COMPLETE DECONGESTIVE THERAPY TREATMENT GOLD STANDARD • Four components: 1. Manual Lymph Drainage (MLD) – manual therapy to decongest swollen area 2. Compression – either with multi layer bandaging or garments 3. Exercise – now proven in prevention and to decrease lymphedema progression 4. Education – skin and nail care, infection prevention, long term management 33
STAGES OF TISSUE HEALING • INFLAMMATORY • FIBROBLASTIC • REMODELING AND REPAIR/ MATURATION • UP TO 5 DAYS • PROLIFERATION • MONTHS TO YEARS • Body produces white • 5 DAYS – 2 MONTHS • Collagen matures and blood cells, plasma proteins and becomes firm and • New collateral blood cytokines into tissue fibrotic and lymph vessels • Very basic exercises • Goal is to optimize form tissue function • Fibroblasts are laying through exercise and down immature manual therapy collagen • Most important phase of rehab • Prevent atrophy and begin exercise 34
MANUAL THERAPIES • Manual Lymph Drainage (MLD) • Scar management • Stretching/trigger point work • Joint mobilizations • Compression (multi ‐ layer) bandaging 35
MANUAL LYMPH DRAINAGE • Manual technique that is NOT massage • Goal is to mobilize fluid • Decreasing sympathetic nervous system activity(pain) • Increasing parasympathetic nervous system activity (relaxation) • Increase in venous return of the superficial venous system 36
MANUAL LYMPH DRAINAGE: CONTRAINDICATIONS • ABSOLUTE: • RELATIVE: • CHF • Bronchial asthma • Acute infection • Hyperthyroidism • DVT (acute) • Hyper/Hypotension • Renal failure • Treated/active cancer • Acute UNKNOWN • Patient tolerance inflammation • Acute malignancy 37
MANUAL LYMPH DRAINAGE • Very gentle, light manual technique • Composed of two phases: 1. Active/working phase • Applying a STRETCH to the lymph vessels and underlying subcutaneous tissues • Moving the skin over underlying tissue; NOT moving the hands on the skin • Moving fluid in the proper direction 2. Rest phase • “snap back” of the tissue allowing fluid absorption and propulsion centrally • Clear system proximally first • Mobilize fluid distal to proximal 38
MANUAL LYMPH DRAINAGE • Used on body areas that are very congested; at or proximal to surgical area • Used around, and later over, incisions to promote scar mobility and decrease pain • Sometimes use of SLIGHTLY HEAVIER pressure is warranted if an area is very fibrotic and stiff • Repetition is key with fluid mobilization • At least 5 repetitions at each site before moving to next hand position 39
STATIONARY CIRCLES • Used to stimulate regional lymph nodes and can be performed over all aspects of the body • Very relaxing stroke • It is a stationary stroke: Start at proximal area, then lift and move hands to next position distally for clearing • Working phase – therapist places palmar aspect of fingers and distal palm flat on skin surface. Light pressure stretches perpendicular to lymph collectors (to open capillaries) and then parallel to the collectors to move fluid towards regional lymph nodes • Resting phase – do not release hands from skin, but pressure is completely released allowing skin to ‘snap back’ to starting position, completing the circular motion 40
STATIONARY CIRCLES Action phase = dark arrow Rest phase = lighter arrow Whole motion appears circular, however the arrow should be pointing straight up towards inguinal regional lymph nodes because that’s where the action portion ends. **Do not pull the skin back up! 41
PUMPS • Used to move fluid on larger areas of the body • It is a dynamic stroke; begin distally and move proximally • Working phase – the palm and web space between the thumb and second finger are contacting skin and performing the work. Action comes from the wrist pushing the skin proximally • Resting phase – the release comes from the wrist pivoting up and removing the palm from the skin allowing the ‘snap back’ underneath the palm. The fingertips maintain contact, and now pointing downward establishing the next starting position. 42
