Hi Laura,

So sorry for the delayed answer. In order to be appropriately sized for an OTC garment, I generally suggest going to a surgical supply store that has a garment fitter onsite. For breast and lateral/side swelling, you may be able to use a sports bra that isn’t too tight at the bottom or even an OTC compression tank top (similar to spanx for example) that goes down to the waist so that you do not have a pressured area.

I hope this helps.

Excessive heat and heaviness can be a sign of infection. If it is a difference for you, always best to seek medical care.

Wishing you the best.

Hi,

In terms of finding a bra, I typically recommend coverage to the armpit (or very close) to avoid fluid pooling in your side/lateral trunk. Here are some bra companies that should be able to help. In addition to the companies listed below, Athleta also has a post breast cancer surgery line of bra’s and insets that many patients like.

You can also go to a sporting goods store and look for a supportive high armpit sports bra. You can also add a “swell spot” (https://jovipak.com/pads.htm) to your bra to keep the breast tissue soft.

http://amazon.com 
CW-X Women’s High Impact Stabilyx Full Figure Sports Bra

https://www.anaono.com/

https://www.brilliantcontours.com/

https://www.prairiewear.com/

https://www.lymphedemaproducts.com/products/bellisse-bra

Best,
Cynthia

Hi,

Sounds like a terrible accident, I’m glad you are here to speak about it. Management of swelling can assist in increasing range of motion, muscle firing, and overall healing. In order to do so, you have to see a lymphedema therapist for a full evaluation.

You can search for therapists in your area on the LE&RN; site or on the national lymphedema networks website.

Unfortunately, I have to evaluate you in order to provide additional information. A good clinician should be able to assist in management and identifying your “triggers”, etc.

Wishing you the best in your wellness journey,
Cynthia

Hi,

Have you see a lymphedema therapist to work manually on your leg to assist in decreasing the swelling? Building muscle does assist in decreasing the levels of extracellular fluid in your tissue. Do you know how to wrap/bandage your leg? Do you have compression garments? Have you received a vasopneumatic pump? All of these things can help you get a reduction in swelling, pain, and all other things associated with leg swelling.

Hoping you are able to find a clinician who can assist. You can find people close to your home y searching the link on the LE&RN; site or on the National Lympedema Network website.

Best,
Cynthia

Hi,

If compression stockings are appropriately fitted they should assist in preventing any increase in swelling. That said, there is no guarantee that they will work for everyone. Often individuals have issues tolerating compression stockings due to increased skin folds, etc.

I suggest going to an experienced fitter but also recommend working with a PT/OT for swelling reduction prior to being measured for new garments. Once your swelling is reduced, that is when stockings are most beneficial.

Hoping that helps.

Best,
Cynthia

Hi,

Wrapping with a wound vac can be tricky depending on where the vac is positioned, but it is possible. I think you should be able to wrap avoiding the vac attachment site. Can you email me images of what you are dealing with so that I can assist in a more direct and effective fashion?

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Thanks and I look forward to hearing from you.

Hi,

I think that perhaps you should see an OT/PT who specializes in breast cancer and lymphedema rehabilitation to ensure that your posture, range of motion, scar tissue, etc is normalizing and to releave some of your symptoms. Sometimes a heaviness post-operatively is indicative of a subclinical lymphedema and is often reversible with care.

Have you seen a clinician? You should not have to stop playing, you just need to get your body and positioning set. You can even bring your violin to treatment so that your therapist can analyze what needs modification as far as positioning, etc.

Actually, in the book “Let’s Talk Lymphedema” has an example;le discussing a violinist. Here is the link:
https://lymphaticnetwork.org/documents/Lets_Talk_Lymphoedema_Complete.pdf

Hope this helps and wishing you all good things.

Hi,

Unfortunately, many prefabricated upper extremity arm sleeves bind at the upper arm. There are some companies with prefabricated large sleeves.

I am going to list companies/items. The international companies may be difficult to order from. I have no experience. Hoping this helps

1. Medi Harmony Lymphedema Armsleeve w/Top Band (goes to size VIII, but also Wide sizing)
2. Juzo Soft Armsleeve w/ Silicone Border 20-30mmHg (sizing includes width)
3.  Tynor compression garment arm sleeve (international company)
4. Mojo Compression Opaque Lymphedema Armsleeve (international company)

Best, Cynthia

Hi,

NO, you do not have to avoid martial arts. You should be able to do everything that you did before, knowing your precautions and gradually working your way up to where you were before. Do you utilize padded gloves during martial arts practice? It may be something to look into if you are concerned about the effects of repeated impact on your hands. I actually have patients who box and find that the impact and motion actually assists in reduction of swelling.

Limiting the things that you enjoy and have done in the past is not something that you should feel is needed. It’s a matter of getting your body ready to perform the activity.

Hope this is a helpful response. Wishing you the best.

Hi Shari,

Post-op rotator cuff repair, your shoulder will be more than likely immobilized and you will likely not be able to utilize your pump due to positioning and your post surgical precautions. The likelihood is that you will not be able to utilize your sleeve as donning/doffing will be very difficult and painful. While you will likely have an increase in swelling initially, it should go down once you are able to move. Perform hand pumping exercises (opening/closing of fingers) wrist circles, and your elbow as able.

Your post-surgical precautions take priority to your lymphedema management to ensure healing of the repaired rotator cuff.

Best of luck, and if you need anything, please feel free to contact me. .(JavaScript must be enabled to view this email address)

Hi Sally,

For head and neck swelling, the only product that I know can assist is the FlexiTouch pump made by Tactile Medical

https://tactilemedical.com/our-lymphedema-solutions/for-head-and-neck/

Here is an article on the efficacy of head and neck lymphedema treatment.

https://onlinelibrary.wiley.com/doi/epdf/10.1002/hed.24995

Some people find wearing compression garments difficult, but they do make some options. Here is a link to the L & R Tribute for head and neck swelling. Most patients tolerate this garment overnight and assists in reducing swelling.

http://suprasorb.eu/us-en/products/solaris-collection-by-lr/tributenight/head-and-neck-garments/

Also, sometimes you need to change the lymphatic drainage technique to facilitate drainage. I am attaching a link to an instruction sheet for simple lymphatic drainage for the head and neck. If this is the same technique you have used in the past, perhaps see a different clinician for alternative techniques.

https://www.lnni.org/sites/default/files/documents/Simple Drainage Head and Neck JULY17 V3 FINAL.pdf

I have no allegiance to any companies mentioned in my answer. These are simply head and neck lymphedema reduction devices/garments that I have proven effective in my experience.

Trial and error, though costly, will help find the tools that work for you and your swelling. No two patients are the same, and nothing works for everyone.

