Ask Cynthia Shechter

Areas of expertise:
  • Rehabilitation after surgery
  • Lymphedema risk
  • Axillary web syndrome
  • Exercise
  • Air travel
  • Cellulitis/infections
  • Wrapping
  • Compression garments
  • Compression pump use
  • Self MLD
  • Surgical options for lymphedema
  • Breast reconstruction
  • Lifting and risk of exacerbation or developing lymphedema
  • Radiation in relation to lymphedema and motion
  • Evaluation and treatment of lymphedema

Cynthia Shechter is an Occupational Therapist who earned her Master’s degree in occupational therapy at New York University. She has devoted her clinical practice to Breast Cancer and Lymphedema rehabilitation as well as hand/upper extremity therapy. Cynthia previously launched a Breast Cancer and Lymphedema rehabilitation program at a private facility in New Jersey and has now opened ShechterCare, a facility devoted in its entirety to treating individuals who have had surgery due to breast cancer and/or lymphedema. Cynthia has lectured on the topic of Breast Cancer Rehabilitation and Lymphedema to several Cancer groups in the community as well as to different physician's groups. Her main focus is on educating her patients on the management of Lymphedema and enabling them to return to their regular lifestyle. Cynthia is dedicated to increasing the awareness of the medical community to the benefits rehabilitation can have on patients following Breast Cancer surgery.


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  1. Acute Care Lymphedema Treatment
    Question (Mel, ):
    • Hi Cynthia, I am a physical therapy student finishing up a rotation at a large acute care hospital. This hospital does not have a lymphedema certified PT on staff, and I am planning an inservice to better educate the therapists on lymphedema. That being said, I was wondering what you thought was the most beneficial thing that PTs/OTs can do for patient's with lymphedema in the acute care setting especially when you may only be seeing them for a few days before they are discharged to a new floor or setting. Is education and referral to an outpatient specialist most realistic, or would teaching a patient upper or lower extremity exercises be beneficial? From what I have gathered from asking other providers/professionals in our hospital network, the hospital I am at does not have immediate access to treatment garments and would most likely be unable to receive them in time for patient discharge if ordered. Thanks in advance!

    Answer:
    • Jul 2017

      I am sure that every clinician would have a different answer to this question, but I truly believe that education about the risk of lymphedema post-surgically is of the utmost importance.

      Teaching active range of motion exercises, precautions, and a little about lymphedema therapy would be helpful.

      I do not believe in fitting patients with compression garments in the acute stage of care as much of what you are seeing is post surgical swelling, NOT true lymphedema. If a patient is non-surgical than they likely have been hospitalized for an infection, and the swelling would need to be reduced prior to fitting someone with a garment to prevent future infections.

      If a therapist is trained in lymphedema therapy, they can bandage to encourage increased lymphatic flow.

      Hope this helps.

  2. Occupational therapy student
    Question (Delta, ):
    • Dear Ms. Schecter, I am a future OTR in training, I am interested in lymphadema, ,specifically the treatments, exercises, and compression garments. I am nearing graduation and wondering how I can get more exposure in this area. I live in San Antonio TX, but any help on how I can proceed will be greatly appreciated.

    Answer:
    • Jul 2017

      Congratulations and welcome to a wonderful profession. As a new graduate, you can try to find facilities offering lymphedema therapy in your area and ask to observe. If you have a full time job lined up, look for a private facility with flexible hours.

      You could also, proactively, attend a continuing education or certification class. I also suggest completing a breast cancer rehabilitation course so that you can completely assist in a patients recovery.

      There are many certification programs for lymphedema therapy, and, LE&RN; is actually running a scholarship program for therapists looking for financial assistance with training.

      I hope that this helps, and I wish you the very best.

  3. Test Question
    Question (Steve, ):
    • Hi Cynthia, This is just a test question. When you have a chance, can you forward me the email that you get about this question? Thanks so much! Steve Palmer

    Answer:
    • Jul 2017

      never received

  4. cording
    Question (Belinda, ):
    • I'm 5 months post op mastectomy, ALND and reconstruction. I had severe cording that extended down to my thumb which has improved a lot due to physio I received. I have had to change my physio and I am getting conflicting information. I wonder if you can help. My previous therapist was gentle with the cording, advising strongly against heating and aggressive massages. The current therapist I am seeing believes the exact opposite. She says that cording requires a brutal approach and that if the cording isn't treated it could lead to lymphedema.I do have strange sensations in my affected arm and hand with mild swelling that comes and goes. I am concerned.

    Answer:
    • Apr 2017

      Hi,

      Therapists differ which can become confusing for patients, but that is because often we go based off of our experiences. Patients are treated particularly cautiously in the early stage post-operatively. Initially patients are provided with gentle stretching exercises, soft tissue mobilization, manual lymphatic drainage, and gentle joint mobilization.  Therapists use their judgement in terms of the amount of pressure to use with manual techniques and often manual fixation of the web in the arm accompanied by stretching can produce a non-painful, breakage of the web which results in increased mobility of the shoulder.  Often axillary web is accompanied by scar formation and adhesion which increases pain and movement limitations which can be helped with scar mobilization and stretching. Personally, I do often employ a more aggressive manual technique depending on patient tolerance.

