Whether a patient’s lymphedema is primary—which is when the condition is inherited—or is secondary—meaning it was caused by an injury to the lymphatic system—the result is the same: a swollen limb that can be painful, cumbersome, and prone to infections.

For those suffering from lymphedema—many of whom are women recovering from breast-cancer treatments—the condition can be debilitating and demoralizing.

"I have had some women tell me that having the lymphedema was worse than having the breast cancer," says Kathy Stiner, BA, CLT, senior medical education adviser, CircAid. Women can experience their first symptoms years after having breast-preserving surgeries or radiation. "After initial therapies, there is the impression they are going to be as good as new; and when they start experiencing these swellings, they are horrified. It can be disfiguring and has health implications."

This can present a considerable challenge to therapists eager to help patients reduce limb size and get back to the business of their lives.

"Because it is a progressive and chronic condition, it does require a great deal of sensitivity and creativity on the part of the therapists so the patients don’t get discouraged," Stiner says.

One way to make this happen is with treatments that work.

THE RIGHT FIT

Sandra A. Shaw, president of CircAid, is passionate about CircAid’s ability to make a difference. She insists it only be implemented on patients who it can help.

"The worst thing we could ever do with people who have chronic diseases—who are dealing with something that is not going away—is make promises we can’t keep," she says. "If you defeat them, they may stop doing everything. So our goal is to make sure we have the right product on the right patient for the right reason."

CircAid’s products boast a series of nonelastic, interlocking Velcro® straps that provide compression for patients suffering from both venous disease and lymphedema.

"It’s important to use nonelastic material because elastic will allow the limb to refill, meaning the fluid will come back into the tissue and the limb will swell up again," Stiner says.

The company’s line of garments are designed to provide resistance to the fluid, helping to maintain the limb size. Using adjustable straps has another advantage: Users are able to adjust the size as needed, without the aid of an assistant.

"Stockings work for some patients, but they can be challenging to get on and even more challenging to get off, especially for patients with limitations," Stiner says. Such patients include those with cognitive impairments or arthritis. "The CircAid products can be applied onto a limb simply by opening it up. As long as they can reach their ankle, they can open this product up, put it on, and Velcro it down—it’s easy on and easy off."

CircAid’s wares are intended to be used in conjunction with a complete treatment plan. Therapists and physicians will often recommend the patient put it on over stockings—such as a panty hose or thigh-high stocking—in order to treat the entire limb.

"We want to be part of the armamentarium for the treatment of venous and lymphatic disease," Shaw says. "Just look at us as the fluid-mover part of that, the compression part."

THE BIG PICTURE

The "compression part" is just one component in any plan designed for the successful management of lymphedema. Such plans are put together by Mary Rosenberg, PT, CLT-LANA, who practices the Dr Vodder method of manual lymph drainage and complete decongestive therapy (MLD-CDT) at Hollywood Physical Therapy Associates, Los Angeles.

"The Vodder method teaches a comprehensive, yet conservative, method for dealing with lymphedema," Rosenberg says. The approach entails multiple steps, beginning with the careful cleaning and moisturizing of the skin, followed by MLD massage—a type of procedure targeting very specific tissues. "The lymph-drainage massage increases the pumping action and helps restore the natural action of the lymphatic vessels. In addition, it helps redirect fluid."

Figure 1. The CircAid® Custom Legging.

Immediately after MLD, compression is applied using short-stretch bandaging, a nonelastic cotton binding that conforms to the extremities, making them safe to wear overnight. Patients keep the coverings in place around the clock until the girth decreases significantly, usually within the first 2 to 3 weeks, at which point they can be fitted with compression garments. These custom-made sleeves and stockings enable them to fit into more attractive clothing that makes their condition less conspicuous.

Rosenberg also works with patients to put together a suitable exercise regimen. While the traditional advice for those with lymphedema was to avoid lifting more than 10 pounds, the current philosophy is that slowly increasing the weight—and subsequently strengthening the muscles—actually benefits the lymphatic system.

"It helps the lymphatic pump, but we like them to do the exercises only in the compression bandages," Rosenberg says. In some cases, this can be awkward because of the limited range of motion. However, it is imperative because contracting muscle during exercise increases blood circulation, automatically increasing lymph volumes. "That lymph has to be directed somewhere, and that’s what those garments or bandages do: They direct the lymph up and out, rather than expanding in girth."

A HELPING HAND

In her practice, Rosenberg has had extensive experience in treating long-suffering lymphedema patients, yet she continues to be frustrated by the lack of information passed from oncologists to breast-cancer survivors.

"I appreciate they are interested in saving lives, and many of them appreciate that once you save a patient’s life it’s not over. But there are many physicians who are not interested in anything but saving the patient’s life, so that’s where their resourcefulness ends," she says. "Many patients have to find us on their own. It’s frustrating, because by the time they get to me, they could have had a better outcome."

One oncologist who is committed to restoring a patient’s quality of life after cancer is Tony Reid, MD, PhD, who received a patent for his invention designed to provide optimal compression for arms and legs swollen by lymphedema.

Structured to work with the body’s natural physiology, the convoluted foam and adjustable straps of the ReidSleeve® provide effective compression while minimizing obstruction of venous or lymphatic outflow.

"I had patients who were on compression devices, but the problem was it was just flat compression and it wasn’t well-adjusted. If you have exceeding venous compression for any period of time in the upper arm, for example, you are going to obstruct whatever lymphatic flow you have, further inhibiting that process," says Reid, who is an associate professor of medicine and the director of clinical research program at the University of California, San Diego, Medical Center Moores Cancer Center.

Reid focused on creating something to mimic the ebb and flow that takes place in a healthy lymphatic system. "That led to the idea of having a discontinuous surface that provided intermittent periods of higher and lower pressure, so the lymphatic gates could function and cause the fluid to move forward," she says.

Alternating high and low pressure should stay within range of the "set point"—the amount of pressure that provide the most benefit for patients. Each person’s degree of lymphatic obstruction is unique, so a garment promising 30 mm worth of pressure may actually be delivering far more—or less.

The ReidSleeve also incorporates a sophisticated gauge that measures a garment’s true level of compression over a reasonable area. This is possible by inflating a very small bladder—similar to what is used with a blood-pressure cuff—with a tiny amount of air. Using highly sensitive, custom-made pressure gauges, patients and their caregivers are able to determine the exact level of pressure exerted by the ReidSleeve.

Knowing precisely how much pressure is being applied means the garment can be adjusted as swelling reduces, if needed, to maintain the fit required in order to achieve the best possible results.

"It’s really critical to remember that if you raise the interstitial pressure too much, the lymphatics become too dilated, those valves become separated, and then they become incompetent," Reid says. In such cases, the patient is actually worse off, because the whole system will suffer from total backflow. "If you go too high, then you really don’t take advantage of the physiology, and I think that is one of the fundamental problems. People tend to see the arm as something with an inlet and outlet and think the harder you squeeze, you’ll just wring all this fluid out somehow—but that’s not how things work."

Cooperating with the body’s natural processes is a top priority for Reid—not only when he’s working to create new products, but also when he cares for patients.

"It is very incapacitating and debilitating for patients, but you can’t just get out of lymphedema overnight; you’ve got to work with the tissues, you have to let those little valves become competent again," he says. "I think there are long-term, curative solutions that really require us to understand the physiology. You have to have the patience to be able to establish the right pressure range and understand that it’s a tissue—it’s not a sponge."

Doyle Benjamin is a contributing writer for  Physical Therapy Products. For more information, contact .