Hope this helps, and wishing you the best.

Hi,

Though I do not generally use dry brushing in my practice, it can assist in stimulating the lymphatic system. The brushing itself can assist in maintaining healthy skin, and getting rid of toxins and impurities, and the strokes can stimulate lymphatic function. The Cleveland Clinic published a paper regarding dry brushing.

Here is a link to their page: https://health.clevelandclinic.org/the-truth-about-dry-brushing-and-what-it-does-for-you/

I am actually doing a zoom symposium for LE&RN; tomorrow which will cover this area if you are interested in tuning in.

I am aware of the research coming from Australia. As far as stimulating the affected nodes, and, I recently took the CORE certification with the International Lymphedema & Wound Training Institute (ILWTI) and stimulation of the affected side is part of their training.

As far as pressure, I use the standard rule that I learned at the Academy of Lymphatic Studies,  “the firmer the tissue the firmer the touch”. I use significantly different pressures throughout treatment as tissue changes, etc. Fibrosis is no longer believed to be permanent.

Hope that helps and that you watch the symposium tomorrow.

Hi Sherry,

Post-op rotator cuff repair, your shoulder will be immobilized and you will not be able to utilize your pump due to positioning and your post surgical precautions. The likelihood is that you will not be able to utilize your sleeve as donning/doffing will be very difficult and painful. While you will likely have an increase in swelling initially, it should go down once you are able to move. Perform hand pumping exercises (opening/closing of fingers) wrist circles, and your elbow as able.

Your post-surgical precautions take priority to your lymphedema management to ensure healing of the repaired rotator cuff.

Best of luck, and if you need anything, please feel free to contact me. .(JavaScript must be enabled to view this email address)

Hi,

I completed the CORE certification and Modern MLD courses with Heather Hettrick, Robyn Bjork and Lisa Marshall and found it really helpful in educating on the Endothelial Glycocalyx Layer (EG. It disproves Starling’s Law and states that 100% of all interstitial fluid is reabsorbed by lymph capillaries alone as opposed to the 90%/10% (venous system/lymphatic system) stated in Starlings law.

Robyn and Heather do a wonderful job explaining the concepts. Perhaps look them up. I also encourage completion of the Modern MLD course with ILWTI. Hope this helps.

Hi,

All exercise can assist in the reduction of swelling with lymphedema. According to a study performed by Dave Scrivens, Certified Lymphologist, rebounding is reported to increase lymph flow by 15 to 30 times. Also, bones become stronger with exercise.

Furthermore, Scrivens states that vertical motion workouts such as rebounding are much different and much more beneficial and efficient than horizontal motion workouts, such as jogging or running. The lymph fluid moves through channels called “vessels” that are filled with one-way valves, so it always moves in the same direction. The main lymph vessels run up the legs, up the arms and up the torso. This is why the vertical up-and-down movement of rebounding is so effective to pump the lymph.

For the full article about rebounding and lymphedema, here is the link.

https://www.curetoday.com/view/rebounding-for-lymphedema

All exercise assists in the movement of lymphatic fluid as muscle movement moves fluid. I find that in addition to rebounding, I find the vibration plate and strengthening exercises helpful as well.

All the best and I’m always her if you need anything.

Cynthia
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Hi

It is often difficult to find data on techniques for lymphedema reduction that have not been researched enough to give concrete answers.

Brushing: The action of dry brushing is excellent for exfoliating dry skin, unclogging pores in the exfoliation process. It is said to help detoxify your skin by increasing blood circulation and promoting lymph flow/drainage.

https://health.clevelandclinic.org/the-truth-about-dry-brushing-and-what-it-does-for-you/

Vibration Plate: Our lymphatic system is a detoxification system and keeps our body functioning in a healthy way. Toxins form, and, without physical activity, cannot be flushed by our lymphatic system. The best way to drain out the harmful toxins in your body is through massage and exercise. Fortunately, vibration plates are able to deliver both exercise and circulation, through varying settings and stances on the vibration plate. You can even turn use of the vibration plate into a full body exercise regimen.

https://www.froothie.com.au/how-do-vibration-plates-work

Alternative therapies can be helpful in the management of lymphedema, though Complete Decongestive Therapy is standard of care. At my clinic, therapy varies based on a patients response to treatment. Though I do not use dry brushing in my practice, I do have a vibration plate for use post manual therapy and I find it very helpful.

There needs to be more data, but trial and error is OK in finding your own self management regimen.

Best of luck, and please reach out again if I can be of any assistance.

- Cynthia

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Where do you live? Do NOT give up! I do need more information to assist you. Can we email off-line? .(JavaScript must be enabled to view this email address)

Hi,

I recommend finding a lymphedema clinician to help you with reduction of swelling in the leg, scar work as needed, and to see where you are functionally so that you can be prescribed an appropriate home exercise program.

Generally, it is recommended that you get at least 30min of exercise daily. We utilize many different types exercise equipment, ie: vibration plate, the recumbent bike, the Mirror, TRX, etc.

As far as nutrition, have you ever read “The Complete Lymphedema Management & Nutrition Guide” by Jean Lamantia and Ann Dimenna? It’s
a good reference and resource.

Hoping this information is helpful. If I can assist in any other way, please let me know. .(JavaScript must be enabled to view this email address)

Ask your doctor to a referral to a lymphedema therapist, preferably one with a bioimpedence machine to measure fluid levels. You can see a clinician who performs circumferential measurements alone if no one has the bioimpedence machine. Your doctor may ask you to have to rule out other possible causes of the symptoms, such as a deep vein thrombosis (blood clot), or infection.

Once referred to a lymphedema clinician, your first visit will include an “interview” regarding your symptoms. Your therapist should ask about the symptoms you’ve noticed, such as heaviness, tingling, or swelling, as well as their patterns of onset and triggers, any pain in the arm, chest, trunk, or whatever part of the body is affected — what the pain feels like, how long it lasts, how intense it is; manual examination (called palpation) to feel for any signs of fibrosis, or scarring of the soft tissue under the skin, etc.  Typically, your therapist will make a diagnosis at this appointment and discuss treatment options. Together you can develop a treatment plan that meets your needs and suits the kind of lymphedema you have — ranging from mild to moderate to severe.

If there is time remaining and the doctor has ruled out any clots, a therapist may choose to initiate treatment the day of the evaluation (my preference) to give you an idea of what therapy may be like and to see how your body responds to manual lymphatic drainage.

If you have any further questions, please contact me on the “Ask the Experts” page or directly at .(JavaScript must be enabled to view this email address)

Best of luck.

