• LecturehallEdema Management Best Practice
  • Lecture Transcript
  • [00:00:00:00]
    FEMALE SPEAKER: Now, Heather is going to talk to us about best management for these conditions. Okay, great.

    HEATHER: Okay, there we go. All right, oops, I bumped it again. Okay, so a couple of things, I didn’t … I kind of removed a lot of the things about CDT, but I want to talk a moment about complete decongestive therapy because that is the standard of care to manage patients with lymphedema, but we’re finding it to be incredibly effective for really all forms of edema, and even a post-op, after total knee replacements, those types of things.

    So basically, what complete decongestive therapy is, it’s done in two phases. There’s an intensive phase, which is clinician-driven, and then there’s a maintenance phase, which is patient-driven. And the maintenance phase is for life. And that’s one of the things we have to educate our patients on day one about is that this is a condition without a cure, at least right now, but it is something we can manage.

    And so complete decongestive therapy involves very vigilant and diligent skin care, which is inclusive of nail care, taking care of the skin, if there’s any wounds, managing the lesions, and what I always like to reiterate to patients, too, the importance of … with skin care, is that your hair and your nails are extensions of your skin. It’s really just a different form of keratin, but they are also reflective of the overall health of the body. And you see this a lot of times in those nail changes, whether it’s dystrophic nails that usually due the perfusion problems, or the onychomycosis which is due to the fungal problems, and things along that line. But it’s really, really important that we take care of that skin.

    And somebody had asked me earlier what products I like, and this is me, this is anecdotal because I tend to, like, only put things on skin that I can pronounce, and because of the way that the skin picks up the things and takes to your lymphatic system. So what I find that is really, really beneficial for skin, and even hair, is extra virgin coconut oil. [00:02:06]

    Coconut oil is phenomenal. So is olive oil. And it’s cheap, it’s inexpensive, it’s readily available. You can pretty much find it anywhere. And again, I don’t have the evidence to back it up, to tell you this is what you should use, but I’ve done it on a lot of people. And it’s not necessarily off label, it’s just very effective. And you’ll find a lot of these products now at Target. You can find these products at Whole Foods, you can find these products at Trader Joe’s, at Amazon, they’re out there. So coconut oil-based products, and olive oil-based products are very, very nice.

    I do not like to use anything that has petrolatum in it, because petrolatum are mineral oils, shut off the skin’s respiration system and close it. So, olive oils, coconut oils, those types of things don’t shut off the skins respiration system and the skin responds beautifully to it.

    FEMALE SPEAKER 2: Just as a side, coconut oil, we’ll get fractionated coconut oil, anything inorganic. Fractionated coconut oil stay liquid, it never solidifies, and you will not have oily residue on your skin because your skin completely absorbs the coconut oil.

    HEATHER: So did you hear that? Fractionated coconut oils stays in a liquid form versus, like, the crystal form. And so it’s more readily absorbed by the skin, but all of them work. And it’s a really … there are really, really good products out there, so just that aside.

    So skincare is critically important. Nail care is critically important. And with patients with lymphedema, it’s really important when the limb that’s involved, or the limbs that are involved, that when you do nail care, we’re trying not to cut the cuticles, or you just go to a healthcare provider who knows how to do it properly. Because even a minor trauma, like, cutting the cuticle or venipuncture, blood pressure on that affected limb can actually exacerbate the lymphedema. So we try to make sure that they’re really cautious about any trauma. Bite marks, cat scratch marks, gardening, you know, bee stings, all of those things we really … they need to really be mindful of.

    So a lot of this is patient education, too, and teaching them a little bit about the lymphatic system, teaching about what the condition is, so they appreciate it. [00:04:02] Sometimes they are so just – there are so grateful to know what they’re experiencing actually has a name, that they are the most compliant patients, really, that you’ll have, because for years they’ve dealt with this, and nobody’s able to help them.

    So skincare, wound care, then what we’re going to do is we do manual lymph drainage. A manual lymph drainage is basically a manual technique, it’s not massage. So when you see people talk about lymphatic massage, that’s different. There are massage therapists who do lymphatic massage, and it does mobilize fluid, but manual lymph drainage is just a very specific technique that is individualized to the patient, where you can customize and reroute the lymphedema around the congested area.