      I hope this helps.

  5. therapist
    Question (Barbara, ):
    • I am 80 years old and am traveling on a plane in April. What precautions can I take ? Have you heard of Medshoola Compression Pump? I found this on the internet. It is not FDA approved but it is portable and weighs less than 3 lbs. I runs on battery. I would appreciate any information you can give me. thank you so much. Gratefully yours….Barbara Galler  Thanks again.

    Answer:
    • Mar 2017

      Hi Barbara,

      Although I am unfamiliar with the Medshoola, I have used other very similar devices in the past. My issue with these pneumatic devices is that they do not have a foot/toe/ankle component which has a tendency to cause fluid pooling in the distal extremity. Have you looked at other devices? They are not as light and portable, however, they do compress the distal extremity so the issue of fluid pooling does not exist.

      Here are a few of devices for you to research:

      http://biocompression.com/
      http://www.lympha-press.com/
      http://www.tactilemedical.com/products/flexitouch/
      Huntleigh Healthcare Flowpress Hydroven Fpr Pump, 5.25 lbs
          (I have never used this device, but it appears to be more portable                                     than any others and it has 4 chambers which is ok)

      Hope this helps,
      Cynthia Shechter
      http://www.shechtercare.com

  6. Breast cancer
    Question (Marilyn, ):
    • My problem that I'm running into is getting my arm wrapped. I leave in a little town that does not provide much knowledge of lymphedema. I do go to a PT in Wichita ks which is 50 miles from me. So she is not much help. I do have a pump that I use once a day for a hr ok. So my life is pretty much keeping the arm up. Medicare will not let someone come in to wrap it because I'm not home bound an don't wanto be. This is all wrong by not letting home health care do this. I had 17 lymphs removed for I'm a stage 4 cancer patient. Went threw chemo an radiation , will have pet scan Feb7th to see if they got it all. It seems like my PT in Wichita is dragging this out an keep putting me off with a compression sleeve. I have to get fluid off arm before she can put me in sleeve. What can I do? Thanks for your time

    Answer:
  7. Arm and hand lymphedema
    Question (Linda, ):
    • I am a breast cancer survivor and I have arm and hand lymphedema. I normally wear a sleeve and a full finger hand compression garment but I am a nurse and I am unable to wear the full finger hand garment during my 12 hour shift. It seems like when I wear my sleeve my hand swells up more so I'm not sure if I should wear the sleeve without the hand compression garment any advice?

    Answer:
    • Jan 2017

      Thank you for your message. The majority of my patients do not wear compression sleeves and gloves throughout the day and do quite well keeping their swelling controlled. Unfortunately, wearing a sleeve without a glove when you have hand swelling is not advised. A compression sleeve stops increased fluid from traveling down the arm, however, without a glove, the sleeve can force fluid into the hand. A general rule of thumb… you can wear a glove without the sleeve but not a sleeve without a glove when your hand is involved.

  8. Leg/Thigh Lymphedema Compression Stockings for Those With Limited Hand Strength
    Question (Pam, ):
    • Hi. I'm writing on behalf of my mom. She has been living with lymphedema for 25 years in one leg following the removal of her bladder and lymph nodes during surgery for bladder cancer. She has been wearing heavy duty compression stockings and pantyhose for the past 25 years with a waist hernia belt around her oestomy. She is now at the age (80) where she no longer has the strength in her hands to manage the stockings the tight waist bands from the garments and pantyhose are hurting her spine. In addition, her mobility is now severely reduced because of pain and the size of her leg. She can no longer walk without the aid of a cane or walker. I've read about different types of stockings with zippers but so far we haven't been able to find anyone who is knowledgable on the issues with lymphedema to help. My mom is still independent and living alone, but this is becoming increasingly frustrating for her and the series of connected issues are affecting her overall physical and emotional health. The local nurses in southern MD have limited experience in lymphedema treatment and tend to gawk more than they help. The place where she gets measured for her stocking doesn't seem to know much either and generally she ends up getting new custom stockings that don't fit right. So here are my questions, given the background above, 1) Has the issue of leg lymphedema in the elderly come up and are others struggling with similar issues regarding compression garments? My mom is a champ and has done well for 25 years... but she is now at a transition point and what used to work no longer is achievable. 2) Is there such a thing as a lymphedema RN or Physician Assistant specialist and if so, how do you find them? Ideally, it would be awesome to find someone who could help us look at the situation and help devise a new holistic management program. She lives in the southern MD/Washington, DC area but we could potentially drive elsewhere if there was someone who could really help. 3) Is there a good source for advice and a creative approach to finding a suitable leg/thigh lymphedema compression stocking that is easier to manage? 4) Do you have any other advice for us? She's also tried flexi-touch but it is way too difficult for her to manage right now. She doesn't have the mobility or hand strength to get the velcro straps in the right places and tight enough to be effective. THANK YOU SO MUCH. This is pretty frustrating but I am guessing she isn't the only one with these issues. Pam

    Answer:
    • Dec 2016

      Response as per Cynthia Shechter
      Hello Pam,
      You are right; one of the biggest problems for individuals of advanced age with lymphedema is that it is nearly impossible to don/doff compression garments. They do make donning aides, which help a portion of individuals and I am attaching a couple of links of aides for you.

      http://www.juzo.com/en/products/accessories/donning-and-doffing-aids/juzo-arion-donning-aids/

      http://www.jobst-usa.com/product/jobst-stocking-donner

      I have also found that some of my patients can more easily pull on a nighttime garment like the Tribute or Caresia, as they are easier to grip.