Your therapist may need to rule out other possible causes of the symptoms, such as a recurrence of the cancer, deep vein thrombosis (blood clot), or infection
They will look at several things including tissue texture,

Hi,

There is no one specific thing to do for lower extremity lymphedema. Generally, suggestions include:

1.  Put your legs on pillows to raise them above your heart while lying down.
2.  Exercise your legs. Examples can include ankle pumps, writing the alphabet with your toes, towel scruches, swimming, stretching, yoga, etc.

3. Follow a low-salt diet, which may reduce fluid buildup and swelling.

4. Wear support stockings

5.  When traveling, take breaks often to stand up and move around.

Always ask your lymphoedema specialist for advice and talk to your doctor before you start any exercise regimen.

Check out this link for some more detailed information on exercise. 

https://www.lymphedemaproducts.com/blog/leg-exercises-stretches-to-manage-lymphedema/

Also, do you have a lymphedema pump like the Aeros, Biocompression, Lymphapress or Flexitouch? Can you self bandage or do you have a night-time garment?

If you have “flat” feet, sometimes orthotics can be of assistance as well.

I hope this helps. If you have any additional questions, please contact me on either this page or via email at .(JavaScript must be enabled to view this email address)

we spoke offline due to the sensitivity and specificity of this question. thank you

A compression sleeve (and glove if your hand swells as well) may assist in preventing swelling during exercise.

Compression sleeves and garments are designed to apply pressure to the arm, hand, or trunk to keep lymphatic fluid moving in the right direction. You just have to be sure that the sleeve fits appropriately and does not cause fluid pooling in your forearm or elbow regions. I’d try using it to exercise to see if the garment stops fluid level fluctuations.

There are many brands of compression garments for the arm.

Examples:
LymphaDiva’s
Medi
Jobst
Juzo
Solaris

Best of luck and if you have any additional questions, feel free to contact me. .(JavaScript must be enabled to view this email address)

Hi Ruth,

Pre and post-surgical lymphedema therapy is important. After total knee replacement, therapy and treatment has to be modified due to inflammation, surgical site pain, etc, but the swelling should be manageable.

Post-operative swelling will lend to an increase in overall leg size, but remember, the inflammatory response is not permanent, but it does require care.

Try not to worry and please contact me at any time with additional questions and concerns. .(JavaScript must be enabled to view this email address)

Therapy with a clinical specialist. Have you referred to LE&RN;‘s listing to find a provider? If one therapist doesn’t work for you, then try another. Clinicians are definitely not “one size fits all”.

Here are links to schools of lymphatic studies:
Academy of Lymphatic Studies (ACOLS)
ACOLS Directory

Dr. Vodder School International
http://vodderschool.com/contacts/therapist

Klose Training
http://klosetraining.com/therapist-directory/

Norton School of Lymphatic Therapy
http://www.nortonschool.com/therapistreferrals_form.html

Pacific Therapy Education, Inc.
http://lymphedemamanagement.com/members/#participants-list

Hi,

In short, not directly. I think that clinicians would be concerned regarding the pressure of both the strap and the brace itself. That said, a flexion contracture in and of itself is bad for swelling as muscle movement moves fluid.

You and your medical team could evaluate risk/benefit ratio. Perhaps the brace could be used with very subtle/gradual stretch and for shorter periods of time.(please do not use as medical advice as I would have to evaluate you myself for any recommendation.)

Wish I had a better answer but hoping this helps,

Cynthia

Feel free to contact me with any additional questions. If your PT/OT would like to reach out to troubleshoot, I’m always here to help.

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Hi,

So without meeting you, it’s difficult to know, but generally, wearing a sleeve after a procedure requiring sutures to your affected arm may cause increased wound pressure, pulling or tugging on the suture line, and may increase moisture around the wound, making healing a bit more difficult.

Generally, with lymphedema, wound healing tends to take a bit longer.  My concern with the sleeve would be that between the lymphatic back-log and the moisture healing could be quite delayed. Also, depending on the location of the wound, pulling the sleeve on could pull at the suture line.

All of the above considered, if your physician says to wear the sleeve, you should follow his/her advice.

Hope that clarifies. Fell free to reach out anytime with additional questions and concerns. .(JavaScript must be enabled to view this email address)

Hi,

Yes, Manual Lymphatic Drainage (MLD) can assist with reduction in cases of lipedema. Frequency of therapy generally depends on findings during a detailed evaluation, but if I had to give a guess I’d say 2-3 times a week for about 6 weeks.

MLD is recognized in the lymphedema/lipedema world as a first step in the management of lipedema and is useful in the reduction of swelling that accompanies this disorder. Compression bandaging and use of compression garments are also typically a part of treatment by a certified clinician.

Best,
Cynthia

Hi,

With the surgical wound site, I typically would not recommend using the sleeve as I believe you should protect and care for the wound. You may have a slight increase in swelling after the excision, but it is more important to protect the site from infection.

The doctor should clear you for use, but I would recommend lymphedema treatment after the wound is clean and dry without sutures to decrease any increase in upper extremity girth overall.

Hoping that helps, and please contact me with any additional concerns.

Best,

Cynthia
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Hi,

There are many compression options. Usually, despite no distal swelling, it is recommended that you use compression throughout the extremity to avoid fluid traveling down the leg. That said, I like to experiment for the most effective and comfortable option.

Here are a few options, though it is difficult to know what will work as I have not evaluated you. Also, have you been evaluated by a clinician? Treated to get a reduction? This may assist as well.

1.  https://www.shapewearusa.com/products/marena-compression-bodysuit-for-bbl-fat-transfer?variant=34670156218527&currency=USD&utm_medium=product_sync&utm_source=google&utm_content=sag_organic&utm_campaign=sag_organic&gclid=Cj0KCQjwtsv7BRCmARIsANu-CQcP66smcqw1LCv8BAflR33DRxSmbTeXlzb_Mg8Cb8DzFxXERrFOlVMaAss9EALw_wcB

2.  https://www.lipoelastic.com/products/garments-catalog/

3.  https://www.jobst-usa.com/product/jobst-plastic-surgery-female-girdles

Hoping this helps.

Generally, I do not have my patients measure themselves and their swelling. I find it is anxiety provoking and does not assist in self management unless you have a specific area of pooling that you are trying to get down.

That said, if you want to measure, here is a link to the most recommended tape-measuring option that only require one hand:

https://www.amazon.com/Measure-Measuring-Myotape-Shipping-Worldwide/dp/B00FYTOFDA/ref=asc_df_B00FYTOFDA/?tag=hyprod-20&linkCode=df0&hvadid=343974923691&hvpos;=&hvnetw=g&hvrand=9160329506765225859&hvpone;=&hvptwo;=&hvqmt;=&hvdev=c&hvdvcmdl;=&hvlocint;=&hvlocphy=9003646&hvtargid=pla-761908307436&psc=1&tag;=&ref;=&adgrpid=68456165959&hvpone;=&hvptwo;=&hvadid=343974923691&hvpos;=&hvnetw=g&hvrand=9160329506765225859&hvqmt;=&hvdev=c&hvdvcmdl;=&hvlocint;=&hvlocphy=9003646&hvtargid=pla-761908307436

They do also have self adhesive tape measures that could also work, but I prefer no adhesive on the skin.

