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Gay Lee Gulbrandson CLT-LANA LY M P H E D E M A Wellness Manual Li Vo ve dd an erM d Le LD ar .co n m M LD 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 Li Vo ve dd an erM d Le LD ar .co n m M LD [email protected], 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 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) 32 33 34 35 36 36 37 38 40 41 42 43 45 48 Action 55 Action Li Vo ve dd an erM d Le LD ar .co n m M LD 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 76 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 117 125 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 APPENDIX B: GLOSSARY 211 Selected Lymphedema-related Terms Selected Research Statistical Terms Selected Online Lymphedema Glossaries 211 183 185 187 Li Vo ve dd an erM d Le LD ar .co n m M LD 189 191 193 197 198 198 199 200 202 203 204 205 206 207 220 222 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 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 Classification of Causes of Secondary Lymphedema Therapist Assessment Guide Contraindications Specific Contraindications The Pressure (Intensity) of MLD Treatment Standards Guide Patient Daily Checklist Myth vs. Fact About MLD Locate a Certified MLD Therapist or Clinic Selected Patient Information Websites Selected Lymphedema Medical Information Selected Lymphedema Research Organizations Selected LE Supplies Sources 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 vi vii viii 12 42 43 41 88 90 92 97 109 129 160 161 162 163 164 165 167 168 169 170 171 173 175 176 180 204 205 207 209 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. Li Vo ve dd an erM d Le LD ar .co n m M LD 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! Li Vo ve dd an erM d Le LD ar .co n m M LD ASSESSMENT & PROTOCOL 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: Li Vo ve dd an erM d Le LD ar .co n m M LD 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 Some benefits/risks Practices that therapists and patients should contrast for benefits and harmful effects regarding individual status Effectiveness Unknown 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 2 3 4 5 5 6 7 7 8 8 9 10 Li Vo ve dd an erM d Le LD ar .co n m M LD 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 11 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.) LYMPHEDEMA WELLNESS Manual 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. www.voddermld.com/b 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. www.voddermld.com/b 11 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 LYMPHEDEMA WELLNESS Manual The Lymph System Lymph System Overview Li Vo ve dd an erM d Le LD ar .co n m M LD 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. • Li Vo ve dd an erM d Le LD ar .co n m M LD • 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.” SOURCE: National Cancer Institute PDQ®. 2011.12 9 LYMPHEDEMA WELLNESS Manual 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 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 LYMPHEDEMA WELLNESS Manual Lymph Drainage of the Upper Body Understanding Lymphedema Terminus Right Lymphatic Duct Li Vo ve dd an erM d Le LD ar .co n m M LD 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 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 Classification of Causes of Secondary 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 Combined Decongestive Therapy (CDT) Surgery Manual Lymph Drainage (MLD) 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 LYMPHEDEMA WELLNESS Manual 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 Patient Authorization 2 233 Photo Release Patient Authorization 3 235 HIPAA Notice of Privacy Practices Patient Disclosure 4 239 Patient History & Authorization Patient Entry Option 5 251 Lymphedema Assessment & Intake Therapist Entry 1 255 Li Vo ve dd an erM d Le LD ar .co n m M LD 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 LYMPHEDEMA WELLNESS Manual 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 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:) East-West Lymphedema Clinic, LLC _____________________________________________________ 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 EXAMPLE – SEE BLANK FORMS IN BACK of BOOK East-West Lymphedema Clinic, LLC CLINIC / PRACTICE __________________________________________________ Patient: If possible, fill out first 2 pages before the initial appointment. Be as candid and complete as possible. Patient History & Authorization 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 Li Vo ve dd an erM d Le LD ar .co n m M LD EXAMPLE Do you know the cause of the lymphedema ? x Yes _________________________________________________________________ If Yes, Circle all applicable: Combined Decongestive Therapy (CDT) Manual Lymph Drainage (MLD) 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 ! www.voddermld.com/b 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 21 Section 2 Assessment and Authorization EXAMPLE – SEE BLANK FORMS IN BACK of BOOK Li Vo ve dd an erM d Le LD ar .co n m M LD EXAMPLE This form is a downloadable PDF calculator. Enter measurements, all totals then display in black. 