• Exercise only with the limb in a compression garment or wrap.
• Include Deep Abdominal Breathing before and after every exercise program.
• Do not wear tight restricting clothing (eg.  Bra straps, tight underwear, etc.
• Perform exercise in a slow, controlled manner.  If any exercise causes pain, decrease number of repetitions or do not perform that particular exercise.
• Alternate each contraction of the muscle with equal time of full relaxation.
• Progress exercises slowly as to avoid soreness.
• After exercising, rest and elevate the limb for 15 to 20 minutes.
• You should rest 20-30 minutes between Manual Lymph Drainage Massage and exercising.

Sonja M. Maul PT, CLT-LANA

National Board Certified Lymphedema Therapist

St. Luke’s*Idaho Elks Rehabilitation Services (SLIERS)

Boise, Idaho 

1. Keep extremity clean and dry.
2. Apply moisturizer daily to prevent chapping/chaffing of skin.
3. Attention to nail care; do not cut cuticles.
4. Protect exposed skin with sunscreen and insect repellent.
5. Use care with razors to avoid nicks and skin irritation.
6. If possible, avoid punctures such as injections and blood draws.
7. Wear gloves while doing activities that may cause skin injury (i.e., gardening, working with tools, using chemicals such as detergent).
8. If scratches/punctures to skin occur, wash with soap and water, apply antibiotics, and observe for signs of infection (i.e. redness).
9. If a rash, itching, redness, pain, increased skin temperature, fever or flu-like symptoms occur, contact your physician immediately.

II. Activity / Lifestyle

1. Gradually build up the duration and intensity of any activity or exercise avoiding soreness.
2. Take frequent rest periods during activity to allow for limb recovery.
3. Monitor the extremity during and after activity for any change in size, shape, tissue, texture, soreness, heaviness or firmness.
4. Maintain optimal weight.

III. Avoid limb constriction

1. If possible, avoid having blood pressure taken on the at risk arm.
2. Wear loose fitting jewelry and clothing.

IV. Compression Garments

1. Should be well-fitting.
2. Consider supporting the at risk limb with a compression garment for strenuous activity (i.e. weight lifting, prolonged standing, running).
3. Consider wearing a well-fitting compression garment for air travel.

V. Extremes of Temperature

1. Avoid exposure to extreme cold, which can be associated with rebound swelling, or chapping of skin.
2. Avoid prolonged (> 15 minutes) exposure to heat, particularly hot tubs and saunas.
3. Avoid immersing limb in water temperatures above 102° F.

VI. Additional practices specific to lower extremity lymphedema

1. Avoid prolonged standing or sitting.
2. When possible, avoid crossing legs.
3. Wear proper, well-fitting footwear.

Sonja M. Maul PT, CLT-LANA

National Board Certified Lymphedema Therapist

St. Luke’s*Idaho Elks Rehabilitation Services (SLIERS)

Boise Idaho

Medicare Coverage of Compression Garments:    Current Medicare policy does not cover the cost of the compression bandages, garments and devices required in the daily Phase 2 treatment of lymphedema. In mid-2000 Robert Weiss and the NLN made formal requests for a National Coverage Determination (NCD) on the treatment of lymphedema. Responses from the HCFA (now CMS) Coverage and Analysis Group centered around the claim that “the supplies, namely the compression garments used for the treatment of lymphedema, do not fall within a separate benefit category set forth in the Social Security Act.” (Dr. Sean Tunis, Director, in a letter dated March 1, 2001 ).

This unsubstantiated statement from HCFA/CMS, the basis for continuing denials of compression bandages and garments, has been disputed by Medicare Administrative Law Judges (ALJs) around the country. Most recently, four different California ALJs ruled in four different cases that compression bandages, sleeves and stockings used in the treatment of lymphedema meet the statutory definition of “prosthetic devices” in §1861(s)(8) of the SSA as expanded by CMS Pub. 100-2, Medicare Benefit Policy Manual , Ch. 15, §120 Prosthetic Devices.