Best of luck and if you require additional assistance, please email me at .(JavaScript must be enabled to view this email address)

You should definitely be in touch with Donna Wilson at Memorial Sloan Kettering in NYC. She’s wonderful and has a dragon boat team in New York.

Generally, breast cancer thrivers can participate in many different exercise groups. Many groups exist for yoga, Reiki, Chi Gong, Tai Chi, and more.

I love the idea of fly-fishing and archery with finger and forearm protection. Hiking is also a wonderful way to bond with one another, and can end with kayaking - many areas have rentals. This gives the paddling component without the closeness in the boat itself.

Bowling may be difficult as people have difficulty lifting, perhaps have lymphedema and cannot fit their fingers in the ball, etc. 

I’ll keep brainstorming, but in the meantime I hope this helps.

Hi,

Clinicians prefer short stretch bandages as opposed to long stretch/elastic compression.
- Long-stretch bandages contain elastic fibers that enable stretching to approximately 140% to 300% of their original length. Ace™ bandages are an example.
• Short-stretch bandages are stretch to about 30% to 60%. Examples include the Rosidal K® and Comprilan® bandages typically used in lymphedema management.

The purpose of compression bandaging for lymphedema is to create a muscle pump to facilitate fluid re-uptake. As you layer the short stretch bandages, you are actually creating a low resting pressure with a high working pressure, facilitating fluid re-uptake in the body.

When using elastic bandages (long stretch) with a high resting pressure, fluid typically temporarily moves up the extremity, but does not assist with fluid re-absorption into the lymphatic system. Typically this type of compression is typically used in the maintenance phase of treatment.

As far as working on bilateral extremities, it is usually up to a therapists discretion. Often I treat the most affected extremity if there is a drastic difference in girth, skin health, etc, but will wrap both extremities post treatment.

Generally, I, as a clinician, am flexible and do not typically adhere to the “certification” as much as I evaluate the individual every session to ensure the best care possible. I’m sure if you have additional questions, your clinician can assist as well and having an open stream of communication is helpful.

If you have any additional needs, please feel free to contact me at .(JavaScript must be enabled to view this email address)

Hi.

So sorry for the delay in answering. You should really speak to your surgeon about antibiotics pre/post operatively. The wound will likely take a bit longer to heal, but as long as you are infection free, you should do well.

Ask your surgeon if they will be taking lymphnodes from the groin region, and also discuss wrapping for lymphedema over the wound dressings once able. If the swelling stays stable, the wound should be ok.

I would plan on going to a lymphedema clinician to work on scar tissue and swelling to minimize risk of complications. The likelihood is that you will not be able to utilize your compression stockings, at least initially, due to the fragility of the tissue post surgically. That is ok, so try not to worry (easy for me to say).

Do you have a clinician you trust?

Hoping this was helpful. If you have any follow-up questions, please feel free to email me directly at .(JavaScript must be enabled to view this email address)

No. Do not use compression stocking to sleep. The purpose of the stocking is to stop increased fluid from building up in the limb when out and about due to gravity.

There are night garments and there is a bandaging technique for night-time use, however, I recommend finding a clinician to help guide you through your lymphedema care.

You can find a clinician near you on the LE&RN; website or through the National Lymphedema Network. Wishing you the best, Cynthia

There are many products on the market that you can use. To avoid spraying your sleeve. See some options below:

Mosquito Repellent Lantern by Thermacell
MosQuitO Repellent Bracelets
Mosquitno Citronella Mosquito Repellent Wristbands
Cliganic Mosquito Repellent Bracelets​
OFF! Clip On Mosquito Repellent

All of these are available on amazon. I do not know first hand how effective these products are as I have not tried them personally, but I wanted to present options. The bracelet is OK for short term use if it is not tight around your wrist. If you are too swollen or have very sensitive skin, I would recommend the wearable fan or tabletop item.

Enjoy the summer outdoors!

Generally, you want your body at 90 degrees of flexion at your hips, knees and ankles. That said, you may benefit from either an under desk elliptical or even an under desk vibration plate. See links to examples below.

Example Elliptical:

Cubii Pro - Seated Under-Desk Elliptical - Get Fit While You Sit - Bluetooth Enabled, Sync with F…
https://www.amazon.com/vdp/0ebbe14f192e45ff957dc673f6a63e99?product=B0189VJD1I&ref=cm_sw_em_r_ib_dt_oxbtl6AH9m4H6

Example Vibration Plate

  https://lifeprofitness.com/products/the-waver-vibration-platform?gclid=CjwKCAjw_qb3BRAVEiwAvwq6VspvrtEHwbUTaC1-3RsRJTQGMAN9PD1JNdLOJoH8X4doMIScdLhWPRoCBL0QAvD_BwE

• An ergonomically supportive chair with adjustable seat height,                adjustable arm rests, and lumbar support.

• An ergonomic/natural keyboard with gel pad

• An ergonomic track ball or Evoluent mouse

• An ergonomic keyboard tray to position the mouse at the same height as the keyboard and as close to the keyboard as possible.

• Raise the monitor (laptop) so that the middle of the screen is at eye level.

The above changes will help to foster good sitting posture and minimize stress on the body.

As far as elevating your legs - it is very hard on your back. Typically, I would recommend getting up and moving when able - shoot for at least twice in an hour.

Hope this helps,
Cynthia

Unfortunately, garments are often not covered. Lower extremity garments can be covered, especially with I diagnosis of diabetes. You need to find out from your primary insurance if you have coverage for durable medical equipment (DME)- it’s usually a separate benefit. If so,you can typically go to an in network DME/medical supply store and get coverage.

I am also providing a link to the Lymphedema Treatment Act so that you can see what is in the works.  https://lymphedematreatmentact.org/

Hi,

Unfortunately, compression garment fitting is often trial and error. Rather than the WearEase, have you tried any of the traditional garment companies like Jobst, Juzo, Solaris, or even Solidea? Here are the names of a few garment types that may work.

