Lymphedema afflicts an estimated 2 million people in the United States. It is a chronic, persistent condition characterized by accumulation of protein-enriched fluid in the tissue spaces of the body. It is caused by a disruption in the lymphatic system that results in obstructed lymphatic flow. This leads to swelling—most often in the arms and legs, but it can occur in other areas as well. Left untreated, lymphedema usually deteriorates over time, resulting in reduced skin integrity, fibrosis (hardening and loss of elasticity of the skin), impeded wound healing, and increased potential for infection.

Primary lymphedema may be hereditary, can be present at birth (Milroy’s disease), develop during the teen years (lymphedema praecox), or present in older adults (lymphedema tarda) as the result of a gradual deterioration of the lymph system due to the aging process. Secondary lymphedema is more common and can occur following an infection, a traumatic injury, the surgical dissection or resection of the lymph nodes, or as the result of surgery—primarily the excision of malignant tumors, or radiation therapy. Unfortunately, there is no cure or effective surgical option for lymphedema. Early intervention, proper treatment, and vigilant self-management are essential to control it.

Patients Should Know
When working with lymphedema patients, it is important to stress that lymphedema is lifelong and requires continued efforts to manage the condition. If ignored and allowed to advance, it will almost always become steadily worse and more unlikely to return to a less severe stage. Although managing lymphedema may involve some lifestyle changes and a few restrictions, those afflicted will still be able to live a normal, active life.

Determining the appropriate therapeutic program depends greatly on severity, as well as patient tolerance and compliance. A combination of treatment modalities, based on the individual, often proves to be the most effective way to manage lymphedema. The recommended treatment plan is normally based on an approach called complete or complex decongestive therapy (CDT) or complete decongestive physiotherapy (CDP), both essentially sharing the same meaning.

This approach combines manual lymph drainage (a treatment method using a series of light, rhythmic strokes to reduce swelling and improve the return of lymph to the circulatory system) with compression techniques and self-care education and training.

There are many different methods to apply compression. With heightened attention on the prevention and management of lymphedema, manufacturers are researching and developing new products to reduce swelling and control the condition.

Compression garments are widely used and specially designed to maintain and support the limb, limit swelling, slow the advancement of lymphedema, and maintain the reduction in swelling following other therapy. Medical compression hosiery and arm sleeves promote venous and lymphatic return by gently compressing the limb with graduated pressure—pressure that is greater distally (direction farthest from the heart) than proximally (direction closer to the heart).

Cindy Ciardo, CO

The specific external pressure applied to the limb also has a massaging effect on the muscle pump. Garments should be applied in the morning to prevent gravity from pulling fluid down into the limb, be worn daily while active, and be removed for sleeping when the body is recumbent and the stronger external pressure of elastic garments is not necessary.

Compression garments can be ready-to-wear, but the size and frequently disproportionate shape of the extremity often require the use of custom-made garments. The graduated compression lasts for approximately 6 months, at which time patients should be encouraged to be refitted and remeasured to allow for changes in limb size.

Short-stretch compression bandages are minimally elastic. They compensate for the diminished skin pressure associated with lymphedema, and prevent the reaccumulation of evacuated, stagnating lymph fluid. The more inelastic the bandage is, the greater the potential working pressure (pressure produced when the muscle pump works against the resistance of the bandage, as when exercising).

Inelastic and short-stretch bandages have advantages over elastic garments because they force a higher working pressure and greater muscle pump efficiency. Conversely, because of the low resting pressure (pressure exerted when the muscle is inactive and relaxed), compression bandages may be worn day and night.

Compression bandaging is applied in layers. The digits (fingers and toes) are individually wrapped with gauze bandages. A tubular bandage, made of primarily cotton, is worn underneath the compression padding and bandages to protect the skin and absorb excess perspiration. Padding bandages are applied just prior to the actual compression bandages to cushion the limb (especially over skin creases or bony prominences) and to prevent sharp indentations and irritations to the skin. In addition, they serve to distribute the pressure evenly over the limb.