      As far as RN’s or PA’s I’m not aware of anyone. There are physicians who specializing in lymphedema, but I think that your mother would benefit from manual therapy to assist in reduction of swelling and associated discomfort. Here are two links of clinicians in the Washington/Maryland areas.

      Therapists WA

      http://lymphnet.org/sites/custom-scripts/stateResults.php

      Therapists MD

      http://lymphnet.org/sites/custom-scripts/stateResults.php

      As far as pneumatic compression devices, some are more simple to use and some are more difficult. The FlexiTouch has many parts which can be overwhelming. Although I do not endorse one product versus another, perhaps you can look at the BioCompression or the LymphaPress? Both of these companies make devices that are easy to use.

      I think that if you are able to find a therapist willing to modify treatment based on your mothers needs, tolerance, etc, she can get her swelling back under control.

      I hope this info was helpful. If you have any further questions, I am always here to help.

  9. Overview of which garments to wear when
    Question (Karen, ):
    • Are there general guidelines for which lymphedema management garments to wear when? I have lymphedema in my legs, pelvic area, and genitals. I am still, I believe, in stage 1, so we started treatment early on and things are going pretty well. I went through 2 weeks of wrapping one of my legs and have since been wearing thigh-high compression stockings with 30-40 mm of compression, a genital pad, and customized compression biker shorts. I wear them pretty much full time except when I exercise, where I wear the stockings and genital pad but just regular biker shorts for comfort. This seems to be maintaining things relatively well. The legs are pretty good, but I continue to deal with swelling in my pelvic area. I have recently been told I should be wearing night garments instead of the compression garments at night because it allows the protein to move. I also have a FlexiTouch that I have been using nightly. Basically what I am looking for is a "day in the life" of lymphedema garment wear. Specific questions are: 1. Should I wear a night garment instead of the compression garments when sleeping? 2. Should I wear the compression garments all day? Because my schedule has not been stable, we have not experimented with not wearing them all day to see how the swelling does, so I guess the question is, is there any harm in wearing them all day? 3. Should I wear my compression garments when I exercise? 4. Can you explain the reasoning (science) for when to wear or not wear compression garments vs. night garments? If there are written documents describing what should be used when, I would appreciate a reference to that as well. I should also mention that I have a urostomy, so that is another consideration for the shorts and how strong the compression should be, so if you have any recommendations in that regards as well, that would be welcome. What modifications are typically made to compression shorts to accommodate a urostomy bag? Thank you very much.

    Answer:
    • Dec 2016

      Hi. I am going to answer the questions in the order they are listed.

      1. You should not be sleeping in compression stockings as they provide a resting pressure to ensure that when you are upright, increased fluid does not come down the legs. The night garment provides a working pressure to actually assist in the reduction of swelling, so, yes, you should wear it to sleep.

      2. There is no harm in wearing them all day as long as they are not irritating your skin (especially at the ankle crease and behind the knee). If they are irritating, go back to your therapist and discuss the fit of your garments.

      3) Yes. When you are exercising your blood vessels open up and increase blood flow causing an increase in fluid build up. Compression will help to prevent this.

      As far as the urostomy bag, I don’t have an answer. Perhaps a Jobst/Juzo/Solaris rep would be able to assist.

      Attached is a link to a breast cancer related lymphedema and use of compression sleeve vs. wrapping or nighttime garment use. The theory behind the use of different garments are similar in both the upper and lower extremities. Hope this helps.

      https://www.researchgate.net/publication/51108589_Compression_garments_versus_compression_bandaging_in_decongestive_lymphatic_therapy_for_breast_cancer-related_lymphedema_A_randomized_controlled_trial

  10. Open sores/ulsers
    Question (Trish, ):
    • I have suffered from lyphedema for 3 years. This time I have open wounds around the bottom of both legs. They are so bad that they drain heavily, burn, and it's very painful. I use non stick pads, gauze and site bandages then wrap my legs with Ace Bandages. I can not get them to heal. My Dr gave me silvadine(Ms) and it only keeps it moist, I also tried Manuka honey and had a allergic reaction to it. I'm lost, I'm also taking antibiotics because they are so infected. Please HELP!! Thank you for your time. T.Whitman

    Answer:
    • Oct 2016

      Open wounds with lymphedema are not common and usually reflect a concomitant problem. I’m afraid that this is not a problem that can be solved by electronic communication. You should inquire whether the physicians can evaluate your venous circulation and also request a referral to a wound treatment center.