I do not have a company or garment preference as they all work for different individuals. There are so many garment options. None should cause pain or restricted breathing. Hopefully this information is helpful. If you’d like to discuss, please feel free to contact me at .(JavaScript must be enabled to view this email address)

- Juzo Soft
- Juzo DreamSoft
- Silver Wave Active Massage Legging (Solidea)
- JOBST® Elvarex® Lower Extremity

Hi,

Generally, compression garments are not linked to joint problems, however, if your garment tends to bunch at the ankle and knee, it’s possible that the fluid is disrupting the joint space. Perhaps the compression gradient is too high.

When you remove your garment do you have redness and creasing at the ankle or knee? Any pooling of fluid in those areas? I’d love to problem solve this with you, but need additional information.

Please email me at .(JavaScript must be enabled to view this email address) or reply to this thread.

Unfortunately, you really have to ask her physician and wound care team. Sometimes, the wrapping of wounds in elastic (coban self adhesive wrap) gets too tight and causes pain as it tends to tighten as it’s on. Generally, I recommend against pumping with elastic compression as it doesn’t really help. The wrapping actually inhibits efficacy of the pump. Please let me know if there is anything that I can help with.

First, I would contact the active members of her care team.

My contact is: .(JavaScript must be enabled to view this email address)
              201-267-6267

Perhaps. It is difficult to advise without seeing what’s happening. Generally, elastic garments are a tough fit and the hand can exhibit increased swelling due to garment ill-fit.

Are you wearing the elastic garment to bed?  Wearing a compression sleeve and glove is generally recommended during the day, during exercise, air travel, etc.

Can you do a telephone session so that I can see to be of more assistance? It is often hard to make recommendations without knowing a person, what they were told by their clinician and how they were discharged to self management.

My contact is: .(JavaScript must be enabled to view this email address), 201-267-6267

I’m happy to speak and help in any way possible so please feel free to get in touch.

Hi Jan,

Lymphedema is a tricky diagnosis, especially post radiation therapy. That said, 4 years post treatment I’d hope you’d be better. I’m not sure what information you are looking for, but I did find a few articles that may be helpful.

I am also available to speak to you to discuss your case and see what we can do. Where are you located? If you’d like, you can always call the office at 201-267-6267. My website is http://www.shechtercarenj.com

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6649691/  (2019)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3924783/  (2014)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3924783/  (2012)

This truly depends on the severity of swelling, region of the body, the cause of swelling (primary or secondary). Generally I recommend 2-3 times weekly. Please note that many clinicians still follow the certifications and recommend daily for at least 3 weeks for reduction and then garment fitting.

Hope this helps, if you need additional information or want to share more details of your diagnosis, please feel free to contact me at .(JavaScript must be enabled to view this email address).

Without seeing it, it is difficult to answer, however, it is probably from the tightness from the band and the silicone band if you have it. I would ask your clinician or garment fitter to check the fit to ensure that you are wearing the proper garments.

It is essential and beneficial to exercise after breast cancer surgery in a safe and controlled setting once you are medically cleared.

After surgery, it is vital that you work with a skilled therapist who will create an individualized exercise program to alleviate your pain while increasing your mobility and strength. When participating in weight lifting, the general rule is to start with very light weights (like 1 lb) and work your way back to where you were pre-surgically. I usually recommend doing 1 lb for 1 week, 2 lbs for 2 weeks and so on.

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 contractions accelerate lymph drainage (LeDuc, 1990).

Most importantly, working out and feeling better helps to maintain inner strength and a positive attitude.

I recommend being evaluated by a therapist who specializes in breast cancer rehabilitation and he/she can initiate an exercise program for you.

Hope this helps and wishing you the best.

I can connect you with my vendor. Can you email me directly at .(JavaScript must be enabled to view this email address) for details?

There are many garments out there that you may find more comfortable. The Farrow wraps typically have velcro fasteners which can cause discomfort. Having no history on you, it is difficult to make a recommendation, however, I am going to provide some links for garments that are generally tolerated well. Also, you can learn self bandaging.

https://www.lohmann-rauscher.com/us-en/products/solaris-collection-by-lr/tributenight/

https://www.mylymph.com/2017/12/11/different-types-of-night-garments-for-lymphedema/

Hoping this helps.

Hi,

I’m not sure what advice to provide regarding your torso swelling, although if it is just fluid, manual therapy should help. Where are you located? Have you seen a lymphedema clinician for an evaluation?

Honestly, I wouldn’t wrap. Let the patient utilize TED stockings for edema control.

You should be able to wear your wrist band for tennis, just not too tight (must have circulation). You can also try KT tape, see attached image.

https://www.123rf.com/photo_85804988_hand-with-kinesiology-tape-and-stressball-physiotherapy-and-therapeutic-tape-for-wrist-pain-aches-an.html

This may help and is less elastic than the wrist band.

Hi,

Unfortunately, compression therapy is not always or even typically the best first line of care for lymphedema.

The best treatment, especially during the early stages of lymphedema is complete decongestive therapy (CDT). 
There are many components of (CDT):

Manual Lymphatic Drainage (MLD): A manual technique that stimulates the lymphatic system.
Compression: Layered bandaging assist in stimulating lymphatic flow
Exercises: With compression, exercise and muscle contraction will help move fluid out of congested area/limb.
Skin Care: Keeping skin clean, moisturized and injury free can assist in the prevention of infection.
Self-Care Management and Training: Learning how to manage your lymphedema at home.

If your sleeve is causing hand swelling, which is not an uncommon issue, please discontinue use and see a Certified Lymphedema Therapist (CLT) for therapy. Do you have someone to see?

If not, perhaps this link from the National Lymphedema Network can help. https://lymphnet.org/find-treatment

If I can be of any other assistance, please feel free to contact me at .(JavaScript must be enabled to view this email address)

Unfortunately, without meeting and evaluating you, I am unable to make a recommendation. Can you see a breast cancer rehabilitation therapist (OT or PT) to assist you with creating an appropriate strengthening regimen. Generally, when strengthening, you start with very low weight and gradually increase. In November 2008 University of Pennsylvania created a “Physical Activity and Lymphedema (PAL) Weight Training Program” with principle investigator Kathryn H. Schmitz PhD, MPH which gives an excellent full body strengthening program. I believe that you can contact UPenn for a copy.

The length of stockings does matter, but we do have to consider your daughters comfort and ability to comply with wearing recommendations. Without meeting her it is difficult to make any recommendation, however, I will say that care recommendations should be modified to meet her needs. Do you have a clinician to see and follow-up with?

Unfortunately, without knowing anything about your condition or reasons for MLD, who you are seeing, etc. this question is difficult to answer. This response is definitely uncommon.

Not typically. Have you spoken with the pump vendor and your therapist?

I can email you a pattern for facial drainage that I find quite useful. I cannot seem to attach a photo to this response. You can also try a swell spot.