PUMPS Action phase = dark arrow Rest phase = light arrow The web space is directing the motion of the fluid. 43
Effect of Physical Methods of Lymphatic Drainage on Postexercise Recovery of Mixed Martial Arts Athletes. • Eighty MMA athletes were allocated to 4 groups: MLD, the BF (Bodyflow) device, DOT (deep oscillation therapy), and the control group. • The application of MLD reduced the post ‐ exercise blood lactic acid concentration and post ‐ exercise muscle tension. • Findings indicate that lymphatic drainage methods, whether manual or using electro ‐ stimulation and DOT, improve post ‐ exercise regeneration of the forearm muscles of MMA athletes. ***These methods can be used optimize training effects and reducing the risk of injuries of the combat sports athletes. 44
SCAR MASSAGE • Perform MLD on both sides of the scar, inward towards scar • Perform stationary circles over incision • Myofascial work beginning superficially and progressing to deeper work per patient tolerance and lack of reflexive pain and/or swelling • Cross friction only if necessary 45
TRIGGER POINT WORK • NECESSARY type of manual treatment due to significant guarding, fibrosis and shortening of muscles • Very poor patient tolerance, and often leads to MORE reflexive guarding • Use length of thumb or lateral aspect of palm at fifth metatarsal • Start with minimal pressure and stop BEFORE increased pain of patient • Hold 10 ‐ 60 seconds, gently release, repeat as necessary • Start work proximally and progress distally, but promote fluid movement distal to proximal 46
TRIGGER POINTS 47
ASSESSMENT AND TREATMENT OF LYMPHEDEMA RISK AND TREATMENT ACROSS VARIOUS PATIENT POPULATIONS • Post surgery patients • Oncology • Joint Replacement • Arthroscopy/Repairs • Orthopedic patients • Acute or chronic inflammatory disorders and arthritis • Casting/immobility • Diabetes/Wounds/Chronic Venous Insufficiency • Chronic pain patients 48
EVIDENCE BASED MEDICINE: WHAT IS IT AND WHAT IT ISN’T Best Available Research EBM Clinical Individual Expertise Patient Needs 49 Sackett, et al.
PATIENT POPULATION • Why is this patient being referred? • How does this patient present to us? • What does treatment consist of? 50
WHAT DOES ANY TREATMENT LOOK LIKE? • Get patient to relax and trust you • Manual therapy • ROM exercises • Muscle pump/Isometric exercises • Strengthening exercises • EDUCATION! • Avoid soreness and lactic acid build up! 51
THE ONCOLOGY PATIENT • Breast cancer • Pelvic cancers • Melanomas • Head and neck cancers • Radiation therapy patients 52
BREAST CANCER: WHY IS THIS PATIENT BEING REFERRED? • Pain • General Deconditioning • Postural Dysfunction • ROM issues • Frozen shoulder • Needs to get into RT position • Post ‐ op swelling/Lymphedema Stage 0 • Sentinel Lymph Node Biopsy (SLNB) = 5 ‐ 17% • Axillary Lymph Node Dissection (ALND) = 15 ‐ 53% • ALND and RT and/or Chemo = >50% • BMI < 25 kg/m2 = 8% at 5 years post treatment; BMI > 35 kg/m2 = 17% at 5 years post treatment 53
BREAST CANCER: PATIENT PRESENTATION • Incision at breast • Incision at axilla • Expander placement • Drains • May be very red/burnt from radiation • Instructed not to raise arms above 90 degrees • Significant protective posturing and pain • Swelling at breast, chest wall to scapula, axilla, upper arm to full arm • Seromas • Cording within affected quadrant 54
CORDING • Axillary web syndrome • Thick and rope like • Thin like a guitar string • Believed to be scarring and inflammation of the connective tissue that surrounds lymph vessels, as well as blood vessels and nerves • Location anywhere from site of surgery at axilla to hand or chest wall • Painful and restricts motion 55
CORDING 56