      Best wishes,
      Stan Rockson

  11. Lymphedema treatment
    Question (Paul, ):
    • My wife has stage 2 or 3 lymphedema on her arm, following a double mastectomy. The compression garments have been an exercise in frustration, and bandaging does not seem to be progressing. I have read about compression pumps. How well accepted are they? I have come across 2 makes, Flexitouch and Lympha press. Are there other leading makers? How does one evalluate which pump/sleeve is appropriate? Also, what is your view on low level laser treatment, like the RianCorp LTU-904. It seems to have extensive use in Australia, with much less penetration in the US. Thank you in advance. p.s. if this question is better directed to one of your editorial colleagues, can you please refer it to them? thanks,

    Answer:
    • May 2016

      Lymphedema is a complex disease, and, it can also be very individual.

      Each vaso-pneumatic pump works differently, and there is no “perfect machine” for everyone. Each patient responds differently to treatment and to techniques and devices. There are patients who swear by the Biocompression circ. 2004, some require the 2008 (which has 8 chambers), some the LymphoPress, and some require the FlexiTouch.

      The Flexitouch works differently than other devices in that it is supposed to mimic manual lymphatic drainage and theoretically opens alternate drainage points in the body.

      The Biocompression, and devices like it, stimulate the veins to work better and more efficiently while assisting in protein breakdown. It does not, however, remove the protein. That is why most of my clients, who utilize the Biocompression machine at home, follow up with something that provides a working pressure (either bandaging or night time garment application). The Lymphapress is similar to this device.

      As far as low level laser, I have used it in my practice, but have not seen long standing results. I no longer use the device.

      That said, lymphedema is a very individual disorder, and treatment should be modified based on each individuals needs. If the conpression sleeves are not working, stop using them. A therapist should be able to figure out a regimen that will help, without causing increased frustration.

      Does your wife have a therapist? Has she gone through CDT? Any results? Would you like to contact me directly to discuss treatment options? Even if I am long distance, I’m happy to help.

      Good luck,
      Cynthia
      http://www.shechtercare.com

  12. Exercise
    Question (Deborah, ):
    • Do you recommend specific exercise programs? Someone mentioned MELT, which seems to incorporate yoga...I am not too familiar but I read her blog post regarding lymph brushing so I believe she is aware of LE... I have LE in my dominant arm, hand and trunk due to a traumatic injury. I am ready to engage in more active motion now so I am looking for appropriate activity to strengthen my body.

    Answer:
    • May 2016

      I actually recommend an exercise program developed by Kathryn H. Schmitz, an associate professor at University of Pennsylvania. The title of the program is “The Physical Activity and Lymphedema (PAL) Weight Training Program.

      I do also recommend Pilates, as the focus of a Pilates workout is on core strengthening, which, everyone needs.

      Yoga is ok, but my issue with some Yoga programs is that they require too much weight bearing early on. With lymphedema you really have to build up your strength gradually, and, especially after a traumatic injury, your body need to progress slowly.

      Have you ever received therapy? Do you know how to wrap? Do you have a compression sleeve/glove to use during exercise?

  13. Lymphedema
    Question (Ruth, ):
    • I have lymphedema. My upper arm is about 18". I had grama arms before getting the lymphedema. I'm not totally happy with my therapist.... This is my problem.... I am a hairdresser. So I can't wear a gauntlet while working. The sleeve is so confining, I get 4 super tight banding from the sleeve, which feels like it stops the circulation in my arm. I still wear it even with the confining and discomfort. I can't wear the gauntlet, because of shampooing customers, or cutting. I have horrible pain on the under side of my arm. She tells me, lymphedema doesn't cause pain. I know better. She sized me for a 7, and I bought a 10, and it's still super tight. HELP ..... I need some suggestions. I'm so frustrated. I do have a tactile compression machine, which I use. I do manual manipulation so each day, also. Thanks so much, Ruth

    Answer:
    • May 2016

      Hi Ruth,

      I am so sorry that you are struggling. Lymphedema therapy and garments are not meant to be painful, so if your sleeve is causing issue, stop using it for now. I have many follow up questions, but think we may have to speak to troubleshoot together.

      Would you be able to call my office? ShechterCare.com

      Let e know,
      Cynthia

      Hang in there!

  14. Instructions after breast surgery
    Question (Karen, ):
    • What are the current recommendations after lymph node surgery in regards to BP measurement and needlesticks? I have found little current Evidence Based research that is consistent in recommendations. At our facility, we are telling patients for SENTINEL lymph node biopsies (1-4 lymph nodes removed), we say to avoid bp and needlesticks x 2 years (arbitrary number). For axillary node DISSECTIONS we still say to avoid for life.
    Answer:
    • Apr 2016

      As per Cynthia Shechter

      My recommendations:

      Try to avoid as much as possible for both. If an individual has a sentinal node on one side and axillary node on the other, use the sentinal node side if the MD/phlebotomist is unwilling to use the leg.

  15. CDT not successful for my daughter, what do I do?
    Question (Mary, ):
    • My daughter is 16 and around 3 years ago her groin swelled slightly. They thought it was a number of things but blew it off. A few years later, her right leg swelled dramatically. We went through everything, cancer, arthritis, etc. She has had only one incident where her foot swelled. Most of the problem is above the knee in the thigh. We did the bandages for weeks on end and she got close to the same on each side. But both times we have tried special garments they don't hold her even though she wears them all day. She is a fit and healthy athlete other than this. The garments do no more for her than the off the shelf stockings which also don't really work. We are both devastated that her weeks of bandaging herself were for nothing and that the therapy didn't work. She had a therapist but she is out on a medical emergency and we don't know if she'll be back and really the vascular surgeon doesn't seem to know anything. I don't know what to do to help her. Please help me, what do I do? Do the pumps make matters worse and cause dependency? I can't stand the thought of putting her in bandages again. She is a really cheerful kid but this is getting to her.

