1. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective Presenter: Steve Norton CDT Clinical Instructor, CLT-LANA Norton School of Lymphatic Therapy

2. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective Understanding the patient profile Understanding the diagnosis 4 common variations encountered in clinics The CLT perspective (CDT) Alternative therapies Sensible Self Care Final considerations Overview

3. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective Understanding the patient profile Physical attributes Nearly exclusive to females Peri-pubertal onset or later Pelvic crest to ankle involvement Bilateral symmetry Soft skin texture, low skin elasticity Palpable adipose nodules, progressive overtime Bruising, hypersensitive to touch and pressure Prominent superficial veins (in many)

4. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective Understanding the patient profile Mental, emotional attributes You are not obese Although you’ve been told so You do not have an eating disorder (initially) As would a truly obese person You are not lazy On the contrary, you are highly motivated Eager to follow any medical guidelines You feel labeled, misunderstood and dismissed Anger, fear, depression, desperation follow Covering up and limiting body exposure decreases your life’s fulfillment

5. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective Understanding the patient profile Mental, emotional attributes Accurate assessment provides comfort It may be the first time you’ve heard the word “Lipedema” Accurate diagnosis creates distress Because cures do not exist and conventional therapy is less effective Temptation to undergo high risk treatment There must be a “magic bullet” or pill Similar to primary lymphedema Temptation to surrender to depression Which encourages eating disorders and low exercise level

6. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective Understanding the diagnosis Pure Lipedema Adipose congestion (subcutaneous) No infections (cellulitis) No skin thickening (fibrosis) No foot, toe involvement Stemmer’s sign negative Legs only (in vast majority) Bilateral symmetry (always) Qualitatively soft texture Loose skin (tissue compliance) Palpable nodules (with severity) Acute sensitivity Easily bruising No pitting edema Pure Lymphedema Fluid congestion Adipose deposition over time in some Infections are frequent Skin thickening with progression Foot, toe involvement common Stemmers sign positive Arms, legs, face, trunk all possible Asymmetry (always) Qualitatively firm or hard Tight skin Loss of sensitivity No bruising Pitting edema

7. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective

8. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective

9. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective 4 Common Variations Lipo-lymphedema All pure lipedema attributes PLUS + Lymphedema attributes Caused by unmanaged lipedema Toes, foot and calf become edematous Asymmetry clarifies findings Pitting edema Infections Skin changes Why does lymphedema occur?

10. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective 4 Common Variations Lipo-lymphedema All pure lipedema attributes PLUS + Lymphedema attributes Caused by unmanaged lipedema Toes, foot and calf become edematous Asymmetry clarifies findings Pitting edema Infections Skin changes Why does lymphedema occur?

11. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective 4 Common Variations Lipo-phlebo-lymphedema All pure lipedema attributes PLUS + Lymphedema attributes PLUS + Vein attributes Caused by unmanaged lipedema and venous disease Presents as a mixture of chronic venous insufficiency, lymphedema and lipedema Water and lymph accumulation Distribution of each clinical finding varies widely + - lymphedema, + - venous edema, + - lipedema Why does lymphedema occur?

12. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective

13. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective 4 Common Variations Lympho-lipedema All pure lymphedema attributes PLUS + lipedema attributes Caused by primary or secondary lymphedema with a predisposition for lipedema Presents as if lymphedema is the sole diagnosis Underlying lipedema becomes apparent with treatment outcome (edema reduction)

14. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective The Certified Lymphedema Therapist Do no harm Lymphatic are fragile, finite and responsive Lymphatic vessels exist in the subcutaneous adipose layer

15. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective The Certified Lymphedema Therapist Objective: support the structure and function MLD creates increased contractile frequency Compression supports valves and increases absorption of fluids Loose skin requires external support (veins, lymphatics, pre-lymphatics)

16. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective The Certified Lymphedema Therapist Pause before inviting risk Lymphatic constitution is a mystery Can we afford to lose lymphatics? Are we predisposed to lymphedema? Can we improve the long-term outcome with select elements of CDT? Primary objective Halt the progression of lipedema Avoid secondary lymphedema Support the venous system (CVI) Welcome early identification and intervention Are surgical alternatives safe?

17. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective The Certified Lymphedema Therapist What is Complete Decongestive Therapy? 5 modalities (USA) MLD Compression bandaging Exercise Skin care (infection prevention) Self care education 2 phases Intensive clinical treatment Home care optimization CDT- Two phase Therapy

18. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective The Certified Lymphedema Therapist What is Complete Decongestive Therapy? 5 modalities (USA) 2 phases Strengths and Limitations of CDT ++++ Best suited to edema reduction Prevents progression to “combined” forms Relieves discomfort Improves movement and function Supports weight control and exercise Provides slow improvement over months, years CDT- Two phase Therapy

19. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective The Certified Lymphedema Therapist Complete Decongestive Therapy 5 modalities (USA) 2 phases Strengths and Limitations of CDT ------ Adipose requires support but does not reduce markedly For pure lipedema (no edema) elastic garments are sole therapy Avoid overtreatment! May seem impotent as compared to interventional therapy Emotional “let down” is common CDT- Two phase Therapy

20. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective The Certified Lymphedema Therapist 1st establish an accurate diagnosis Lipedema (pure) Lymphedema (pure) Lympho-lipedema Lipo-lymphedema Lipo-phlebo-lymphedema Adapt CDT to severity and complexity Avoid “overtreatment” or experimentation Provide accurate guidance Stay current with literature Stay true to empirically derived treatment options Address the anatomical deficits (skin compliance) Consider the emotional impact of living with lipedema Counsel accordingly

21. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective The Certified Lymphedema Therapist If no edema exists……. Treatment for “pure lipedema” Compression garments only OR “Short” intensive phase (1) MLD Analgesic benefit Compression bandaging Initiate controlled working pressure Compression garments Mainstay of ongoing therapy High resting pressure CCL 2, Flat knit, pantyhose style Diet/ Exercise Adopt a safe regime Self care Sensible, customized to each individual

22. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective The Certified Lymphedema Therapist If edema exists (venous, lymphatic or both) Two phase CDT Treatment for “complex lipedema” Openly share expectation for results Adipose will not respond markedly Edema will always respond Modalities: Compression bandage MLD Skin care Exercise Garments Self care education All account for a high work burden!

23. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective Sensible Self-care Wear elastic compression except when sleeping Flat knit, CCL 2, pantyhose Stay current with re-ordering (fabric fatigue) Find a CLT to measure appropriately Lipedema requires special considerations Improvements will occur slowly over time Wear compression bandages (or alternatives) if lymphedema coexists Nightly and while exercising Consider “alternatives” to streamline procedure Skincare to avoid infections (if lymphedema coexists) Diet and Exercise Stay connected to your CLT

24. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective Alternative Therapy: assessing risk Special diets and supplements Special exercise routines Pneumatic compression pumps Acupuncture Surgery Spa treatments, Others What constitutes risk? Any attempt at cosmetic enhancement and volume reduction that introduces new problems CDT does not introduce new problems

25. ©2003-2014 Norton School of Lymphatic Therapy Understanding Lipedema and current, safe therapeutic options A Conservative Perspective Final Thoughts Awareness is growing CLT’s are more accessible Provide a foundation of sound knowledge Treatment options will expand Interventional techniques always improve and refine. Carefully asses risk when seeking alternatives Long-term treatment outcomes tell the story

26. ©2003-2014 Norton School of Lymphatic Therapy Thank you for this gracious invitation! Presenter: Steve Norton, CDT Clinical Instructor, CLT-LANA Norton School of Lymphatic Therapy Www.NortonSchool.com Email: Steve@NortonSchool.com