25 LYMPHEDEMA WELLNESS Manual EXAMPLE – SEE BLANK FORMS IN BACK of BOOK 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 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 LYMPHEDEMA WELLNESS Manual EXAMPLE – SEE BLANK FORMS IN BACK of BOOK 30 Li Vo ve dd an erM d Le LD ar .co n m M LD EXAMPLE Therapist: This form is for chronic condition reporting per the Patient Protection and Affordable Care Act. Section 2 Assessment and Authorization EXAMPLE – SEE BLANK FORMS IN BACK of BOOK 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:________________________________________________________________ Li Vo ve dd an erM d Le LD ar .co n m M LD Physician’s Guide: Combined Decongestive Therapy, Manual Lymph Drainage Chemotherapy:____________________________________________________________ EXAMPLE Herceptin: ________________________________________________________________ Combined Decongestive Therapy (CDT) 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. Manual Lymph Drainage (MLD) 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 LYMPHEDEMA WELLNESS Manual EXAMPLE – SEE BLANK FORMS IN BACK of BOOK 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 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. Section 2 Assessment and Authorization 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) Li Vo ve dd an erM d Le LD ar .co n m M LD - 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 Section 2 Assessment and Authorization 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) Li Vo ve dd an erM d Le LD ar .co n m M LD 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 LYMPHEDEMA WELLNESS Manual 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 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) SOURCE: Moffatt C, et al. 2006. "People at risk of lymphedema should be identified early during routine assessment, monitored and taught self care." SOURCE: Moffatt C, et al. 2006. 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. Li Vo ve dd an erM d Le LD ar .co n m M LD *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 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. 45 LYMPHEDEMA WELLNESS Manual 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. Li Vo ve dd an erM d Le LD ar .co n m M LD 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 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, 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 Li Vo ve dd an erM d Le LD ar .co n m M LD The lymph vessels and structures of the skin. 47 LYMPHEDEMA WELLNESS Manual EXAMPLE – SEE BLANK FORMS IN BACK of BOOK Li Vo ve dd an erM d Le LD ar .co n m M LD Individual Treatment Protocol: Wellness Action Plan (WAP Short Form) 48 Section 3 Individual Treatment Protocol EXAMPLE – SEE BLANK FORMS IN BACK of BOOK 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 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 NLN Position Statement 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 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. 57 LYMPHEDEMA WELLNESS Manual 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. Li Vo ve dd an erM d Le LD ar .co n m M LD 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. 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). 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 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 LYMPHEDEMA WELLNESS Manual EXAMPLE – SEE BLANK FORMS IN BACK of BOOK Risk Factors: Risk Reduction & Safe Practices Worksheet (Short Form) East-West Lymphedema Clinic, LLC 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! _________________________________________________________________________________________________________________________________________________________ www voddermld com/b 60 _________________________________________________________________________________________________________________________________________________________ Li Vo ve dd an erM d Le LD ar .co n m M LD 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 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. SOURCE: Moffatt C, et al. 2006. 28 69 LYMPHEDEMA WELLNESS Manual Risk Factors: Recurrent Infections Some Benefits & Risks 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 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 LYMPHEDEMA WELLNESS Manual 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. SOURCE: Moffatt C, et al. 2006. 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. Li Vo ve dd an erM d Le LD ar .co n m M LD 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] SOURCE: Kettenhuber G, et al. n.d. 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 SOURCE: Kettenhuber G, et al. n.d. 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.” SOURCE: National Cancer Institute PDQ®. 