BREAST CANCER: PATIENT TREATMENT • Get patient to relax and trust you • Diaphragmatic breathing • Gentle touch with MLD • Manual Therapy • MLD – where is the swelling? • We may avoid affected axilla • Start proximally and slowly move distally, but move fluid distal to proximal • Gentle scapular PNF • Trigger Point Work – Gently!! • Scar massage 57
BREAST CANCER: TREATMENT FOR CORDING • Soft tissue work at distal most aspect of palpable cord • MLD • Gentle mobilization of cord • PROM into painful range with more aggressive mobility • AAROM • Foam roll – snow angels, butterfly wings, UE flexion • Seated stretches on table • Wand exercises • Standing stretches – multi angle pec stretch • AROM • Neural/lymphatic vessel glides • “bye bye” exercise 58
BREAST CANCER: PATIENT TREATMENT (CONTINUED) • ROM exercises • PROM AAROM AROM • Perform supine for scapular stabilization or seated/standing in front of a mirror • Wand exercises, pulley exercises, seated next to table exercises • Muscle pump exercises/isometrics • Shoulder isometrics ‐ ENTIRE KINETIC CHAIN • Also wrist, elbow, scapula, trunk, etc • Strengthening exercises • Have patient generate her own resistance • Theraband • Weight training – starting very light and progressing slowly • CKC exercises of upper quarter? • Patient may resume whatever exercise they prefer if guided properly and slowly ***Encourage patient to wear compression sleeve!!! 59
BREAST CANCER: PATIENT TREATMENT (CONTINUED) • EDUCATION – National Lymphedema Network (NLN) Position Papers. • Healthy habits • Air travel • Risk reduction • BCRL screening and early detection • Consider cardiotoxicity due to chemo, lowered immune response, fatigue, chemo induced neuropathy, chemo brain, radiation related changes, etc 60
BREAST CANCER: PATIENT TREATMENT • Be careful regarding the use of modalities • Ice • Moist heat • Ultrasound • Electric Stimulation • Laser 61
RADIATION THERAPY • External Beam Radiation Therapy (EBRT) • Brachytherapy • Targeted treatments (gamma knife/cyberknife) • Traditional EBRT is high energy rays used to kill lingering cancer cells • Side effects described as a sunburn ***INFLAMMATION!!!!!! Laying down more collagen causing fibrosis and scar tissue 62
Physical Activity and Lymphedema (the PAL Trial): Assessing the safety of progressive strength training in breast cancer survivors. • Strength training 2x/week reduced the incidence of lymphedema exacerbations that required further treatment by HALF! • The number and severity of lymphedema symptoms were reduced by self, subjective report, with improvements in quality of life. 63
Weight lifting in women with breast ‐ cancer ‐ related lymphedema. • 1 year weight training program • 13 weeks of supervised instruction at a gym, then 9 months unsupervised • The proportion of women who had an increase of 5% or more in limb swelling was similar in the weight ‐ lifting group (11%) and the control group (12%). As compared with the control group, the weight ‐ lifting group had greater improvements in self ‐ reported severity of lymphedema symptoms and upper and lower body strength and a lower incidence of lymphedema exacerbations as assessed by a certified lymphedema specialist. • In breast ‐ cancer survivors with lymphedema, slow progressive weight lifting had no significant effect on limb swelling and resulted in a decreased incidence of exacerbations of lymphedema, reduced symptoms, and increased strength. 64
A Randomized Trial on the Effect of Exercise Mode on Breast Cancer ‐ related Lymphedema. • Exercise mode of resistance training and aerobic training. Lymphedema remained stable in both groups, with no significant differences between groups noted in lymphedema status. The resistance ‐ based exercise group increasing strength compared with the aerobic ‐ based exercise group. The aerobic ‐ based exercise group reported a clinically relevant decline in number of symptoms postintervention and women in both exercise groups experienced clinically meaningful improvements in lower ‐ body endurance, aerobic fitness. • Participating in resistance ‐ or aerobic ‐ based exercise did not change lymphedema status but led to clinically relevant improvements in function and quality of life. As such, personal preferences, survivorship concerns, and functional needs are important and relevant considerations when prescribing exercise mode to those with secondary lymphedema. 65
