventually.
See additional text in Section 2 page 29.
266
Therapist Entry 7
Patient Name __________________________________________ Date: ___________________
INSTRUCTION: All questions - Indicate the severity code for each line. Indicate if a standard assessment technique was
applied; for example a Pain Scale, or test was used. Avoid duplicating other records or measurements on this record. If
clinician is not qualified to make assessment, leave space blank. If patient reported a change or concern, so indicate.
Indicate change if baseline known.
GENERAL, LYMPHEDEMA:
A. Body part(s) affected
B. Amount of swelling (today-compared to prior)
C. Extremity dysfunction overall (today-comp.)
D. Circumference change (today-compare)
E. Volumetry change (today-compared to prior)
Modifier; Impairment Limitation
Restriction à Observational report of pt.
condition or disability.
Enter pt. self-reported comments in Q19.
impaired,
limited or
restricted
CI
CJ
>1 % to
<20 %
impaired,
limited or
restricted
>20 % to
<40 %
impaired,
limited or
restricted
C
K
CL
C
>60 % but
M
<80 %
>40 % to
>80 % to
impaired,
<60 %
<100%
impaired, limited or impaired,
limited or restricted limited or
restricted
restricted
C
N
100 %
impaired,
limited or
restricted
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(Tick 1 box on each line to describe current
status.)
> means more than; < means less than
G8978 Mobility: walking & moving f.l. (functional limitation)
1. Add’l LE Factors: Fatigue
G8981 Changing & maintaining body position f.l.
G8984 Carrying, moving & handling objects f.l.
G8987 Self care functional limitation (f.l.)
2. Add’l LE Factors: Weakness
3. Add’l LE Factors: Pain
4. Add’l LE Factors: Vitality
5. Add’l LE Factors: Weight gain/loss
G8990 Other physical or occupational primary f.l.
6. Add’l LE Factors: Neuropathy
7. Add’l LE Factors: Osteoporosis
8. Add’l LE Factors: Joint arthralgia
G8993 Other physical or occupational subs. f.l.
9. Add’l LE Factors: Skin tone of affected limb/area
10. Add’l LE Factors: Skin color of affected area
11. Add’l LE Factors: Skin condition of affected area
12. Add’l LE Factors: Skin thickness of affected area
13. Add’l LE Factors: Fluid content of affected area
14. Add’l LE Factors: Fibrosis of affected area
15. LE Factors only: Lymphedema Degree of disability
16. General or overall disability (account for LE
factors):
17. Other:
CH
0%
18. Subjective observations/notes:
19. Patient self reported comments (Include all activities limited or unable to do on a percentage scale): ___Sleep on affected side; ___lift
heavier objects; ___clean; ___cook; ___iron; ___garden; ___work on computer; ___sunbathe; ___bathe self; ___drive a vehicle; ___walk 1 mile;
___bicycle; ___vacation; ___do hobbies; ___do sports; ___wear desired clothes; ___do my job; ___socialize; I feel - ___heavy; ___stiff;
___swollen; ___tingling; ___weak; ___pain; ___ride public transportation; ___hurting; ___sad; ___discouraged; ___angry; ___stressed; ___lack
confidence; ___exercise; ___do SLD; ___other - describe below:
Clinician: ________________ Admin. Processing: _________________________________________________________
267
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Section 2
Physician’s Referral Form
For Lymphedema Care T8
Page 1 of 1
1. Enter your full clinic contact information at bottom of sheet.
2. Overprint (clinic info) with office printer, label, or rubber stamp.
3. Give copies to physicians whom you have a relationship with, or who
have referred patients to you, or copies to patients for their physician.
NOTE: Clinics & practitioners are encouraged to
use all forms as a TEMPLATE to improve and
produce your own custom forms. No copyright is
claimed if you change a form and make it your own.
268
Name (PRINT) ____________________________________________ Date: ____________________
QOL RAND 36-Item Health Survey 1.0 Questionnaire
20. During the past 4 weeks, to what extent
has your physical health or emotional
problems interfered with your normal social
activities with family, friends, neighbors, or
groups?
(Circle One Number)
21. How much bodily pain have you had
during the past 4 weeks?