2011.12 98 Section 5 CDT - Combined Decongestive Therapy 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. Li Vo ve dd an erM d Le LD ar .co n m M LD 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. àBandaging 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 àSpecialist knowledge and skills are required for safe and effective application Compression affects the venous, arterial, lymphatic and microcirculation àCompression is only contraindicated in critical ischemia (ABPI < 0.5 or ankle systolic 50mmHg) àCompression enhances arterial circulation in patients with mixed disease (ABPI 0.4-0.8) by removal of edema àCompression 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 àHigh stiffness, tolerable resting pressures to enhance patient adherence àOptimal leg compression levels (40- 60mmHg at rest - 60 -90mmHg on standing) àOptimal arm compression level (30mmHg at rest) àDifferent levels of compression for lower and upper limbs are influenced by the effects of gravity and capillary filtration rates àHigher levels of pressure may impede lymphatic drainage and damage initial lymphatics àCompression 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 àChronic edema/lymphedema requires constant compression, if discontinued edema [will] recur rapidly Continued 99 Section 5 CDT - Combined Decongestive Therapy 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) Li Vo ve dd an erM d Le LD ar .co n m M LD 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. SOURCE: Moffatt C, et al. 2006. 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 SOURCE: Moffatt C, et al. 2006. 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 LYMPHEDEMA WELLNESS Manual 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. SOURCE: Moffatt C, et al. 2006. 28(p39) Types of Therapeutic Failure In Compression Garments Risks - incorrect fit Li Vo ve dd an erM d Le LD ar .co n m M LD “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. SOURCE: Moffatt C, et al. 2006. ♦ 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 Section 5 CDT - Combined Decongestive Therapy 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) Li Vo ve dd an erM d Le LD ar .co n m M LD SOURCE: Kettenhuber G, et al. n.d. 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.” SOURCE: National Cancer Institute PDQ®. 2011.12 For garment standards, leg garment monitoring, and vendors see Section 9 Resources page 170. 103 LYMPHEDEMA WELLNESS Manual CDT: Exercise, Movement and Elevation Recommended As a component of CDT 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) Li Vo ve dd an erM d Le LD ar .co n m M LD 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 SOURCE: Moffatt C, et al. 2006. 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 SOURCE: Moffatt C, et al. 2006. 28(p41) For exercise procedures, guidelines, and opportunities see Section 7 Exercise page 133-on. 104 Section 5 CDT - Combined Decongestive Therapy 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 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. SOURCE: Moffatt C, et al. 2006. 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 LYMPHEDEMA WELLNESS Manual 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. Li Vo ve dd an erM d Le LD ar .co n m M LD 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 Section 5 CDT - Combined Decongestive Therapy CDT: Patient Education Recommended As a component of CDT 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 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 LYMPHEDEMA WELLNESS Manual The sequence of lymph flow from ILV to lymph node. Understanding Lymphedema Li Vo ve dd an erM d Le LD ar .co n m M LD 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 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. LYMPHEDEMA WELLNESS Manual 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. Effectiveness Unknown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ndications 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. LYMPHEDEMA WELLNESS Manual 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. M=#%&,$;%'5%,%"5*3'"&('%=.%5$-%&#"#$+&'3",' a b 1 Gesell, Laurie B. (Chair and editor) (2008). Hyperbaric Oxygen Therapy Indications. The Hyperbaric Oxygen Therapy /"$4%('ISBN #+' $(%&#$/8' "&8' (5):' #3%5".$%,' #3"#' Committee Report (12 ed.). Durham, NC: Undersea and Hyperbaric Medical Society. 0930406230. 2 Jørgensen TB, Sørensen AM, Jansen EC (April 2008). "Iatrogenic systemic .5+;$(%',),#"$&%('6%&%/$#,'/+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. 1$)5%#$*,' -"8' 6%' +/' ),%' $&' *+-.4%=' *",%,' 3 hom SR, Bhopale VM, Velazquez OC (April 2006). "Stem cell mobilization by hyperbaric oxygen". American Journal of Physiology - Heart 290 (4): H1378-H1386. doi:10.1152/ajpheart.00888.2005. PMC 233328. http://ajpheart.physiology.org/content/290/4/H1378.full. Pharmacology: Not Recommended C48-.3%(%-"' *+-6$&%(' 7$#3' +#3%5' *+&($#$+&,E>' 3+7%;%5' %=#%&(%(' ),%' +/' ($)5%#$*,' +;%5' #$-%' 7$44' 4$<%48' $&*5%",%' /$65+,$,9'K%%'(%#"$4,'6%4+79' 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. ISL International Consensus Document 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 90 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. 115 - - - - - - - - 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. LYMPHEDEMA WELLNESS Manual 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). ISL International Consensus Document 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. Li Vo ve dd an erM d Le LD ar .co n m M LD 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. LYMPHEDEMA WELLNESS Manual 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 NLN Position Statement 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: _________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ www.voddermld.com/b 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 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 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. LYMPHEDEMA WELLNESS Manual 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 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. 