    Answer:
    • Feb 2016

      Response from Cynthia Shechter

      I believe that use of sequential compression pumps, in conjunction with manual lymphatic drainage, multi-layer compression bandaging and exercise, are quite useful. Individuals respond differently to different devices, and there are many devices available on the market.  At my clinic, prior to treatment, many clients go on a different compression pump for 15-20 minutes prior to manual therapy to help decrease tissue fibrosis, assist in breaking down protein molecules and stimulate the veins to work better. We find that this helps increase responsiveness to manual lymphatic drainage. There is a lot of data out there supporting use if the vaso-pneumatic pump in conjunction with therapy and compression. Although I typically use 40-45 mmHg, a study performed in 2002 found that a compression gradient of 40-50 mmHg was both safe and effective.  I have never heard of “dependency from pump use. If you would like to read the article, here is the reference information. Szuba A, Achalu R, Rockson S. Decongestive lymphatic therapy for patients with Breast Carcinoma-Associated Lymphedema. A randomized, prospective study of a role for adjunctive intermittent pneumatic compression. Cancer 2002; 95: 2260-7.

      Many clients are discharged from therapy with a self bandaging regimen because bandages (short stretch) are applied to provide a working pressure to the tissue. While the bandages are on, the muscles pump against them, stimulating lymphatic flow and decreasing overall girth. The hope is that the body will learn that there are different drainage points that can help the inefficient ones. I do modify the wrapping to increase a patients ability to tolerate them, and try to utilize as little padding as possible to make them more tolerable. I am also flexible with the amount of time an individual stays wrapped. Sometimes, leaving the bandages on for 2-4 hours is enough. Many of my patients wrap at night before bed, and wake up in the morning and remove them. My overall theory is to assist patients in living with lymphedema, not for it. What I mean by that is that it is important for a clinician to listen to what each individual says regarding their care and tolerance of bandages, including time spent wrapping and being wrapped. Nothing in this world is all or nothing, lymphedema is no exception.

      I am so sorry that you and your daughter are struggling and hope that this answer is helpful and if you need any further information, please let me know.

      Take care,
      Cynthia

  16. Compression Strength
    Question (Tia, ):
    • I was just diagnosed with primary lymphedema of both legs 6 months ago after being misdiagnosed for 6 years. I started seeing a lymphedema therapist and learned the basics in regards to bandaging, proper compression and MLD. I also received a pneumatic pump (Flexitouch) that I use on one leg a day for 60 minutes. It seems that once I was diagnosed the problems with my legs have only gotten worse. The legs are well maintained and regain a softer feel when in bandages but long term they are not feasible for me. Bandaging both legs up the thigh is extremely time consuming and limiting. But as soon as I put on thigh high compression stockings of 40-50 mm/mg my legs progressively get bigger day after day. They decrease a bit at night (I do not have a night garment) but get larger and harder as the days go by until I put the bandages back on. I even tried putting a second compression stocking (lighter weight 30-40 mm/mg) over the 40-50. Should I be looking at an alternative like the CircAid, Solaris, or Farrow full leg velcro options to wear on at least one leg in place of the time consuming bandages? Will a night garment help so I can remain in a compression sock without the relapse? Also, how many times a day should I be doing MLD? Is once a day sufficient and should it be done before the pump? All things concerned with the bandaging, pneumatic pump and 45 minutes of MLD the day is quite full. Thank you.

    Answer:
    • Feb 2016

      From Cynthia Shechter

      1) Flexitouch:

      I believe that use of sequential compression pumps, in conjunction with manual lymphatic drainage, multi-layer compression bandaging and exercise, are quite useful. Individuals respond differently to different devices, and the FlexiTouch is one of many devices available on the market.
      At my clinic, prior to treatment, many clients go on a different compression pump for 15-20 minutes prior to manual therapy to help decrease tissue fibrosis, assist in breaking down protein molecules and stimulate the veins to work better. We find that this helps increase responsiveness to manual lymphatic drainage.
      2) Self Drainage:

      If you do not notice an improvement in your swelling after performing self MLD, I recommend stopping. Try wrapping and exercising instead. As your muscles pump against the bandage they stimulate lymphatic flow and assist in the reduction of swelling. If you find that self drainage works, 1x daily is plenty. That said, since the FlexiTouch is supposed to mimic manual lymphatic drainage, I’m curious if you notice a difference between using the Flexi before/after manual lymphatic drainage vs. not performing manual drainage at all.
      3) Wrapping and Nighttime Garments:

      I find that for many clients, it is easier to bandage at night, before bed, and remove the bandages in the morning. If that doesn’t work, I recommend exploring some of the garments that you mentioned above. I generally prefer garments without velcro as there is less room for human error (ie: pulling velcro too tight in certain areas and not others can cause pooling of fluid and protein.) A night garment or nighttime wrapping should prevent an exacerbation of swelling as long as you are using appropriately fitting compression stockings. For more info on these garments, I suggest that you follow up with your therapist.