    And so an analogy I like to use with lymphedema is, because we can all relate to this, is a traffic accident on the freeway, right? You’re driving on the freeway, everything is great, boom, there’s an accident, there’s all those red lights. So what happens with lymphedema, wherever there is that mechanical dysfunction, whether it’s congenital or a primary form of lymphedema or a secondary form of lymphedema, there’s a problem somewhere that’s causing congestion, so everything behind that problem backs up much like a traffic accident.

    And so what happens, what manual lymph therapists do is we come in and we act like the police officers. So we respond to the traffic accident and we reroute that traffic jam. We’re going to take it on the side streets, we’re going to take it on the shoulder, we’re going to take it wherever we can find it to go, right? To going north, or to the direction that … wherever the people initially wanted to go. We want to – our goal is to basically take it up towards the direction of the heart, because we ultimately want everything to go back to that venous angle. And in doing that, it’s going to reroute itself and take itself to the regional nodes in that area as well.

    So we come in, and we reroute that fluid. And what’s amazing about the lymphatic system is that, just like cars, you know, if you start redirecting those first few cars, everybody else just blindly follows, right? So same thing with the lymphatic system, as soon as you show that system where to go, it’s going to take that path of least resistance and it’s going to go. And in time, it will develop collaterals, and it will just naturally take that new route. So we just redirect it to pathways that are still intact.

    And we … there’s a lot of different ways to do it. There are some patients that have maybe bilateral or extremity lymphedema, and we know these angular nodes are not functional, we’ll take it to the axillary nodes. [00:06:08] We might take it up the back, we might take it up the side of anterior, but we have all these different pathways that we can reroute. So that’s why it’s a lot analogous to driving as you have options, usually, of where you can go, the freeway, the city streets, the side streets, those types of things.

    So we do manual lymph drainage, and then what we’re going to do after that is apply our compression, and there’s different types of compression which we’ll talk about. And then once they’re in compression, then they’re going to do these basic exercises. And these really are basic. And you just have to, you know, have them do, throughout the day, small, little periods of time, some of the things that are really effective.

    Yoga is extremely effective for patients with lymphedema. They’re finding Tai chi is very effective. Water therapy, so hydrotherapy, getting in the pool, obviously not in compression, because they’re going to be getting the hydrostatic benefits in that if they have an open wound, unless it’s in their own pool that’s chemically treated. But you do want to make sure that the exercise is something that they’ll want to do.

    And another good thing, too, particularly for patients with lower extremity lymphedema, is rebounding, which is just getting a little … one of those little circular trampolines. Thank you, that’s the word. And just having them kind of bounce back and forth. The vibration effect in the bouncing is very stimulating to the lymphatic system, and they’re finding some good benefits from that, too. It doesn’t have to be complex. You know, if they’re watching TV, they can be doing the exercises Pamela was discussing earlier. It’s just small little bits throughout the day, combined with the diaphragmatic breathing.

    So that’s really it. And then, we do this intensive phase, this first phase, until they get down to a reduction where they plateau. And what you’ll find is most patients, once you start complete decongestive therapy, you get the maximal gains within the first two weeks of therapy. They reduce really quickly, and it’s really exciting for these patients because finally something is working. And you can get them down to a fairly normal … near normal size lymph. It will never be perfect or back to like it was before, unless it was in early stage. [00:08:00] But with the severe cases, the stage three’s, the elephantiasis, you can get them down to a pretty manageable phase.

    And then once it’s reduced, and you know it’s reduced and plateaued because you’re taking growth measurements every week, once it’s stabilized, you transition them into the maintenance phase. And during the whole intensive phase, you’ve been teaching them how to do all these things on their own. And so by that time, they’ll be able to manage on their own, and they’ll know quickly that if they don’t continue these therapies, then exacerbations can happen. And usually, these patients are quite adherent to the treatment plans because they see the benefits of it.

    And so that’s just the basics of complete decongestive therapy. And a little bit … well, I’ll show you at lab. I’m going to give you some techniques you can use on your patients to at least get them started. And then there’s some resources, too, where you can put in … in two different websites, if you’re trying to find therapists in the area, the Lymphedema Association of North America and the lymphanet.org are two organizations where you can do a find-a-therapist. Put in the zip code, and it will give you a listing of therapists in the area.