(Circle One Number)
Not at all
Slightly
Moderately
Quite a bit
Extremely
1
2
3
4
5
None
Very Mild
Moderate
Severe
1
2
3
4
Very
severe
5
Not at all
A little bit
Moderatel
y
Quite a bit
Extremely
1
2
3
4
5
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22. During the past 4 weeks, how much did
pain interfere with your normal work
(including both work outside the home and
housework)?
(Circle One Number)
2 of 2
These questions are about how you feel
and how things have been with you during
the past 4 weeks. For each question,
please give the one answer that comes
closest to the way you have been feeling.
How much of the time during the past 4
weeks . . .
(Circle One Number on Each Line)
23. Did you feel full of pep?
24. Have you been a very nervous person?
25. Have you felt so down in the dumps that
nothing could cheer you up?
26. Have you felt calm and peaceful?
27. Did you have a lot of energy?
28. Have you felt downhearted and blue?
29. Did you feel worn out?
30. Have you been a happy person?
31. Did you feel tired?
32. During the past 4 weeks, how much of
the time has your physical health or
emotional problems interfered with your
social activities (like visiting with friends,
relatives, etc.)?
(Circle One Number)
How TRUE or FALSE is each of the
following statements for you.
(Circle One Number on Each Line)
33. I seem to get sick a little easier than
other people
34. I am as healthy as anybody I know
35. I expect my health to get worse
36. My health is excellent
All of
the
Time
Most of
the Time
A Good
Bit of
the Time
Some of
the Time
A Little
of the
Time
None of
the Time
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
4
4
4
4
4
4
5
5
5
5
5
5
6
6
6
6
6
6
All of the
Time
Most of
the Time
Some of
the Time
A Little of
the Time
None of
the Time
1
2
3
4
5
Definitely
True
Mostly
True
Don't
Know
Mostly
False
Definitely
False
1
2
3
4
5
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
309
Lymphedema Wellness Manual
Home Study 8 CE Course
COURSE INFORMATION & STANDARD DISCLOSURE:
Gay Lee Gulbrandson is approved by the National Certification Board for Therapeutic Massage
and Bodywork (NCBTMB) as a continuing education Approved Provider # 451083-09.
Florida Board of Massage Therapy CE Provider # 50-11392
8 CEs Home Study Course (NCBTMB) after completion of 40
question exam (70% or 28 correct answers required).
Provider Contact:
Gay Lee Gulbrandson, CLT-LANA, NCTMB, CMT, NAVALT, LANA, AMTA.
GayLee@VodderMLD.com
OFC: 510-849-1388 FAX: 510.558=8363
1791 Solano Ave #A8 Berkeley, CA 94707 USA
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Class Type:
Duration of course:
No time limit (estimated 6 + hours of study plus open book
multiple choice exam, for 8 CEs total).
Prerequisites:
None. Anyone may take this course. Ideal for LMT, CMT,
RMT, MD, RN, PT, OT, Esthetician, LE patient or family,
massage school graduate or equivalent.
Course Material:
Title: Lymphedema Wellness Manual, Sub-Title: Interactive
Lymphedema Management for Patients and Therapists
ISBN-10: 0985866403 ISBN-13: 978-0-9858664-0-2
Ideal Interface:
CEs for state licensure renewal, or prep for attending any MLD
class or refresher class. For RN, PT, OT, CMT, admin or
support staff seeking intro to LE study.
Fee:
Special $19.99. If the LE Wellness Manual was
(See website for more pricing
options. Groups welcome.)
purchased, or included as part of a seminar or class,
this 8 CE Course “Add-On” is only $19.99 via web
entry. Group inquiries welcome.
Source Material:
Bibliography & References list in LE Wellness Manual.
Additional resources available online: www.voddermld.com/b
Cancellation / Refund:
Student may cancel purchase any time prior to logging on to
any Home Study material or starting the exam. After shipping,
download, or entry, there are no refunds. Please see Terms &
Conditions online for details.
Process:
Mark answers on exam in book. Register at website and enroll
in class at www.voddermld.com/b, take exam. Receive your
8 CE NCBTMB Certificate of Completion by email.
8 CEs; STUDY THE LE WELLNESS MANUAL AND MARK A 40 Q EXAM (fee)
310
APPENDIX E: HOME STUDY COURSE
APPENDIX E: HOME STUDY COURSE & EXAM
Lymphedema Wellness Manual
Home Study 8 CE Course
Gay Lee Gulbrandson, Approved Provider # 451083-09
COURSE OBJECTIVE: Lymph drainage therapists, clinicians, researchers, students,and support staff
provide knowledgeable, effective treatment or guidance to clients with Lymphedema (LE). The various
protocols and details are covered in this Home Study Course. Exam performs spot-checking of learning.