      4) Stockings:

      40-50 mmHg should be high enough compression, actually, most of our clients use 30-40 mmHg at the highest as the stockings can cause skin irritation at the instep and knee crease. Stockings are meant to stop increased fluid from coming down the legs, but do not reduce the swelling in your legs. Do yours maintain your legs to any extent? If not, they may not be a good fit. If your skin is being irritated, sometime, that can lend to increased swelling as it can cause inflammation.

      5) Summary
      Treatment of lymphedema involves a lot of trial and error and patience. You and your therapist may have to come up with creative ways to manage your condition, taking into account that you need time in your day for things other than lymphedema. This tends to be the hardest part of therapy, however, once you find out what your body needs to control your swelling, things will seem much more in control.
      Last year I did a webinar for LE&RN; about manual lymphatic drainage and exercise for the treatment of lymphedema. I have attached the link below. Please feel free to watch and listen so that you can get a basic understanding of what therapy will be like.
      http://datab.us/Videos/aY50SnMKrAc


      I hope this information was helpful.

      Take care,

      Cynthia J. Shechter

  17. Pre-op question
    Question (Dana, ):
    • I am 42yrs old and just had a bilateral masectomy and reconstruction. My surgeon was not able to locate my sentinal node during surgery and I am now faced with going back to surgery for an axillary node dissection. I am devastated. I was a very active person with sports and weight training. And am very worried about never getting back to the old me. Can you give me any advice? Things I can do right away to reduce my risk? Thx

    Answer:
    • Feb 2016

      First and foremost, this is a difficult time, but will certainly not prevent you from getting back to feeling like yourself and being active. If you were a mountain climber before breast cancer surgery, there is no reason that you cannot be a mountain climber after.
      After surgery, it is important that you work with a skilled therapist who will create an individualized exercise program to alleviate your pain, while increasing your mobility and strength. Shortly after surgery scar tissue may form which can impair the flexibility of your chest, armpit and abdomen. Scar mobilization will help break down the scar tissue and provide relief during stretching.

      Studies have shown that early therapy after breast cancer surgery and axillary node dissection can help to prevent and reduce lymphedema occurrence (Lacomba, 2010). Additionally, repeated muscle contraction actually helps move fluid, which can reduce the risk of swelling.

      Most importantly, working out and feeling better helps to maintain inner strength and a positive attitude, so please, do not, even for a moment, think that this part of your life is over or has changed permanently as this simply is not the case.
      References:
      Lacomba M, Sanchez M, Goni A, Merino D, Del Moral O, Tellez E, Mogollon E. Effectiveness of early physiotherapy to prevent lymphedema after surgery for breast cancer: randomized, single blinded, clinical trial. British Medical Journal 2010; 340: b5396.

      LeDuc O, Peeters A, Bourgeois P. Bandages: scintigraphic demonstration of its efficacy on colloidal protein reabsorption during muscle activity. Progress in Lymphology XII, 421-423, 1990.

      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4163073/

      I hope this information was helpful.

      Take care,

      Cynthia J. Shechter

  18. Lymphatic Draining Massage
    Question (Elissa, ):
    • I am 70 years old and had a lumpectomy in Sept. of 2014 followed by 3 weeks of radiation. No chemo. In April of 2015 I noticed swelling in a couple of fingers of the hand on the same side as the lumpectomy followed by swelling near the underarm. The latter swelled to the degree of pinkness, redness and finally weeping. That was a staph infection. Got over that with 4 days in the hospital on IV antibiotics. In any case, the fingers are still swollen and the oncologist recommended lymphatic drainage massage therapy which I was going to do in April but the infection stopped that. I am going to resume this month. What are your feelings about this type of therapy?

    Answer:
    • Sep 2015

      Hi.

      Manual Lymphatic Drainage is a primary component of Complete Decongestive Therapy (CDT), which is the current International Standard and therapy of choice for treating lymphedema endorsed by the American Cancer Society and National Cancer Institute (Mayrovitz, 2009).

      That said, manual lymphatic drainage as part of CDT is not the same as the lymphatic massage provided at a spa, unless the massage therapist has been trained and specializes in the treatment of lymphedema.

      Last year I did a webinar for LE&RN; about manual lymphatic drainage and exercise for the treatment of lymphedema. I have attached the link below. Please feel free to watch and listen so that you can get a basic understanding of what therapy will be like.
      http://datab.us/Videos/aY50SnMKrAc

      If you have any questions along the way, please contact me. My email is .(JavaScript must be enabled to view this email address).

      You are on the right track and therapy should help to reduce the swelling and risk of infection, and you will be taught things to manage on your own.