    But there’s definitely a need for more people to get certified, and it’s one of those things that if you build it, they will come, because there are wait list for months for a lot of lymphedema therapists. So it just shows you the gravity of the situation. And lymphedema is severely under reported. They say about 1% of the population has lymphedema. There’s unpublished reports that say 11% of the population have lymphedema in the female population. That’s a very large number.

    So lots we can do. Compression is the corner stone, we know for all forms of edema. And we have to get away from saying, “Well, if they have this, we can’t compress them.” We can as long as we know what we’re doing, using the right products, and we do it safely. So the proper use and support – supports the hemodynamics, again, of the AVL systems. So it’s the arterial system we have to be a little more cautious about, but there’s good evidence stating that we can even support that system when we do compression properly. So it’s going to help reduce venous volume, reduce reflux, decrease that ambulatory venous hypertension, and support the venous system, support the lymphatic’s pump function. Thereby, reducing edema and supporting the arterial system. [00:10:02]

    And what this does … so manual lymph drainage is just going to reroute the fluid and help with decongestion to get that edema reduced. Compression maintains that reduction. And this is why it’s so important that they use it because they could just exacerbate or rebound exceedingly if they don’t put their compression on and use it for life, basically.

    So our goal is really to promote venous and lymphatic function without compromising arterial function. And what’s important to remember is that interface pressure peaks on the lower leg during walking, and it usually exceeds a 50 – exceeding 50 to 60 millimeters in mercury, which reduces venous reflux and increases the venous pumping function. And what we do, and how we do this is by using stiff compression textiles. And so the textiles are just the different products that we can use, and different products we can use in combination. So we’re really looking for a stiffness index, not so much pressure or tightness. Those are not the things we’re looking for, we’re looking for stiffness of the compression that we’re applying.

    So by definition, compression is just an external force that we can apply to a body part, essentially, and pressure is just a continuous physical force exerted on or against an object by something in contact with it. And we have to remember, too, compression’s not just a number. We kind of get hooked on 30 millimeters, 40 millimeters, 50 millimeters, and that’s important because those are guidelines. But what’s more important is it’s the pressure that you create by the materials, with the textiles you’re using or the products you’re using to compress the tissue. That’s where the magic happens. So it’s not necessarily that number and it … the numbers, I’m not saying they’re not important, but we can’t get “So we have to put this number on this patient.” No. It’s more how you’re combining the products to achieve adequate compression for their systems, especially if they have a compromised arterial system.

    And so, the literature is interesting. So we know compression is the standard of care from the management of edema, CVI, venous leg ulcers. [00:12:00] And what we found with some concurrent reviews is that we know it improves healing rates with those … with the existing ulceration, reduces the likelihood of occurrence, improves the symptoms, and helps reduce the swelling. And what we’re finding, too, is that multilayer compression, whether it’s a two-layer, three-layer, four-layer, but now more of the two- or the three-layers, are much more effective than a low compression or a single layer compression/ Okay.

    And then, as we’ve all said today, too, some compression is better than no compression, except Ted Hose, right. Ted or Dead. That’s right. So … well, because they’re just not at a therapeutic level for really anything at all. And how many times have you seen Ted Hose on people that roll down and now they’re pretty crushing the crow Cs or they’re crushing their toes and … they’re just not that, or they fall down by the ankle. But again, some compression is better than no compression for a lot of these patients. And you can always start very cautiously and very light, and see how they tolerate it, and then add more as you need to.

    So we also find that there’s significantly more improved healing rates when using compression and compared to no compression, and you see this clinically. How many times have you had patients come in that say, “I’ve had this ulcer for years” or “I’ve had this ulcer for months”? “Did anybody put compression on you?” “No.” “Well, okay, this is why it’s not healing.”

    And we also find that it helps with the symptoms, reducing itching, reducing the stasis. And compression, too, especially combined with some of the different foam products that are out there, particularly that we use for lymphedema, actually provide like a micro massage component and an exclusivity that actually helps to break down the fibrotic skin. So over time, you can even soften some of that fibrotic tissue with compression.