Long term effects of manual lymphatic drainage and active exercises on physical morbidities, lymphoscintigraphy parameters and lymphedema formation in patients operated due to breast cancer: A clinical trial • 106 women undergoing radical BC surgery. Women were allocated to perform AE or MLD, 2 weekly sessions during one month after surgery. • Age ≤ 39 years was the factor with the greatest association with lymphedema. In women with age ≤ 39 years, BMI >24Kg/m2 was significantly associated with lymphedema. • In younger women, obesity seems to be the major player in lymphedema development and, in older women, improving muscle strength through AE can prevent lymphedema. In essence, MLD is as safe and effective as AE in rehabilitation after breast cancer surgery. 66
Combining Manual Lymph Drainage with Physical Exercise after Modified Radical Mastectomy Effectively Prevents Upper Limb Lymphedema. • In the PE group, patients started to undertake remedial exercises and progressive weight training after recovery from anesthesia. In the MLD group, in addition to receiving the same treatments as in the PE group, the patients were trained to perform self ‐ MLD on the surgical incision for 10 min/session, 3 sessions/day, beginning after suture removal and incision closure • Compared to those in the PE group, patients in MLD group experienced significant improvements in scar contracture, shoulder abduction, and upper limb circumference. • Self ‐ MLD, in combination with physical exercise, is beneficial for breast cancer patients in preventing postmastectomy scar formation, upper limb lymphedema, and shoulder joint dysfunction. 67
PELVIC CANCER: WHY IS THIS PATIENT BEING REFERRED? • Pain • Impaired ROM • Gait dysfunction • Fatigue and general deconditioning • Post ‐ op swelling 68
PELVIC CANCER: PATIENT PRESENTATION • Large abdominal incision vs laparoscopic incision, and possible inguinal incision • Protective posturing and pain/muscle guarding • Antalgia • Balance dysfunction • Swelling throughout abdomen, genitals, proximal LEs 69
PELVIC CANCER: TREATMENT • Diaphragmatic breathing • Manual therapy and scar massage • MLD towards axilla , avoid inguinal regional lymph nodes and bypassing abdomen • ROM • Prone lying • Hip flexor stretches • Muscle pump and isometric exercises • Quad, HS, glut sets and ankle pumps • Abdominals • Kegels 70
PELVIC CANCER: TREATMENT • Strength training • PREs • Begin with bilateral work, slowly progressing towards unilateral work if necessary • Avoid plyometrics • Gait and balance training • Education/HEP ***Compression garments for trunk or LEs 71
Incidence, risk factors and estimates of a woman’s risk of developing secondary lower limb lymphedema and lymphedema ‐ specific supportive care needs in women treated for endometrial cancer. • 13% of women developed lymphedema. Risk varied markedly with the number of lymph nodes removed and, to a lesser extent, receipt of adjuvant radiation or chemotherapy treatment, and use of nonsteroidal anti ‐ inflammatory drugs (pre ‐ diagnosis). • The absolute risk of developing lymphedema was 30% ‐ 50% for women with 15+ nodes removed and additional risk factors • Lymphedema is common; experienced by one in eight women following endometrial cancer. Women who have undergone lymphadenectomy have very high risks of lymphedema and should be informed how to self ‐ monitor for symptoms. 72