On January 2, 2007 a request was made to CMS to add over 100 new and revised codes to the HCPCS Code Book for lymphedema treatment supplies. The CMS HCPCS Workgroup rejected this proposal on November 2, 2007 without referring to legal and medical arguments presented, only stating that “no insurer (i.e. Medicare, Medicaid, Private Insurance Sector) identified a national program operating need to establish unique codes to distinguish all the products listed in this application. Existing codes adequately describe the array of products available.“    

In a recent discussion with SADMERC, the Medicare contractor responsible for developing and maintaining HCPCS codes, I was asked whether I was working with the manufacturers, since I have no standing to submit specific requests for product coding. In August 2006, while preparing the formal request for HCPCS code changes, I contacted major manufacturers of compression bandages and garments (i.e. Bellisse, BSN Jobst, CircAid, Derma Sciences, Hartmann-CONCO, Innovative Medical, Juzo, KT Medical, Lohmann Raucher, Medi, Lohmann, Peninsula Medical, Sigvaris-Ganzoni, Solaris, Telesto) asking them to submit requests to list their products as prosthetic devices with an L-code to demonstrate that there is a need for change. To my knowledge, no formal requests were submitted.

Robert “Bob” Weiss, M.S.
NLN LE Legislative Advocate

Check out more Legislative Updates at    http://www.lymphnet.org/lymphedemaFAQs/legislation/legUpdates/legUpdates.htm

Sonja M. Maul PT, CLT-LANA

National Board Certified Lymphedema Therapist

St. Luke’s*Idaho Elks Rehabilitation Services (SLIERS)

·        Exercise only with the limb in a compression garment or wrap.

·        Include your Deep Abdominal Breathing before and after every exercise program.

·        Do not wear tight restricting clothing (eg.  Bra straps, tight underwear, etc.)

·        Perform each exercise in a slow, controlled manner.  If any exercise causes pain, decrease number of repetitions or do not perform that particular exercise.

·        Alternate each contraction of the muscle with equal time of full relaxation.

·        Progress exercises slowly as to avoid soreness.

·        After exercising, rest and elevate the limb for 15 to 20 minutes.

If you have just had/performed Manual Lymph Drainage massage you should rest 20-30 minutes before beginning exercises.

Sonja M. Maul PT, CLT-LANA

National Board Certified Lymphedema Therapist

·        Continued increasing size of the arm/leg.

·        Risk of recurrent infections (Cellulitis) that may require hospitalization on IV antibiotics.

·        Skin changes:  dry flaking, yellow scaling, wart like growths, lymph blisters…

The earlier you start managing Lymphedema, the easier and quicker it is to get it under control, though at any point in the process CDT can make significant improvements and improve quality of life.

Sonja M. Maul PT, CLT-LANA

National Board Certified Lymphedema Therapist

These conditions occur for several reasons, including:

• Increase of blood volume.
• Loss of venous wall tonicity from Relaxin in the system.
• Increased pressure in the leg veins, caused by the position of the baby.
• Change of blood consistency.

The likelihood of pregnancy-related venous disorders is further increased if the following factors are present:

• Family history of venous disease.
• Pre-existing venous conditions.
• Multiple pregnancies.
• Prolonged sitting or standing.

These factors on their own cause swelling in the legs (and arms) of many, so in the presence of already existing Lymphedema it can, and most likely will, aggravate swelling as it further stresses the lymph system.

This is a time to be extra diligent at your Lymphedema Home Maintenance Program.  You may find increasing the number of times per day you do your Self Manual Lymph Drainage Massage may help.

Sonja M. Maul PT, CLT-LANA

National Board Certified Lymphedema Therapist

Dietary proteins are present in the foods we eat and are important to good health because:

·  Proteins are the building blocks of the body.

·  Proteins are the only nutrients that can repair worn-out tissue and build new ones.

·  Proteins are used by the body in manufacturing hormones.

·  Proteins have a role in building antibodies to fight infections.

·  Proteins aid the blood in transporting oxygen and nutrients.

·  Proteins are essential to the clotting of blood.