    So looking a little bit deeper in the cocrin, there were only 48 randomized control trials. Most of these trials were small, and you really have to pick these trials apart because they’re not always comparing apples to apples. But they even said some compression is better than no compression.

    They did state that single compression bandage systems are less effective than multi-component. And the reason being is the multi0component kind of combined the characteristics of the different products or textiles being used to give you a better stiffness index, a better compression profile for supporting the hemodynamics. [00:14:08]

    So two component system containing an elastic bandage healed more ulcers at one year than without an elastic component. Three component systems containing elastic component healed more ulcers than those without. And five studies suggest clinically significant faster healing with four-layer than short-stretch … than the short-stretch bandage alone.

    But again, you have to kind of really find out what they were comparing because they weren’t comparing similar products. And some of these were actually long-stretch versus short-stretch. And I’ll talk about that difference.

    So interface pressure is a really important term. It’s the pressure exerted on the limb by the compression materials, and it’s measured as sub-bandaged pressure. And that’s usually that number we’re used to hearing about. But these two terms are critically, critically important, resting pressure and working pressure.

    So resting pressure is the inward-first exerted by the bandage that’s put on the limb. And typically, these wraps or long-stretch bandages have a very high resting pressure because they have a very high recoil. And this is why these are not safe to use on patients with arterial disease because they compress significantly, especially at rest when there’s not an active muscle pump. So if you have a patient, maybe they are okay during the day because they’re up and active, but if you have a patient with arterial compromise in long-stretch at night time … remember, at night time, our heart rate slows, our respiration slow a little bit, our blood pressure is lower. So we have less reserves from an arterial standpoint. And if you’re putting them in a support device or a compression device that has a lot of recoil and is very tight at rest, you’re going to really cause some problems with them. So we do not recommend long-stretch bandages for patients with any form of arterial disease.

    Now, what you can use, though, are short-stretch compression or inelastic compression, or Unna boots, those types of things. [00:16:01] Now, Unna boot, I will say, is very effective. It’s very cheap, it’s readily accessible, but it needs to be used in patients that are ambulatory, because they’re too tight if they’re put on and somebody is not ambulatory, because they work to support the muscle pump. That’s how they work. So it’s really important that if you’re using an Unna boot, it’s on an ambulatory patient.

    Again, working pressure, this is the pressure from the inside when the muscles are active. So when you get that muscle contraction, it’s going to have … the compression should be giving it resistance. And that’s the working pressure. And what happens is long-stretch bandages or ACE wraps, which stands for all cut and elastic, if anybody ever wanted a good Jeopardy question, is … it’s a low working pressure. Okay.

    Now, short-stretch compression, which we use and which you’ll see later in the lab, and what is the standard of care for patients with lymphedema, has a high working pressure and a low resting pressure. So it doesn’t have as much recoil but it really supports the hemodynamics when the patients are functional but also when they’re at rest. It’s not going to provide a tourniquet effect. And in doing so, it also doesn’t occlude or harm the arterial system.

    And there’s been some studies that … I have to look at the numbers really quick because I can’t remember off the top of my head. But there has been a couple of studies that have said that short-stretch compression increased arterial blood flow to the limb and periwound skin by 28% when 30 to 40 millimeters of compression was applied using short-stretch, and it increased the venous ejection fraction by 105%. So short-stretch is really, again, the standard of care that supports the venous and the lymphatic, but also the arterial hemodynamics.

    Personally, I would love to see short-stretch just replace everything that’s out there. Anecdotally, we’ve had really good outcomes doing modified complete decongestive therapy on patients that had total knee replacements. We’ll actually have them come in, we’ll do a complete decongestive therapy for a few sessions before their surgery, then we’ll implement it right after their surgery. [00:18:06] And we’re finding less bruising, less swelling, better range of motion, less hospitalization stay, and better outcomes, less pain. It’s amazing and it’s just … it’s all manual techniques, which is pretty remarkable. That’s anecdotal. We need to do more research to publish that.

    But again, these are … these next two slides just kind of break down what non-stretch is versus short-stretch versus long-stretch. And short-stretch, by definition, just means it doesn’t stretch as much. If you pull on it, it’s 30% to 60% of its original length, where long-stretch can stretch almost 300% of its normal … of its original size. And so the key here, then again, is the high working, low resting pressure. This is what we’re working for … what we’re striving for. We want high working pressure, we want them to really be working when that person is up and moving, but we want it to support and not constrict when they’re at rest.