Lower ‐ extremity lymphedema following management for endometrial and cervical cancer. • We identified 165 (135 endometrial cancer and 30 cervical cancer) subjects. In the entire population, 3.6% subjects developed post ‐ operative lymphedema. • Supplementary analyses revealed that a BMI >35 kg/m(2) and possessing numerous ( ≥ 3) co ‐ morbidities significantly correlated with the manifestation of lower ‐ extremity lymphedema. 73
Low rate of lymphedema after extended pelvic lymphadenectomy followed by pelvic irradiation of node ‐ positive prostate cancer. • 22 patients treated with surgery, EBRT, brachytherapy, hormone therapy. 6 patients (27%) experienced grade 1 lymphedema, 2 patients (9%) had grade 2 lymphedema, and none had grade 3 or 4 based on the CTC Common Toxicity Criteria Scale 4.0. 3 patients required treatment with compression stockings. • There is a low incidence of lymphedema in prostate cancer patients who have high risk positive nodes and have undergone pelvic lymph node dissection 74
MELANOMA: WHY IS THIS PATIENT BEING REFERRED? • Pain • ROM and strength deficits • Fatigue and general deconditioning • Post ‐ op swelling PATIENT PRESENTATION: • Incision at tumor site and regional lymph nodes • Guarding and ROM protective posturing TREATMENT: to include MLD to proximal lymph nodes and for scar management 75
Prospective Assessment of Lymphedema Incidence and Lymphedema ‐ associated Symptoms following Lymph Node Surgery for Melanoma. • Twelve months after axillary surgery, 9% had Limb Volume Change (LVC) 5 ‐ 10%, and 13% had LVC >10%. • Twelve months after inguino ‐ femoral surgery, 10% had LVC 5 ‐ 10%, and 13% had LVC >10%. • There was a significant 7 ‐ to 9 ‐ fold increase in symptoms for patients with LVC greater than >10% compared to those with LVC <5%, lymph node dissection versus SLN biopsy • LVC greater than 5% is common at 12 months following nodal surgery for melanoma and is associated with symptoms. 76
THE JOINT REPLACEMENT PATIENT/ SURGERY INTO JOINT CAPSULE : WHY IS THIS PATIENT BEING REFERRED? • ROM deficits • Strength training • Gait and balance training • Post ‐ op pain and swelling 77
THE JOINT REPLACEMENT PATIENT: PATIENT PRESENTATION • Significant soft tissue damage and damage of lymph vessels • Swelling, which is dependent in nature • Usually significant and grossly affects entire extremity • Impaired ROM and contractures • Strength deficits • Gait and balance deficits 78
THE JOINT REPLACEMENT PATIENT: TREATMENT • Diaphragm breathing • Manual Therapy – begin gently and progressively increase pressure • Massage and MLD • Scar mobility • Trigger point work • Joint mobilizations • PROM • Compression bandaging? • AAROM and AROM exercises • Muscle pump exercises/isometrics • LE – full kinetic chain • UE – full kinetic chain • Keep isometrics as part of HEP for long term muscle pump activity 79
THE JOINT REPLACEMENT PATIENT: TREATMENT • Strength training • PREs – be cognizant of weight and theraband placement • Begin with bilateral and progress to unilateral work • OKC vs CKC • Gait and balance training • Return to sport • HEP and long term education • Does this patient need a compression stocking? 80
Randomized trial investigating the efficacy of manual lymphatic drainage to improve early outcome after total knee arthroplasty. • A significantly greater active knee flexion was achieved in the MLD group when compared with the control (no MLD) group at the final measure prior to hospital discharge (day 4 post surgery) and at 6 weeks post surgery. • MLD in the early postoperative stages after TKA appears to improve active knee flexion up to 6 weeks post surgery, in addition to conventional care. 81
STICKS study – Short ‐ sTretch Inelastic Compression bandage in Knee Swelling following total knee arthroplasty – a feasibility study • No complications noted • Improved Oxford knee scores • There was no significant difference between groups regarding knee swelling, knee range of motion, visual analogue pain score, complications and length of stay. 82