When you have completed this home study course, you will be able to:
* Identify the structure of the lymph system
* Identify the risk of acquiring LE
* Identify the signs of LE
* Locate sources of meta-studies on LE
* Locate the relative contraindications to MLD
* Locate the treatment techniques for LE
* Locate the compression garment types for LE
* Locate the skin care techniques for LE
* Locate preventive techniques for LE
* Locate QOL survey instruments for LE
* Workup an individual risk control plan for LE
* Locate alternative treatments ratings for LE
* Locate Weight Lifting limits recommended for LE
* Locate hydrotherapy exercises for LE
* Locate sources of the best books on LE
* Locate best websites for LE information
* Locate the sources of garments for LE
* Locate additional information and assistance
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* Identify the types of lymphedema (LE)
* Locate the statistics and incidence of LE
* Identify some diagnostic techniques for LE
* Locate assessment & diagnostic methods for LE
* Locate the absolute contraindications to MLD
* Locate some measurement techniques for LE
* Identify the bandaging techniques for LE
* Define the CDT techniques for LE
* Define the diagnostic techniques for LE
* Define the assessment techniques for pre-LE
* Identify an individual treatment plan for LE
* Learn the Best Practices treatments for LE
* Learn the exercises recommended for LE
* Learn the Best Practices consensus ratings
* Learn the sources of personal articles for LE
* Learn the location of therapists / clinics for LE
* Learn the sources of supplies for LE
* Learn the sources of major research on LE
And so much more…
*
OVERVIEW: This home study course covers the interface between the LE therapist and the LE patient. It
is recommended refresher training for therapists already certified in CDT, or interested professionals
desiring to learn more about CDT.
PROCESS: The "Lymphedema Wellness Manual" is studied. Then a brief open book exam is taken
covering the major subject areas in the manual. Exam answers are entered online. Certificate is sent.
CEs: Earn 8 CEs approved by the NCBTMB, receive Certificate of Accomplishment by email.
Processing Fee: $19.99, online only, including email Certificate. Manual processing priced differently.
311
Name: _______________________________________ Date:__________ Time: _________
LE WELLNESS MANUAL Open Book Exam 8 CE Home Study Course ($19.99)
WARNING: Only one person may receive NCBTMB course credit for each Wellness Manual.
Contact publisher for other options or group class requests.
INTRODUCTION
Refer only to this LE Wellness Manual Section when answering. Mark the letter of the correct answer.
All questions have only one best answer. When complete, login and enter your answers.
1. A "consensus document" related to treatment or therapy means:
(not specifically defined in text)
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a. the best new ideas of an expert panel on a clinical topic
b. the majority vote opinions of an expert panel on a clinical topic
c. the collective opinions of an expert panel on a clinical topic
d. the individual opinions of the experts on a clinical topic
2. Liposuction is also known as:
a. lymphedema (LE)
b. circumferential ectropic assisted lumpectomy (CEAL)
c. circumferential suction assisted lipectomy (CSAL)
d. circumferential fiber shortening rate (CFSR)
Section 1 LYMPHEDEMA
Refer only to this LE Wellness Manual Section when answering. Mark the letter of the correct answer.
All questions have only one best answer. When complete, login and enter your answers.
3. The lymph system removes excess water, proteins, dead cells, fatty acids, and metabolic waste from the:
a. epithelial tissue
b. bone or nails
c. skeletal muscle tissue
d. loose connective tissue
4. Patients who feel a swelling or accumulation of fluid that drains with elevation, have pitting edema, or have visible
differences with the opposite side limb, may have lymphedema:
a. Stage 0
b. Stage I
c. Stage II
d. Stage III
5. Patients with measurable swelling who cannot rely upon elevation to reduce the swelling, and who might have
either positive or negative results in a pitting test, may have a lymphedema:
a. Stage 0
b. Stage I
c. Stage II
d. Stage III
6. What is the most common cause of secondary lymphedema in the developed world?
a. venous disease treatment
b. inflammation treatment
c. breast cancer treatment
d. burns or trauma treatment
Please continue Section 1 questions on next page.