The last stage is the actual short-stretch compression bandages used to apply the final compression. They are wrapped with mild to moderate tension in an overlapping pattern in a distal to proximal direction.

Compressive wraps can be difficult and time-consuming to apply properly. If the wrap is too tight, it will be painful and obstruct lymphatic and venous outflow. If too loose, it will not be effective. In addition, there is no means to determine the actual pressure that is applied by the wraps, so patients can not tell if the applied compression is accurate. Because of their application problems and unreliability for delivering the appropriate graduated compression, many patients have turned to high-density foam garments, which apply varying degrees of pressure, provide a gentle compression, and help increase and facilitate lymphatic return.

Some systems incorporate Velcro strap closures. This feature allows the applied compression levels to be sustained even when the limb size is reduced by simply readjusting the Velcro straps, rather than completely rewrapping the limb with bandages. Unlike low-stretch bandages and compression hosiery, which lose their compression over time and need to be replaced approximately every 6 months, these products are inelastic and need to be replaced only when worn beyond repair. There is no reduction in compression regardless of the age of the device. Another simple and effective alternative to bandaging is customized night sleeves made of one-way stretch, multilayered material that applies pressure throughout the sleeve, thereby gently and comfortably evacuating fluids and preventing their return.

Compression pumps are designed to promote venous and lymphatic circulation, and remove edema from the extremity by progressively moving fluid in a distal to proximal direction. The effect of the mild intermittent, sequential pressure is to increase interstitial pressure, thereby driving intercellular fluid into the venous capillary system. The most effective pumps are multichambered, and deliver calibrated, gradient pressure. Pumps are generally viewed as being most beneficial when combined with other treatment methods such as manual lymph drainage. Treatments should be followed with compression bandaging or garments to maintain the results.

Self-Care Crucial
Regardless of the treatment method used, be sure to reinforce the importance of self-care. Provide educational resources and reiterate basic guidelines. For example, diet and nutrition are cornerstones of healthy living and have an impact on lymphedema as well. Obesity, smoking, and poor diet can exacerbate the condition.

Encourage patients to practice good hygiene and wash using a mild, unscented, pH-balanced soap and dry thoroughly. Wash cuts, scrapes, and insect bites immediately with antibacterial soap and water, cover with sterile dressing and antibiotic cream, and watch for infection.

Ultimately, successful management of lymphedema depends on patient compliance. Patients may find one method easier to apply or more effective than another. The treatment modality that works best, alone or in conjunction with another, may differ depending on the individual. Sometimes, only trial and error will determine what is most effective.

People who suffer from lymphedema are often anxious to try new treatment methods in their quest to control their swelling, so it is important that consultants are knowledgeable, experienced, and thoroughly trained in the various treatment modalities and can offer a comprehensive assortment of lymphedema products.

Although lymphedema management is a viable niche market, it requires extensive training and complete dedication to providing the most up-to-date products. Treatment methods can present many complications for the sales consultant or fitter, and necessitate an open line of communication between the fitter, therapist, physician, and patient for successful care.

Lymphedema patients often become discouraged because treating and managing lymphedema can be frustrating and time-consuming. Results are achieved slowly and are painstaking to maintain.

Because lymphedema can be disfiguring and is sometimes painful and disabling, there are often psychosocial considerations and lifestyle adjustment issues. Lymphedema can affect self-image, interfere with routine activities, limit what clothes can be worn, and remind cancer survivors of the disease they thought they had overcome. Consultants need to be mindful of this and remain empathetic and understanding when working with this patient population.

Cindy Ciardo, CO, is CEO of Knueppel HealthCare Services Inc, Milwaukee. She is a board member and education committee chairperson for the Wisconsin Association of Medical Equipment Services, and manager of vendor services for an Oxford, Mich-based buying group. She can be reached via e-mail: cciardo@knueppels.com.