THE ARTHRITIC/ORTHOPEDIC/CHRONIC PAIN PATIENT: WHY IS THIS PATIENT BEING REFERRED? • Pain • Loss of function PATIENT PRESENTATION: • Strength deficits and muscle atrophy • Impaired ROM • Antalgia or compensatory gait strategy TREATMENT: OA/RA related pain and swelling would benefit from MLD as part of clinical and home program 83
DIABETES/WOUNDS/CVI: WHY IS THIS PATIENT BEING REFERRED? • Gait and balance dysfunction • Deconditioning • Peripheral neuropathy • Wound care • Swelling PATIENT PRESENTATION: • Swelling of LEs that is not symmetrical • SYMMETRICAL SWELLING IS AN INDICATION OF CARDIAC DISEASE • Chronic inflammation and skin breakdown/wounds due to decreased ability to remove excess fluid • Long term dilation of venous and lymph vessels continue to make valves insufficient 84
COMPRESSION • REBECCA ELWELL • The use of compression bandaging in the intensive phase of treatment is indicated to reduce distortion, lymphorrhea, and achieve wound healing. • CVI specific 85
DIABETES/WOUNDS/CVI: TREATMENT • Teach diaphragmatic breathing for improved fluid return with leg elevation • Exercise • Walking is best for long term muscle pump action • Compression important for these patients for long term management (remain aware of DVT) • Manual therapy as BASIC part of clinical treatment but more for a HEP ***SKIN CARE*** 86
Venous flow during manual lymphatic drainage applied to different regions of the lower extremity in people with and without chronic venous insufficiency: a cross ‐ sectional study. • MLD was applied by a certificated physical therapist to the medial and lateral aspects of the thigh and leg. Blood flow velocities in the femoral vein, great saphenous vein, popliteal vein and small saphenous vein at baseline and during MLD, measured by duplex ultrasound. • Flow volume in the femoral vein increased from baseline when MLD was applied to the medial and lateral aspects of the thigh. MLD had a positive effect on venous blood flow regardless of whether it was applied to the medial or the lateral aspect of the leg. • MLD increases blood flow in deep and superficial veins. MLD should be applied along the route of the venous vessels for improved venous return. 87
OTHER DIAGNOSES • RSD/CRPS • Stroke • Fibromyalgia • High impact sports • Headaches and migraine • Amputation 88
LBS MLD TREATMENT PROTOCOL Non ‐ oncology patients Determine treatment area and regional lymph nodes (RLN) Stimulate RLN with stationary circles Clear the limb by performing stationary circles at most proximal area of injury towards RLN move hands distally and perform stationary circles towards RLN continue moving distally until you reach the end of the limb/treatment area Mobilize fluid distal to proximal now with pumps or stationary circles back towards RLN 89
LBS MLD TREATMENT PROTOCOL Oncology Patients Determine treatment area, RLN, and secondary RLN – the closest group of lymph nodes that have NOT been affected by treatment Stimulate the affected RLN (assuming no skin breakdown) AND secondary RLN with stationary circles Perform stationary circles STARTING at affected RLN and move TOWARD secondary/unaffected RLN Clear the limb by performing stationary circles at proximal area of swelling move hands distally covering entire swollen area Perform pumps or stationary circles to mobilize fluid from distal to proximal towards UNAFFECTED RLN, BYPASSING affected RLN 90
EXERCISES • Diaphragmatic breathing • ROM – begin proximally and move distally • Posture and Stretching – want to have good muscle and tissue flexibility to promote fluid movement • Foam roll for posture • Isometrics for muscle pump activity • Proximal stability • Peripheral strengthening • Open chain vs. closed chain • Lymphatic and neural mobilization exercise • “Bye Bye” exercise • Sciatic/femoral nerve glide 91