312
APPENDIX F: INDEX
APPENDIX F: INDEX
A C CDT Components Compression, 95 Exercise, 104 Manual Lymph Drainage (MLD), 87 Patient Education, 109 Skin Care, 85 Cellulitis A Personal Story of Action, 76 Bandages Contraindicated, 98 IPC Contraindicated, 127 Prevention, 85 Prophylaxis, 70 Symptoms, 3 Treatment, 67 Center For Sustainable Change, 154 Centers for Medicare & Medicaid Services (CMS), 7, 11, 12, 35, 36, 37, 39, 74, 83, 84, 91, 106, 108, 110, 118, 119 Certified Lymphedema Therapist,
Locate, 160 Charts List, ix–x Cheville AL, 118 Classical Massage Contraindicated. See
Risk Factors: Stimulating Massage Clinic Performance Audit, 207 Clothing Source List. See Personal Wear CLT-LANA. See LANA, Also see
Lymphology Association of North
America (LANA) Certified Lymphedema Therapist, 110 Lymphology Association of North
America, 110 Collector Vessels Illustration, 103 Combined Decongestive Therapy
(CDT), 82–83 Competency. See Therapist Competency Complete Decongestive Therapy (CDT), 82–83 Compression IPC. See Pneumatic Compression
Pump (IPC) Pneumatic Pump. See Pneumatic
Compression Pump (IPC) Pump. See Pneumatic Compression
Pump (IPC) Compression Bandagaging (CB) Comparison Chart, 167 Compression Bandaging (CB), 95, 168, 169 Compression Garments, 101 On The Web, 171 Supplement, 170 Vendors, 170 Conflicting Treatments, 129–30 Consensus Documents, 209, 223 Continuing Education 8 CE NCBTMB
Course, 229 Contraindications Absolute, 88 Bandaging, 98 Li Vo
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Abbreviations, viii About Lymphedema. See Understanding
Lymphedema Action Guide, v Acupuncture Risk, 71 Additional Applications for CDT/MLD, 94 Air Travel. See Risk Factors: Air Travel
Precautions ALFP. See American Lymphedema
Framework Project (ALFP) Alternative Healing Methods, 116 Alternative Methods Yoga, 116 American Lymphedema Framework Project (ALFP), ix, 29, 40, 99, 199, 163, 99, 112, 160, 163, 195, 199, 200, 203, 315, 317 Antibiotics, 68, 69, 70, 76 Antibiotics for Recurrent Infections. See
Risk Factors: Prophylactic
Antibiotics for Recurrent Infections Applications for CDT/MLD, 191, 175, 94 Applications of MLD. See Topic Cards:
VI Applications of MLD Arm Assessment, 29 Form, 26 Screening for LE, 34 Armer JM, 29, 40 Assessment, 16 Bioimpedance Analysis (BIA, BIS), 37 Chronic Edema Evaluation, 41 Forms, 25, 22, 29–30 Identifying A Patient At Risk, 42 Intake, 16 Intake Forms, 23 LBCQ Questionnaire, 40 LE Causes Classifications, 43 Patients at Risk, 42 Recognizing LE, 34 Tissue Dielectric Constant (TDC), 36 Ultrasound, 35 Association of Schools. See North
American Lymphedema Education
Association (NALEA) At Work, 227 Audit. See Clinic Performance Audit Author’s Website, cccxxv Authorization, Patient. See Patient
Authorization Bandages, Bandaging. See Compression
Bandaging (CB) Basford JR, 118 BCRL. See Breast Cancer Related
Lymphedema (BCRL) Best Practices Ratings, vii, 81, 115, See
Effectiveness Ratings, Also see
Treatment: Best Practices Bioimpedance (BIA), 37 Blank Forms. See Forms Blank Blood Pressure and Venipuncture, 42, 71 Breast Cancer Related Lymphedema
(BCRL), 8, 40, 34, 78, 93, 124 Breast Center Standards Manual, 227 Breast Drainage Illustration, 173 B Balzarini A, 119 Cancer BCRL NLN Position Paper, 34 Cause, ACS, 4 Head and Neck, 84 LE After, 64 LE Causes, 2 LE Genesis, 8 LE Incidence, 11 LE Myths, 66 LE Prevention, 10 LE Risk After, 9 LE Risk of, 42 Metastasis, 130 Prevention of LE, 10, 78 Treatment, 3 Carati C, 7, 8, 326 CB. See Compression Bandaging (CB) CDP Combined Decongestive
Physiotherapy, 83 CDT. Also see Combined Decongestive
Therapy (CDT) Applications for, 175 Applications for MLD, 94 Applications TC VI, 191 CLT-LANA, 112 Combined Decongestive Therapy, 83 Complete Decongestive Therapy, 83 Contraindications, 88 Daily Checklist, 109 Dr. Vodder School, 112, 160 Indications, 94 LANA Certification, 112 MLD Pressure, 92 Modifications, 90 Myth vs. Fact, 129–30 NLN Standards, 111 Quality Control, 110 Quality Management, 110 Schools (NALEA), 112 Success of CDT, 110 Therapist Competency, 111 319
LYMPHEDEMA Wellness Manual
This very useful and comprehensive manual provides a wealth of practical information for patients and therapists on all aspects of lymphedema assessment and management, and includes an impressive array of charts,
illustrations, forms, checklists and resources rarely available in a single publication.