    And so we can also … what I want to show you here is kind of a progression. So a lot of times, patients that have open wounds might be using a non-stretch such as the Unna boots, or they might be doing some of the short-stretch two-layer systems or things like that that are fairly disposable, when they have an active wound. But once the wound resolves or closes, and I don’t like to say heals because heals takes up to two years for that scar to mature, but once it’s resolved, we can move them into compression stockings or garments. And these can either be over the counter or custom made.

    And for a lot of patients, to the knee is appropriate. But if you have any type of swelling that goes up into the high area, you need to bring that compression all the way up to the groin.

    And this is a good time when you can employ things like Spanx or spandex or bike shorts, because it’s really hard to keep that compression up. It tends to roll down. And a lot of people don’t like to wear a hose that go all the way up to their leg or trying to tell a gentleman he needs to wear a pantyhose are like, “That’s not going to happen.” So what you need to do is just really provide good education and let them know why you’re asking them to do this. And a lot of companies are coming out with much better products now that are easier to don and doff but also more patient-friendly. [00:20:03]

    And then we have alternatives. I’m very personal to a lot of these alternative wraps. These have Velcro closure systems. We use these a ton down in Haiti, because we do very intensive complete decongestive there. We’ll go down there and we’ll treat patients for several … you know, intensively for an hour or two a day, for about a week, reduce them down significantly. We’re getting about 20 or 30 centimeters of reduction per day with these patients and then quickly get them into a compression device. And they’ve never used compression in third-world countries because they say it doesn’t work and it’s too hot and it’s not safe. And we’re proving that, “No, you can. You actually can use these.”

    And what’s nice is these are adjustable. So patients, as they start to reduce in volume, they can adjust them to make them fit better. And they’re safe to use during the day or at night. So these are a nice alternative for people that can’t don and doff regular compression.

    And then with intermittent compression pumps, there’s still some controversy out there with them. You know, it is indicated with pure CVI and it can be very effective, but once you have a lymphatic component, we have to be careful using pumps because much like diuretics, they’ll mobilize the fluid but they’re not going to do anything with the protein. And so we’ve got to be able to get that protein mobilized as well.

    So there’s newer pumps out on the market now that are geared more for … that are geared more with … and the design … sorry, more with the lymphatic system in mind. So there is much more chambers, and the compression actually mimics that of manual lymph drainage. So there’s newer products out there now. So if you’re using it for patients with lymphedema, please look to see or talk to me later. I can give you the name of the company in particular that uses that specifically designed for patients with lymphedema.

    But diuretics or pumps should not be your first go-to if you have somebody with lymphedema because it just … it can actually make the condition worse. Yes, it mobilizes the fluid but it doesn’t address the protein, and that’s the underlying problem with lymphedema.

    So again, it’s not just compression. [00:22:00] What’s important is this concept of static stiffness index. And I’m using some slides from my colleague, Susie Imam. And what this is is the measure of fabric flexibility and it’s ability to contain the fluid and contain that limb.

    And I have a funny story with containment. So I have twins and they’re12 now. But when they were little, I had to contain them because sometimes it was just me at home and I’m like, okay, what am I going to do? So I had this little… it sounds terrible but it’s like a gate in the playroom, right. And so one day I’m watching them and they’re maybe 11 months old or whatever, and I see a toy go flying over the gate. I’m like, huh, this will be interesting. So Mason walks over and lifts the gate up, Ethan crawls under, grabs the toy, comes back. I’m like, all right, well, there we go, that’s not effective anymore.

    So when I talk about containment, I always kind of have this smile. But containment here really means that it’s containing exactly what you wanted to hold in. So these gates don’t work, but these things do. In no ways they’re in trouble, they’re very bright kids.

    But anyway, and also this static stiffness is defined as the difference in pressure between standing and lying positions because it’s going to change. As soon as we engage that muscle pump, we’re going to get different dynamics going on. So stiffness of the final banded system determines the performance rather than the individual components. And this is why sometimes when we combine products, we’re actually getting a better quality compression when we think about the textiles we’re using.