PHARMACOLOGICAL CONSIDERATIONS • Diuretics – removing fluid only. There is no removal of proteins. • Not indicated for long term use • May help for very short time in an incredibly swollen limb or with lymphorrhea • Benzopyrones – increase macrophage activity for protein breakdown • Cause liver toxicity • Not FDA approved 92
CASE STUDIES • SK ‐ 62 y/o female • B breast CA ER+ PR+ HER2 ‐ • Treated with B lumpectomy and R SLNB (5) and L SLNB (3) followed by Canadian RT protocol • Presented with 4 incisions, post operative B breast swelling and referred for lymphedema education and sleeves • Very active; flies and hikes at altitude annually, yoga, TRX, weight training • Benefitted from MLD for chest swelling with use of B axilla and inguinal LNs • Wears B sleeves for activity and night garments when staying at altitude; does not wear compression bra 93
CASE STUDIES • JH – 55 y/o female • R breast CA ER ‐ PR ‐ HER2 ‐ • Treated with R mastectomy and ALND (7, 2+) and chemo; no reconstruction • R UE post surgical swelling and L UE swelling secondary to port placement • Had prophylactic L mastectomy • Wore B compression sleeves • Recurrence 6 months later, large tumor deep in chest wall. Surgery to remove tumor, part of pectoral mm and ALND (7, 1+) followed by RT • Severe burn, had to stop all PT, able to resume 6 weeks later to work on scar tissue, fibrosis, mild R upper arm lymphedema • Wears B sleeves to fly, R UE sleeve intermittently with exercise 94
CASE STUDIES • MH – 74 y/o female • Congenital L LE lymphedema x30 years with history of cellulitis (x3) which she self managed for years with self MLD, self bandaging, compression pump use and thigh high compression stocking 40/50 mmHg • Increased swelling and lower abdominal redness following air travel 1 year prior • L THR approx. 3 year ago and begins having increased pain and girth after 3 months treatment • Has L TH revision, cleared to resume CDT after 4 weeks, has not yet begun PT. Just resumed wearing stocking and pump • Progressive, significant L LE weakness and antalgia; and progressive swelling • Discharge to begin aquatic PT 95
COMPRESSION: BANDAGES AND GARMENTS • Necessary component of treatment due to the change in elasticity of lymphatic vessels • Improves the effectiveness of muscle pump activity • Stronger distally and decreases gradually proximally • Continues to promote lymphatic and venous return by improving effectiveness of valve function • Helps maintain decongestive effect of MLD and prevents re ‐ accumulation of fluid 96
COMPRESSION BANDAGES • Multi ‐ layer bandages required to treat a true lymphedema • Short stretch bandages preferred due to the higher working pressure (allows 60% elasticity) and low resting pressure vs ACE bandage (140% elasticity) which has a high resting pressure and low working pressure • 1 ‐ 2 layers in a temporary lymphedema MAY be sufficient • Longer wear time = better results • Part of HEP – involve caregiver if able 97
COMPRESSION GARMENTS • Better long term option • Compression classes: • CCI: 20 ‐ 30 mmHg • CCII: 30 ‐ 40 mmHg • CCIII: 40 ‐ 50 mmHg • CCIV: >60 mmHg • Graded compression – stronger distally • Anything that is available OTC is non ‐ medical strength • Usually anywhere from 8 ‐ 12, 12 ‐ 15, or even 15 ‐ 20 mmHg 98
COMPRESSION GARMENTS • Most likely recommend CCI for prevention in oncology patients • For performing exercises and HEP • For air travel • For strenuous or repetitive activity • Recommended for daily wear for at least 4 weeks for subclinical swelling • CC1 for treatment in orthopedic patients • Long term wear for those who present with clinical lymphedema 99
DOCUMENTATION • SUBJECTIVE REPORT • HPI/PMH – especially infection history • Time of onset? • Pain scale • Altered sensation • Social history • Questionnaire • SF ‐ 36 • LLIS – Lymphedema Life Impact Scale • Offers a subjective scale for physical, psychosocial, and functional concerns on a scale of 1 ‐ 5 • Any swelling self management? 100
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