Have you tried this?

https://www.lymphedemaproducts.com/products/jovipak-eye-pad.html

There are no contraindications that I know of.

There is no real reason that I know of dictating use of the FlexiTouch pump more than once daily. You may want to contact Tactile Medical for additional information, as well as the clinician who recommended the device for you.

https://tactilemedical.com

Best,
Cynthia

I am not very familiar with Lymphatic Enhancement. It is often used in conjunction with manual lymphatic drainage, not as a stand alone device. Lymphedema requires evaluation and analysis to be appropriately treated prior to knowing whether or not an individual will respond to various treatment modalities.

Hi. Unfortunately, it is often difficult to get the flexitouch covered by insurance. I have written letters stating medical necessity and have articles to provide. I am inserting some in this response.

See below:

Review Article
A Review of Pneumatic Compression
Therapy in the Treatment of
Lymphedema
Muluk SL1* and Taffe E2
1Harvard College, Cambridge, USA 2Allegheny General Hospital, USA

fulltext_smvm-v1-1003.pdf

https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=37&ved=2ahUKEwiEpbWHurfkAhUoq1kKHZhbBdo4FBAWMBB6BAgJEAI&url=https://smjournals.com/vascular-medicine/download.php?file=fulltext/smvm-v1-1003.pdf&usg=AOvVaw0Tgh16PxZjwcsMOxnBQXr3

Lymphedma and pneumatic pump use:

https://link.springer.com/article/10.1007/s12282-013-0481-3

Clinical Trial:
https://clinicaltrials.gov/ct2/show/NCT02650297

Best of luck and I hope that this helps.

Hi,

Unfortunately, quite often, the tissue requires manipulation by a lymphedema clinician. Do you have access to care? You need a clinician familiar with treating fibrotic tissue, scar tissue, neck range of motion and manual lymphatic drainage - an OT or PT typically. I can help you find someone if you do not have access to care at this time. My email is .(JavaScript must be enabled to view this email address) if you’d like to contact me directly.

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. We generally utilize the Bio-compression pump as a preparatory treatment for MLD. It helps soften the tissue and decrease girth overall. At discharge, we try to obtain a pump for our patients as part of their self management regimen.

Typically, we recommend that a patient wrap or use nighttime garment after to activate some lymphatic flow. Also, at times we find that the pump is more comfortable with stockinette on your leg or even a chip sleeve under the pump sleeve (farrow makes one we just order an xxl).

Here is an article recently published.

https://www.the-hospitalist.org/hospitalist/article/122046/lymphedema-patients-benefit-pneumatic-compression-devices

There is no way to know if it will cause pooling in the upper thigh, but with appropriate follow up (wrapping or nighttime garment), the pooling should be controlled.

Hoping this helps. If you need additional information, or even want to trial a device, you can always come to our office to give it a shot.

My email is .(JavaScript must be enabled to view this email address) should you want to contact me. Best,
Cynthia

We utilize the Bio-compression pump as a preparatory treatment for MLD. It helps soften the tissue and decrease girth overall. Typically, we recommend that a patient wrap or use nighttime garment after to activate some lymphatic flow. Also, at times we find that the pump is more comfortable with stockinette on your leg or even a chip sleeve under the pump sleeve (farrow makes one we just order an xxl).

Here is an article recently published. 

https://www.the-hospitalist.org/hospitalist/article/122046/lymphedema-patients-benefit-pneumatic-compression-devices

Hope this helps,
Cynthia

This is a tricky area. Personally, I do not recommend that my patients without a swelling condition utilize and arm sleeve, however, if you do, please be sure to utilize a glove as well.

There has not been a real study on the use of compression preventively for air travel, so my recommendation is based off of what I have seen and what makes sense to me. If a system is working, I do not see why we would instruct you to stop it from functioning for an entire flight. I have seen many patients who have worn their compression sleeve without a glove develop swelling in the hand due to the nature of circulation and gravity. Below are our tips for air travel if you have lymphedema. If you do not, you will still benefit from the exercise recommendations below. I hope this helps and have a wonderful trip.

If you are traveling by airplane and you have lymphedema:

1. Wear compression
• Compression includes compression sleeve with gauntlet/glove, compression stockings, and/or compression bandages
• Wearing compression during air travel ensures you will not swell during the flight
• Leave the compression garment on for two hours AFTER you land to allow your body adequate time to adjust from all the climate and pressure changes.

2. Exercise
• Take a lap around the plane
• Ask for an aisle seat when purchasing your ticket so you can easily get up and walk around the plane without disturbing your neighbors
• On particularly long flights, keep your limbs moving to promote circulation and blood flow.
• Drink plenty of water to keep hydrated.

4. Invest in a rolling suitcase to pull rather than carrying a bag on your shoulder to reduce shoulder pain and overuse.

If you are driving for more than two hours
1. Wear compression (see above)
2. Drive with a friend so you can take a break from driving

If you are taking a bus/train
1. Keep your limbs moving to promote circulation and blood flow
2. Get a seat on the aisle to allow room to stretch those limbs and easy access to the restrooms.

General precautions

• Bring an emergency first aid kit containing Band-Aids, Neosporin, Bacitracin or any other anti-bacterial ointment in case of any cuts, scrapes, or open wounds.
• Know the signs of cellulitis: redness, pain, and increased swelling. If you experience these symptoms, please contact your Doctor or go the nearest emergency room.

All UNTREATED metastatic disease is contra-indicated for lymphedema therapy.

If your patient is receiving care by and oncologist/radiation oncologist/chemo, she is cleared for therapy. I would be sure to obtain a prescription for therapy from the doctor, but treatment is not contraindicated. Stage IV patients need care as well.

Thanks for the question.

I believe you are asking about post elective liposuction surgery, correct? There are many aspects of care complications that are covered, however, in the US health system it can be very difficult to get garments covered. Therapy is covered for post surgical swelling and scar/tissue mobilization much of the time. I don’t know about hospitalization, however, compression garments may be covered depending on your insurance policy and your Durable Medical Equipment coverage (DME). Contact your insurance provider for details as every single plan is different.

It is difficult for me to answer this question without having met you, but generally, time in water provides a working pressure to assist in the reduction of swelling in the extremities, so it is not usually necessary to wear compression.

A splash pad does not provide the same water emersion, so all that I can do is recommend trial and error. Try the capri, if your swelling increases, try without. You should be able to go periods without compression, especially if swelling is mild.

Good luck and enjoy the summer.

A lymph massage differs from manual lymphatic drainage by a lymphedema specialist. You need to look for someone who is a certified lymphedema therapist. Lymphatic massage is generally used to stimulate a healthy lymphatic system, you need a clinician who specializes in lymphedema therapy - typically with the initials CLT after their name.