      Good luck and I’m here if you need me.


      http://www.play.tojsiab.com/dlB4N3Vhb0RrU0Ez

  19. Lymphedema worsened by surgery on affected leg
    Question (Debra, ):
    • I've had lymphedema since 2001 from radiation/surgery for a large retroperitonral liposarcoma. I had it under control until I broke my femur and hip last year. Since then, nothing has worked to bring the lymphedema back to my normal. I wear 30/40 Juzo stockings and have worn them for over 14 years. I have a lymphedema pump, a CircAid juxta fit non elastic sleeve. I also exercise. Nothing is working. It's huge and heavy. Is this my new normal? Any advise is greatly appreciated. Kindest Regards, Debra

    Answer:
    • Jul 2015

      Hi Debra,

      It is not abnormal that your swelling was worsened initially by surgery, but it should be responding to treatment. Have you been back for MLD/CDT since you broke your hip and femur? Did you have surgery to repair the breaks? Where is your surgical site?

      Sorry to answer your question with additional questions, but I look forward to hearing from you.

      Cynthia

  20. pressure settings on compression pumps
    Question (Brigitte, ):
    • I have Stage 2 secondary lymphedema, diagnosed about a year after a mastectomy w/lymph node removal and radiation. It is concentrated in my hand and lower arm, with some fibrosis in my lower arm. My therapist recommended that I obtain a compression pump for home use. I've seen reps from 2 different companies. Both offer a sequential gradiated pump with a sleeve and vest. While the products are similar, the companies suggest very different compression settings -- one is at 20-25 mmhg and the other is around 40-45 mmhg. Is there no established medical protocol for what the proper compression setting should be? Could a higher pressure setting actually worsen my lymphedema?

    Answer:
    • Jun 2015

      Hi Brigitte,

      There is a lot of data out there supporting use of the vaso-pneumatic pump in conjunction with therapy and compression wrapping. Although I typically use 40-45 mmHg, a study performed in 2002 found that a compression gradient of 40-50 mmHg was both safe and effective. If you would like to read the article, here is the reference information.

      Szuba A, Achalu R, Rockson S. Decongestive lymphatic therapy for patients with Breast Carcinoma-Associated Lymphedema. A randomized, prospective study of a role for adjunctive intermittent pneumatic compression. Cancer 2002; 95: 2260-7.

      I hope that helps. If you need anything else, please feel free to contact me.

  21. Importance of each of the 4 steps in CDT
    Question (Jacquie , ):
    • Thank you for making yourself available to answer our questions! It is a relief to know that there is an expert to turn to when the doctors in my area are not as versed about Lymphedema. How important is each of the 4 steps in CDT if someone has Stage II, Primary Bilateral Lymphedema of the lower extremities? I just started CDT and was wondering when MLD should take place and on average, how much time should be allocated to this procedure? Is MLD done each time the bandages are removed if fluid is still present in the limb? Is it a waste of time to do MLD when transitioning to compression stockings? When you have a patient who is initiating CDT, in which the entire lower limb is effected, how long should each CDT session last? If you can break it down as to the amount of time within each of the 4 steps (MLD, bandaging, exercise, skin care) that would be helpful. If someone has bilateral lymphedema is the required time doubled? Do insurance companies regulate the amount of time each session is in CDT or if someone has bilateral lower extremity lymphedema, can the therapist bill for both limbs and twice the amount of time or number of procedures? I am trying to get a handle on standard of care and what I should expect from a CDT session. Thank you for your help! It is much appreciated.

    Answer:
    • Apr 2015

      1)  How important is each of the 4 steps in CDT if someone has Stage II, Primary Bilateral Lymphedema of the lower extremities?

      It is important to understand that each individual with lymphedema is different, and the condition should be evaluated as such. Each step to CDT is important, but what is even more important, in my opinion, is that a treatment regimen that is realistic for each individual be established. For example, my practice is in NYC, and many of my lower extremity patients have difficulty wearing bandages to the office. I modify therapy to what is realistic for them, and, although visit frequency may increase a bit, we are still able to get the swelling under control and patients are discharged to a home self management program.  In addition to manual drainage and compression wrapping at each session, I do stress the importance of skin care and exercise to achieve the best results.

      2) I just started CDT and was wondering when MLD should take place and on average, how much time should be allocated to this procedure?

      Many therapists follow the theory that treatment in the acute stages of lymphedema, should be daily over a 3-4 week time span. This becomes quite difficult for the patient and insurance does not typically approve therapy visits in that way. Session times vary, but on average MLD should be a 45-60 min session. Please note, a therapist can typically only see a patient for about 60 min total, so if there is a lot of wound care required, MLD may be performed for shorter periods of time.

      3) Is MLD done each time the bandages are removed if fluid is still present in the limb?

      If you are seeing a therapist who tells you not to remove bandages yourself, until your next session, then certainly MLD should be performed when they are removed. That said, many clients are discharged from therapy with a self bandaging regimen, and MLD does not need to be performed when bandages are removed. MLD is a manual technique to re-route fluid from the affected area to the healthy lymphatics, in it’s most simplistic form.  After MLD is performed, bandages (short stretch) are applied to provide a working pressure to the tissue. While the bandages are on, the muscles pump against them, stimulating lymphatic flow and decreasing overall girth. The hope is that the body will learn that there are different drainage points that can help the inefficient ones.

      4) Is it a waste of time to do MLD when transitioning to compression stockings?