159 LYMPHEDEMA WELLNESS Manual 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): Li Vo ve dd an erM d Le LD ar .co n m M LD 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 LYMPHEDEMA WELLNESS Manual Li Vo ve dd an erM d Le LD ar .co n m M LD 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 LYMPHEDEMA WELLNESS Manual 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. Copyright ©2006-2011 Gay Lee Gulbrandson, Berkeley, CA, USA All rights reserved. www.vodderMLD.com 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 ™ Dr. Vodder MLD Topic Series 4A 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. www.voddermld.com/b 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 LYMPHEDEMA WELLNESS Manual 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. IV. Loose Connective Tissue 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 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 Copyright ©2006-2011 Gay Lee Gulbrandson, Berkeley, CA, USA All rights reserved. www.vodderMLD.com 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 Li Vo ve dd an erM d Le LD ar .co n m M LD s Dr. Vodder MLD Topic Series 1A 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 IV. Loose Connective Tissue Copyright ©2006-2011 Gay Lee Gulbrandson, Berkeley, CA, USA All rights reserved. www.vodderMLD.com HEALTHY LCT (1 of 2) 4.95 USD ™ Dr. Vodder MLD Topic Series 4A 3-10 CONGESTED LCT Li Vo ve dd an erM d Le LD ar .co n m M LD 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 APPENDIX A: SOURCES & SUPPORTING DATA 195 APPENDIX B: GLOSSARY 211 APPENDIX C: REFERENCES 223 APPENDIX D: BLANK FORMS 229 APPENDIX E: CONTINUING EDUCATION COURSE 310 CE Course Credit Examination for 8 NCBTMB CEs 319 Li Vo ve dd an erM d Le LD ar .co n m M LD APPENDIX F: INDEX 312 APPENDIX A: Sources and Supporting Data APPENDIX A: SOURCES & 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 LYMPHEDEMA WELLNESS Manual 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 _________________________ Li Vo ve dd an erM d Le LD ar .co n m M LD 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. Li Vo ve dd an erM d Le LD ar .co n m M LD 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. __________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________ 227 APPENDIX D: BLANK FORMS 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 Patient Authorization 2 233 Photo Release Section 2 Patient Authorization 3 235 HIPAA Notice of Privacy Practices Section 2 Patient Disclosure 4 239 Patient History & Authorization 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 Letter of Medical Necessity - CDT/MLD Section 2 Therapist Entry 6 265 Patient Continuing Report 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 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. (Enter Clinic Name. Privacy Officer, clinic address, phones, email, website - here:) _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ 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 Lym ph ed em a W elln ess M an u al Li Vo ve dd an erM d Le LD ar .co n m M LD 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. DO NOT COPY THIS BLUE TEXT UNLESS NEEDED 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: _____________________________________ Li Vo ve dd an erM d Le LD ar .co n m M LD 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:) _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ 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 Lym ph ed em a W elln ess M an u al Li Vo ve dd an erM d Le LD ar .co n m M LD 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. DO NOT COPY THIS BLUE TEXT UNLESS NEEDED 264 Letter of Medical Necessity - CDT/MLD 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. Li Vo ve dd an erM d Le LD ar .co n m M LD 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 Lym ph ed em a W elln ess M an u al 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. Li Vo ve dd an erM d Le LD ar .co n m M LD 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 Patient Continuing Report 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 Li Vo ve dd an erM d Le LD ar .co n m M LD (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 Lym ph ed em a W elln ess M an u al Li Vo ve dd an erM d Le LD ar .co n m M LD 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. DO NOT COPY THIS BLUE TEXT UNLESS NEEDED 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 Li Vo ve dd an erM d Le LD ar .co n m M LD 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 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. [email protected] OFC: 510-849-1388 FAX: 510.558=8363 1791 Solano Ave #A8 Berkeley, CA 94707 USA Li Vo ve dd an erM d Le LD ar .co n m M LD 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 Li Vo ve dd an erM d Le LD ar .co n m M LD * 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 LYMPHEDEMA WELLNESS Manual 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) Li Vo ve dd an erM d Le LD ar .co n m M LD 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) ASSESSMENT & PROTOCOL 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 ve dd an erM d Le LD ar .co n m M LD 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. Li Vo ve dd an erM d L Le D ar .co n m M LD 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 >