When There is a Shortage of Dietary Proteins

The goal for each individual should be to eat the appropriate amount of dietary protein to meet nutritional needs. This protein should come from a variety of sources, not only meat, and include only a minimum amount of fat.

When there are not enough dietary proteins available to meet the daily needs of the body, proteins are taken from the tissues and muscles to maintain the proper protein level of the blood. A severe shortage of dietary proteins will weaken connective tissues and causes them to swell. This is known as hunger edema and it can be seen in the swollen bellies of starving children.

Seriously restricting the intake of dietary protein in an effort to control the swelling of lymphedema does not help. It has just the opposite effect: It increases the amount of swelling that is present. It also weakens the muscles and other tissues.

Sonja M. Maul PT, CLT-LANA

National Board Certified Lymphedema Therapist

Eating a Balanced Diet

Eating a well-balanced diet that includes a variety of fruits and vegetables is recommended for maintaining good general health. It also aids the body in coping with the added stress caused by lymphedema.

High salt foods, which encourage the body to retain fluids, are not part of a recommended healthy diet.  High sodium foods cause the body to retain fluid in general, and will make the lymphedema swelling worse.

Staying Hydrated

The term hydrated describes the state of having adequate fluids in the body. Maintaining this state helps the body remove impurities from the blood and this is important to good health.

Drinking plenty of fluids, particularly water, is essential to maintaining this balance within the body. Cutting back on fluid intake in an effort to reduce the swelling of lymphedema doesn’t work! Instead of the desired effect, the protein-rich lymph of lymphedema attracts more fluid from the other parts of the body. This can cause increased swelling in the affected area.

Drinking eight 8-ounce glasses of water a day is recommended to maintain good health; however this need increases in hot weather, or in very dry conditions, when the body looses fluids more rapidly.

Being well hydrated, by drinking plenty of water, is particularly important after an MLD or pump treatment because it is necessary to flush out the impurities that were moved during treatment.

Caffeine, which is a mild diuretic, reduces the level of body fluids by encouraging the kidneys to excrete more urine. For this reason caffeine containing substances (coffee, tea, chocolate and many soft drinks) should be consumed only in moderation.

Alcohol also has a diuretic effect that stimulates the kidneys to excrete more water and thereby increasing dehydration.

Sonja M. Maul PT, CLT-LANA

National Board Certified Lymphedema Therapist

The swelling of lymphedema stretches the skin and disrupts the skin’s basic protective mechanisms. Also, as lymphedema increases in severity the skin loses its elasticity, becomes thicker and scaly, and is increasingly at risk.

Protective Structures of the Skin
The secretions from oil and sweat glands in the skin flow through the pores and onto the surface of the skin to form a thin protective layer known as the acid mantle. The acid mantle is normally mildly acidic with a pH that ranges from about 4 to 5.5. (A pH of 7 is neutral. A pH higher than 7 is described as being alkaline. A pH lower than 7 is described as being acidic.)  The acid mantle inhibits the growth of harmful bacteria and fungi on the skin. With the loss of this protection, and the increasing fragility of the skin, those with lymphedema are at increased risk of infection due to bacteria invading through the skin.

Skin Care Steps

Examine the affected skin thoroughly each day. Look for changes in the tissues, any possible cracks, or signs of a developing infection.

Use only mild soap.

Wash gently, and thoroughly, with warm (not hot) water.

Dry gently by patting and taking particular care to dry within the skin folds. A hair dryer on a very low setting can be used to dry awkward areas or between folds. Never use the hair dryer on high heat!

Moisturize the skin thoroughly using a low pH moisturizing lotion. This helps to restore some of the normal protective acid mantel. Moisturizing also helps the skin retain the elasticity that helps to avoid cracks/breaks. I like Eucerin or Cetaphil, but there are many good products out there.

Protect against sunburn. Lymphedema affected skin is particularly sensitive to the sun and a compression garment does not protect it from the UV rays.

Do not perform exfoliation. It can damage lymphedema affected skin.

Sonja M. Maul PT, CLT-LANA

National Board Certified Lymphedema Therapist