      No, not at all. MLD is helpful in the reduction of fluid. While waiting for compression stockings to come in, it is imperative to continue with MLD to ensure that your measurements do not change drastically, which would make your new custom stockings an ill-fit. Additionally, clinical research has shown that using both compression and manual lymphatic drainage is the optimal combination to achieve a positive effect on reducing pain and volume of a lymphedema limb (Johansson, 1999).

      Reference:

      Johansson K; Albertsson M; Ingvar C; et al. Effects of compression bandaging with or without manual lymphatic drainage treatment in patients with post-operative arm lymphedema. Lymphology 32: 103-110, 1999.

  22. Compression wear
    Question (Roberta, ):
    • Hello, I am 54 yrs old and was dx with lymphedema tarda in my 20s. I have been very diligent in using compression wear with great success. However over the years the edema has been getting worse. I started with knee highs bilat 30-40 and now have to wear thigh highs. I am very active enjoying yoga, hiking, and biking. I live in New England and during the winter I can "take" wearing the stockings. However during the warmer weather I don't know what is worse, the pain from the swelling or the heat of wearing the stockings. Do you have any suggestions or links to resources perhaps for compression for athlete? Or compression wear that can be worn during the hotter months.

    Answer:
    • Feb 2015

      Hi Roberta,

      Lower extremity swelling is very difficult to manage in the summer months. What I typically recommend is that people try 20-30 mmHg of compression for the summer months, rather than 30-40, simply because the garments are lighter weight.

      I also have several patients who, despite distal swelling, utilize open toe compression in the summer months so that they have more flexibility with shoe choice. I tend to recommend stockings rather than thigh highs, both for comfort and for proximal compression.

      There is a company called rescue legs that advertises summer weight compression garments, however, I have not used their products with my clients as of yet.

      I hope that helps at least a bit, sorry I have nothing more concrete. Garments and treatment are so individual.

  23. bra for side lymphedema
    Question (Melanie, ):
    • I had breast cancer, had separate mastectomies, one with with axillary dissection (18 lymph nodes removed because sentinel node was cancerous). I have lymphedema in my hand, arm an side. I also had delayed bilateral diep flap reconstruction. I am in search of a bra that has a wide band under the breasts so the bra doesn't ride up, something with adjustable shoulder straps, side of the bra that comes high under the arm, and something that will give me compression on my side or where I can put a "swell spot" or something in without compressing my breasts. Do you know if such a bra exists? I've looked at the compression bras and I don't want to compress my breasts. Other bras I've seen just don't come up high enough under the arm to give comfort because of the side lymphedema. Another problem I have is that I am small. I wear between a 32 and 34 with a small "b" cup.

    Answer:
    • Feb 2015

      Hi Melanie,

      It is very difficult to find a bra meeting all of your needs, but I think I was able to find something. Have you ever looked at Leonisa bra’s? I have never seen one myself, but it looks like it will give good support, accommodate the swell spots as needed, and has an adjustable back to help prevent riding up. Please let me know if this works for you so that I know if it is a good option for others. Please see the link below:

      Best of luck and if I can help with anything else, I’m here.

      http://www.leonisa.com/en/products/perfect-everyday-posture-corrector-bra/

  24. compression therapy
    Question (Pamela, ):
    • Do you believe in compression therapy to help lymphedema? I have heard that compression pumps are very helpful. Where can I find one? Thanks, Pamela

    Answer:
    • Dec 2014

      I believe that use of sequential compression pumps, in conjunction with manual lymphatic drainage, multi-layer compression bandaging and exercise, are quite useful.

      At my clinic, prior to treatment, many clients go on the compression pump for 15-20 minutes prior to manual therapy to help decrease tissue fibrosis, assist in breaking down protein molecules and stimulate the veins to work better. We find that this helps increase responsiveness to manual lymphatic drainage.

      While there have been clinicians and patients who have not had good results with pumps and do not recommend their use, hundreds of people have experienced great results with the proper use of the right pumps. Pumps are not for everyone, and success does depend on which pump is used, and the proper application of pumps.

      When looking for the right device for you, look for a pump that contains multiple chambers, operates on a short thirty-second cycle time, and applies graduated compression. The body operates on a pressure gradient system, so it is imperative to obtain a gradient or graduated compression pump. Gradient or graduated means the pressure at the feet or hand is greater than the thigh or shoulder.

      In my clinic, we quite often order a compression pump as part of a home management program for our clients. Typically we obtain authorization, etc for our patients, so I recommend contacting your rehabilitation therapist or physician to discuss.

      I hope that helps, and if you need any further information, please let me know.

  25. Bilateral mastecmy w reconstruction
    Question (Reba, ):
    • I have Lymphadema in R arm not in left . Unfortunately I'm one those % wasn't told I could get Lymphadema from surgery Q: if had 2 lymphnodes removed Fr left arm chances of getting Lymphadema & what to do to prevent ?

    Answer:
    • Oct 2014

      Well, the data states that you have between an 8 and 14% chance of developing lymphedema in the left arm. (at least when I last checked) All that you can do to prevent lymphedema is increase your range of motion, loosen as much scar tissue as possible and get on a strengthening regimen. Also, be sure to use SPF 30+ and have neosporin handy if you get a scrape/cut/bite. Do you have a rehab therapist near you who can do an evaluation and see how your motion, scar tissue, etc is?