It would be difficult for me to tell you what’s happening without evaluating you since this is unusual. I would see a breast cancer rehabilitation/lymphedema rehabilitation therapist to start. Where do you live? Have you asked LE&RN; to assist you in connecting with a local therapist?

I do have some follow-up questions:
1. Do you have full range of motion?
2. Was the lump benign? If not, are you sure they didn’t perform a sentinal node biopsy?
3. Did you require any additional treatment (like radiation therapy)?
4) Do you have full range of motion in the upper extremity?

Hi. Surgery on the affected side can be frightening, however, the surgeon will typically prescribe antibiotics to prevent another cellulitis infection. If you have any other questions, please feel free to contact me directly at 212-421-1969 to discuss.

Unfortunately, not very much. You can gently massage the tissue affected by the radiation to try to soften it, and perform ankle pumps and ankle circles throughout the day to increase muscle pump and fluid flow.

Are you sure that there are no therapists available until the end of May? Perhaps contact another office if available.

There are individuals who utilize bandaging for lower extremity swelling with end stage liver failure, but I caution that with open wounds and weeping skin, it could have an alternate effect, increasing skin breakdown due to bandage saturation from fluid seeping through. I would go back and speak to your wound care specialists and your doctor to discuss options. Sorry I cannot be of more assistance. Best of luck, and if you have any further questions, I’m always here.

Generally, MLD is useful for any stage lymphedema. Without having met the patient I cannot make any further recommendations, however, I would contact the school where you were trained with this question.

I could recommend vendors offline in the NYC area if that would be of assistance. I am not sure where you live, but if this would be helpful, please email me at .(JavaScript must be enabled to view this email address)

Cupping is pretty aggressive for lymphedema. I utilize cellulite cups in practice for fibrotic areas and it works well. Please note, I am not a cupping specialist and have never been trained in the use of cupping.

Hi. Sorry for the delayed response, technical glitch.

Most therapists trained in manual lymphatic drainage are also trained in the bandaging technique.  I recommend private pay sessions with a therapist who can do both or MLD alone. Traditional precautions are also recommended.

If you need anything, please message again.

Hi. So sorry for the delayed response, technical glitch.

Have you ever had therapy for your lymphedema? Here is a link to the National Lymphedema Network’s website with a directory of websites based on zip code.

https://lymphnet.org/find-treatment/

Hope that helps. It sounds like you need a good clinician to help you get back on your feet.

Sorry for the delayed reply, there was a technical glitch.

It sounds like you may not be using distal (hand) compression. There is also a technique to wrap your hand which it sounds like you need. I recommend returning to your therapist or a different clinic to learn how to self bandage the hand. They also make compression gloves to be used with the compression sleeve. The sleeve should not be used without the glove, but you can use the glove without the sleeve.

Hope this helps.

Hi,

So sorry for the delayed answer, computer glitch. Anyway, primary lower extremity lymphedema can be quite difficult to control. Typically, you would see a therapist for MLD, but also, compression bandaging, kinesiotaping, and/or nighttime garment fit and use. It is very difficult to control lymphedema with just MLD and elastic compression stockings. I truly believe that part of the treatment should in fact involve use of a vasopneumatic pump.

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.

When looking for the right device, 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. Pressure at the feet is greater than the thigh.

There are many types of compression pumps, however, I utilize the device to stimulate venous involvement in the management of swelling and to assist in softening often hard/fibrotic tissue. There is nothing wrong with using compression stockings after the pump, but I personally find a better result with a garment that provides a working pressure.

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

Thank you for your message. Unfortunately, there is really no way to know which compression garment brand will work best for you. The only thing that I can suggest is that if you have a problem with irritation behind your knee crease, that you discuss it with your fitter to find a garment that will work for you. Do you have a good garment fitter?

I am attaching an online article that discussed some differences in garments that may be of assistance to you.

https://themighty.com/2018/01/compression-wear-brands-pain-swelling-circulation/

If I can be of any further assistance, please let me know.

Hi,

So the rules are gray as always. What they mean in the certification courses is that you cannot perform manual lymphatic drainage on a cancer patient NOT under the care of a physician to treat the disease. Meaning that, the patient must be receiving some sort of chemotherapy. I am curious regarding the blood cancer, and you may want to follow up with the patients oncologist prior to treating.

Hope that helps. If you have any further questions, feel free to contact me.

I would recommend seeing your lymphedema therapist to get the swelling controlled. Do you have one? If not, LE&RN; has a directory of clinicians as does the National Lymphedema Network. Unfortunately, sprains can cause terrible swelling and it’s better to get it controlled early.

Hi,

Unfortunately, having never met you or evaluated your swelling it would be very difficult for me to say whether or not your plan of care is “correct”. There are many components of lymphedema treatment that may be of assistance, for example, you could add self bandaging, use of a vasopneumatic pump, etc.

Is there another clinician near you who you can see for an evaluation? If you are not satisfied with the reduction of swelling obtained, then I would certainly see someone else and hear what they can offer.

If you read through some of the other questions and answers on this site I have answered many questions regrading treatment, my beliefs and theory, and treatment tips. Please read through and see if any of the other answers can help.

Reduction-wise, I believe that most patients with very mild swelling should be able to have their arm girth within .5 cm of the other side.

Hope this helps, but if you want to speak further, please feel free to contact me directly. I’m here to help. http://www.shechtercare.com

There is, it is called the Bellisse. I recommend trying it on as many individuals find it uncomfortable.

Otherwise, I typically recommend a high cut (armpit) sports bra or compression tank top. I have attached the website for both a compression tank (as a sample - I do not know any particular brand, as well as a link to the belisse website.

Additionally, the vaso-pneumatic pump should have an option for an arm sleeve with vest which might help as well.

https://www.amazon.com/Womens-Compression-Layer-Black-White/dp/B074FVBXD4/ref=sr_1_10?ie=UTF8&qid=1525711586&sr=8-10&keywords=compression+tank+tops+women

http://www.jobst-usa.com/product/bellisse-bra

Hello Felicity,

Unfortunately, if your swelling has been present for 2 years, the likelihood is that it is not reversible. Have you gone for therapy yet? This can help to reduce swelling, and, if treated properly, though you will always have a propensity to swell, the swelling can be reduced to an unnoticeable state.

Hope this helps,
Cynthia
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Hi. Sorry for the delayed response.

After total knee replacement, you will likely be given an ice machine that will provide circumferential cool therapy to control post-op edema. This machine requires a ton of ice so have a loved one get bags of ice and keep some as a backup in a cooler. Once you feel like you can be out of the house, I would recommend getting to your lymphedema therapist for manual lymphatic drainage and modified bandaging (based on comfort). Utilization of a vaso-pneumatic pump could be of assistance as well, but you probably will not be able to tolerate the pressure until at least 6 weeks post-op. Do you have anyone who can wrap you at home? Compression bandaging will definitely assist.