Kathleen Francis M.D., Medical Director Lymphedema Physician Services, P.C., Medical Director of the St Barnabas
Lymphedema Treatment Center, Medical Director of Klose Training and Consulting, author.
The Wellness Manual is an excellent resource and provides state of the art information about the lymphatic
system and lymphedema. Gay Lee has created a concise reference and practical guide for lymphedema
patients and CDT therapists. If you have lymphedema, or if you treat lymphedema, this manual is for you!
Saskia R.J. Thiadens, RN, Founder and Executive Director of the National Lymphedema Network (NLN), founder of
the first lymphedema clinic in the U.S., and author of numerous articles on Lymphedema.
A user friendly resource for patients and therapists alike. I commend Gay Lee for linking the components of
practice with the levels of scientific evidence to support them! This manual will open many eyes for those who
pay careful attention to the expansive contents. Read it and prepare to change the way you think about
lymphedema and its treatment.
Sheila H. Ridner, PhD, RN, FAAN, MSHA, Martha Rivers Ingram Professor- Vanderbilt University School of Nursing.
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The Lymphedema Wellness Manual will be on your desk at all times! Not only does it summarize − but it also
organizes important studies and recommendations. All this information in a condensed manual will increase
your confidence when fielding questions in the clinic. The sections on controversial or confusing topics such
as medications, pump use and infection are very helpful in sifting through the data and hearsay to make
sound recommendations. The countless patient handouts, teaching tools and forms are well-designed and
illustrated. This manual serves as an excellent bridge from the textbook to the clinic and home.
Sarah Stolker, MSPT, CLT-LANA, senior instructor- Norton School of Lymphatic Therapy, author of No Rules:
Lymphedema and the Young Women at Risk, and many other publications and articles.
The Lymphedema Wellness Manual is a tour de force! An invaluable resource for therapists working their
way through the maze of information − and mis-information − available about lymphedema. Gay Lee has
taken the guesswork out of assessment and management decisions. This manual is a must-have for therapists, and should be required reading in all lymphedema courses.
Jan Douglass RMT BHSc (Hons) Dr Vodder CLT Dr Vodder School International Instructor, author
Gay Lee Gulbrandson is a longtime resident of Berkeley, CA, USA. Happily
married, she has 3 children. She is an innovative, dynamic and respected
teacher who travels throughout the USA to teach MLD. After earning a BA
in Biology Gay Lee began her therapy practice in Swedish massage and
Shiatsu, then added Orthopedic Massage (The Hendrickson Technique).
When she discovered Dr. Vodder’s Manual Lymph Drainage (MLD) and
became certified in 1996 she found her calling. In 2002 she completed her
Teacher Training as an MLD Basic Course Instructor. Following her motto
"Live and Learn MLD," she now teaches the advanced level Dr Vodder MLD
course offerings for the Dr Vodder School International. She has maintained
a full-time therapy practice since 1979 treating many lymphedema clients
along with other conditions using MLD/CDT.
ISBN 978-0-9858664-0-2
9 780985 866402
58995 >

VodderMLD.com Live and Learn MLD

Transcription

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