1. Introduction to Lymphedema Part 2

2. Possible Effects of Lymphedema Damage of interstitium Valvular insufficiency Occlusion of lymph vessel Fibrous area limiting function of lymph system Decreased muscle pump function Inflammatory processes of lymph node Sclerosis of arteries and veins Tissue changes Changes in Lymph Transport

3. What is CDT CDT= Complete Decongestive Therapy Manual Lymph Drainage Compression Bandaging Remedial Exercise Skin and Nail Care Instructions in Self-Care

4. MLD MLD=Manual Lymphatic Drainage Improves lymph circulation and production Re-routes the lymph flow around blocked areas Special techniques of MLD help break down fibrous tissues Promotes relaxation: dim lights, music MLD sessions last between 30 – 60 minutes

5. Compression Bandaging Reduces ultrafiltration rate Improves efficiency of muscle and joint pumps Prevents re-acummulation of evacuated lymph fluid Helps reduce fibrosis of tissues Wear bandages all night during stage I Bandaging sessions can last approximately between 30 and 60 minutes

6. Remedial Exercises Gentle active strengthening (may slowly progress) Gentle stretching (may slowly progress) Low intensity Diaphragmatic breathing Improves muscle pump, lymph vessel activity, and lymphatic return Done with bandages (or compression) in place

7. Skin and Nail Care To help prevent and eliminate bacterial and fungal growth  Use PH balanced lotion  Work with physician if other topical agents are needed To reduce risk of infection  Avoid nicks and cuts  Clean all injuries immediately  Avoid extreme temperatures  Learn signs of infection and when to contact the physician

8. Instructions in Self Care Skin and nail care Infection prevention Self massage Self bandaging Compression garments Exercises When to contact MD or PT: increase in swelling

9. Phase 1 (Treatment Phase) Phase 2 (maintenance) MLD Skin and nail care Compression Bandaging Ordering compression garment=end of phase 1 Exercises: gradually add more Self Care Training: manual lymph drainage, wear schedule for garments, exercises MLD as needed Skin and nail care Compression Garment during the day Bandaging at night Exercises Phase 1 & Phase 2 of CDT

10. Lymphedema Banadaging A multi-layered bandaging system Creates compression  Increase reabsorption  Decrease ultrafiltration Uses short stretch bandages

11. Short Stretch Bandages Contain no elastic threads Stretches to only 50% Pure cotton Like a soft cast: no soft spots

12. Working Pressure Resting Pressure Does not yield to fluid refilling Constriction generated by elastic thread Can cause tourniquet effect, soft tissue damage, or loss of sensation Working Pressure Vs. Resting Pressure

13. Methods of Compression Bandaging Application Apply graduated widths of compression bandages Each bandage should be applied from distal to proximal Use uniform spacing and tension Use lotion prior to application

14. Bandaging Products Tricofix/ Tg- Tubular Gauze stockinette  Can use as a chip bag of foam for high compression area, fold over at end Artiflex/Cellona synthetic cotton padding bandages  Malleolus, skin folds Other padding Elastomull/ Transelast Classic gauze  Fingers and toes, wrap to get toes softened up Isoband/Idealbinde short stretch cotton bandages  Not for compression really, just padding still Comprilan/ Rosidal K short stretch cotton bandages  6-10cm for decreasing compression, tape not hook.

15. Objectives and Considerations for use of Foam Improved comfort Even pressure distribution Increase protection for skin over bony prominences Custom tailored pressure for odd shapes and sizes of areas Caution for allergic reaction Aggressive response where foam overlaps

16. Care and Maintenance of Bandages Washing Drying Re-rolling Re-ordering

17. Exercise Tips Work with Physician Use compression Maintain hydration Monitor environmental temperatures May need to adapt exercises to patient Need to “ease into” intensity of exercise Don’t wear tight or restrictive clothing Start exercises twice a day for 15 minutes each session

18. Upper Extremity Remededial Exercises Abdominal Breathing Head isolations Shoulder rolls and shrugs Arm Exercises  Hand isolations  Climb the ladder  Swimming  Canoeing/ Stick exercises  Softball exercises

19. Lower Extremity Remedial Exercises Abdominal Breathing Foot and Leg Exercises  Toe Clenches and abduction  Ankle Curls and rotation  Riding the bike  Heel slides  Resist knee flexion in supine  Bridging and knee to chest Walking

20. Billing for Lymphedema Services Use Good documentation language  MLD vs massage  Bandaging vs wrapping Forms to keep  Education  Volumetric  Photos  Daily notes

21. Billing (cont) Bill for  Eval  Re-eval  Ther ex  Functional activities  Manual therapy  Orthotic fitting training (Jobst measurements) G Codes  Bill under “Other”

22. Compression Garments Ready made or custom