If you have any further questions or even need to follow-up post-operatively, feel free to contact me directly at .(JavaScript must be enabled to view this email address)
http://www.shechtercare.com

Hi,

Bandaging should not hurt. There are many ways to modify the way in which we wrap for the comfort of the patient.  I never pull the bandage. Once it is rolled firmly, I simple unroll the bandage along the extremity trying to keep contact with the skin at all times.This helps make the bandage more comfortable. If you require additional info, please feel free to contact me at 212-421-1969 or via direct email, .(JavaScript must be enabled to view this email address)

Bandaging should not hurt. Can you call me to discuss? This is a very personal and specific issue and I want to be able to answer all of your questions. I am happy to discuss a plan with your therapist to see if we can get things under control. Again, bandaging should not hurt and there are many ways to modify the way in which we wrap for the comfort of the patient. I never pull the bandage. Once it is rolled firmly, I simple unroll the bandage along your arm trying to keep contact with the arm at all times.

I follow my mentor Linda Miller, so these are her directions, slightly modified. Also, I would like to share the self wrapping instructions.

Self-Bandaging Instructions
1. If necessary, wrap the white underwrap (cotton-like material) beginning at the wrist and taking it up to just below the armpit. Overlap about 1 /2 way for each turn (or just use to protect the elbow crease.
2. If the fingers are to be wrapped, anchor the white finger-wrap (gauze-like) at the wrist.
3. Continue with the stretch wrap: Begin the 6-cm (smallest in width) at the hand.
4. Go around the palm and the back of the hand to anchor the end of the bandage.
5. On the next turn, go around the palm and back of the hand below the thumb (i.e., closer to the wrist).
6. Repeat steps 3 and 4, alternating around the palm through the webspace, making figure-eights. You should have at least 3-7 layers of bandage on the hand.
7. Continue up the arm, ending just below the elbow. You should not cross the elbow with the 6-cm wrap. If you have some excess wrap, go back down towards the wrist, but do not pull wrap
tightly as you go back. Use tape or elastic catch to secure end of bandage in place.
8. If you are to continue with another wrap, begin with the next size (usually the 8 cm) wrap at the wrist.
- Continue up the arm, overlapping each turn by approximately half the width of the turn before it
- As you approach the elbow, secure a piece of underwrap (puff-piece) at the crook of the elbow.
- When you wrap over the elbow, make sure that you overlap enough so that your elbow does not pop out between the bandage layers in the back. )quite often I make an “x” so that the wrap doesn’t rub the elbow crease
9. If you are to continue with another wrap, begin with the next size (usually the 1O cm) at the wrist.
- Continue up the arm again, overlapping each turn by approximately half the width of the turn before it.
- End the bandage just below the armpit, securing it with tape.
- If there is any excess bandage, go back down towards the elbow, but do not pull the wrap tighUy as you go back down.

- The wrap should be tightest at the hand and become slightly looser as you go up your arm towards your armpit
- When completed, the wrap should feel “firm” but not too tight.

Your compression comes from layering, not from pulling the wrap tightly!

- Make sure to perform your exercise program with the bandages on to get maximal results. Performing exercises in the wrap improve your muscles’ ability to pump lymphatic fluid and wil;l optimize your reduction.

My contact is 212-421-1969, .(JavaScript must be enabled to view this email address)

Hi. The simple answer is no, most clinicians no longer believed that you cannot lift more than 5 pounds. If you were a mountain climber in the past, you should still be a mountain climber! It’s not really about the amount of weight/added resistance you use, it is about making sure that your body is ready for the increase.

It is important and beneficial to exercise after breast cancer surgery in a safe and controlled setting once you are medically cleared. Although we like to restore range of motion prior to strengthening muscles, there is no reason that you cannot lift weights. You do, however, have to start very light and slowly and gradually increase the weight. Most of my patients use a weight for at least two weeks prior to increasing.

There is no real difference between exercises as long as your form is correct. Without knowing about your surgical history, I cannot recommend exercises, however, I will say listen to your body, and your arm. Pay attention to how your arm responds to the workout. If you have increased swelling, then something isn’t working.

Studies have shown that exercise after breast cancer surgery and axillary node dissection can help to prevent and reduce lymphedema occurrence (Lacomba, 2010). Additionally, repeated muscle contractions (with the limb bandaged) accelerate lymph drainage (LeDuc, 1990).

Most importantly, working out and feeling better helps to maintain inner strength and a positive attitude.

Hope this helps, and wishing you the best.

Regards,
Cynthia Shechter
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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.

Hi,

Generally, you do not want to sleep in your elastic sleeve and glove. These items are typically used during the day to prevent increased fluid from moving down the extremity, however, do not reduce the swelling. Have you been treated by a lymphedema therapist? Have you been taught self bandaging or been provided a nighttime garment to provide a working pressure?

Sorry to answer your question with questions. Please feel free to email me directly at .(JavaScript must be enabled to view this email address).

Thanks,
Cynthia

Hi,

Without knowing your husband, it is difficult to make a recommendation that will work, but here goes. Your PT may want to try using Rosidal soft 12 cm rolled foam for the thighs and abdomen and it will help to prevent the bandages from slipping.

Otherwise, I often recommend a compression short, even a “spanx-type” garment to help control the abdominal and thigh swelling as well. This can be used under the compression wrapping if comfortable.

I hope this helps,

Cynthia
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Hi.

I’m sorry that you have been struggling. Although with traditional lymphedema treatment therapists work to reduce the swelling and fit with a garment, however, this does no work for all.

The problem is that not all patients react the same way to treatment. What kind of pump do you have? If it is the flexitouch, use it as directed, however if you have a more traditional device, you do not need to pump more than 30-45 minutes a day.

Have you been taught self bandaging? Do you have a nighttime garment? Does your therapist do manual lymphatic drainage with you? Do you have an individual exercise program to assist in lymphatic flow?

I’m sorry that I have so many questions, but lymphedema can be treated differently and I think we need to fill the gaps in care.

Thanks so much,
Cynthia

Feel free to contact me directly: .(JavaScript must be enabled to view this email address)

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.

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.

never received

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.

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

Your therapist should be teaching you a self bandaging technique. Here is a video of me wrapping my own arm to get you started.

http://dev4.b2fnyc.com/video/ue_wrapping_instruction-final2.wmv

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.

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.

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

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

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

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?

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!

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.

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

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

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

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

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

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.

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.

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.

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/

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.

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?