    So the types of materials utilized really matter. So we get high amplitude with inelastic bandages, have a massaging effect and increase dejection, fraction and volume more than elastic bandages and they were tolerated better. So these inelastic bandages, again, because they provide very good containment and resistance or something for those muscles to work against that high working pressure.

    So bandage systems that deliver high working pressures and lower resting pressures have a much better therapeutic effect even in mixed venous and arterial disease. And this is important. This is where… because a lot of our patients are mixed, right? [00:24:02] They don’t just come in with CVI or phlebolymphedema. They have arterial disease in the presence of venous insufficiency and now lymphatic components. So these short-stretch bandages are very safe to use. And we can use them with ABIs of 0.5 and higher.

    And there are some evidence, some places are using them even with an ABI a little bit lower, but that’s under very close medical management. So what we find when we have CVI, we have reduced volumes and ejection fractions. And what we’re finding is that inelastic compression, short-stretch compression is more effective than those long-stretch or elastic bandages that stretch too much because they have just… they don’t contain it well.

    And inelastic compression is able to normalize that venous pumping function. This is why we want to get them on a good walking program. Patients with arterial disease benefit from a really good walking program as well. And these elastic bandages help with the ejection fraction and the ejection volume even when… I just confused myself what I’m saying here. Elastic bandages. So with the ejection volume and the ejection fraction, they remain below normal even when applied at a resting pressure, that’s very tolerable.

    So we have to be careful because these elastic bandages can hurt patients particularly when they have arterial insufficiency. Remember, they’re already compromised from a perfusion standpoint. And if you’re adding elastic bandages which provide a lot of recoil and a lot of compression, you’re going to shut off potentially whatever remaining arterial supply they have. So that’s why a lot of times patients just are not comfortable in traditional compression.

    So size does matter. And if you remember your physics going back to LaPlace’s Law, it’s just pressure equals the tension over the radius. And so this is what we’re always thinking about when we’re looking at some of these abnormally shaped limbs. It’s like how am I going to compress that?

    And some of them have those really large lobules. You have to actually bolster those lobules up a little bit so you don’t induce a pressure necrosis. And there’s some new products out in the market now that actual… they’re called lobule containment systems. [00:26:00] And they’re very, very effective and rapidly reduce and then you can get them into a more normal compression profile.

    But another thing I’ll say just quickly about, you’re talking about the really weepy edematous extremities and the cost of a lot of dressings. A lot of times what we use initially is adult diapers. We’ll just put them in adult diapers and put the compression over it, get them reduced down and then get them into sometimes a little bit more manageable.

    The amazing thing is as soon as you start complete decongestive therapy, those wounds resolve pretty quickly. And it’s really, really remarkable. So sometimes you can just go back to the basics and use some very simple strategies.

    So tension is delivered by the bandage or their garment. And again, how much you’re putting this on, and this is why short-stretch does require some type of specific training so you’re not putting it on to too tight. But the type of material matters as well. And we have to remember too, sometimes in those limbs down by the ankles or at the wrist, the smaller the radius, you’re going to have greater pressure exerted there. So sometimes what we’ll do is we’ll fill that in with some padding material to make a more columnar shaped extremity so we have more even distribution of pressure and we’re balancing out the LaPlace’s Law.

    So compression choices. The shape and the size of the limb, the larger the limb, the greater the stiffness is going to be required. So the stiffness, the textiles we’re using, the products we’re using. It’s not that you’re putting it on tighter. Don’t think you have to wrap it tighter. That’s not the case. And the more layers you put on, the tighter it’s going to become or the more compression you’re going to be adding.

    So pressure can be increased by layering our padding compared with increased tension. And the smaller the limb, the less force needed to create the same amount of compression. So if you have a really large extremity, you’re going to have to use a lot more product and materials to get a good compression profile versus if you have a smaller extremity.

    The location of the swelling, we definitely have to make sure we… you know, if they have full extremity edema, we don’t stop just at the knee, okay, that would be problematic. And a lot of times, you have to ask this question because they don’t always to volunteer it. [00:28:00] But if patients have lower extremity edema, you want to ask do they have any genital edema. Men or women. Because it’s very, very common and it’s also something that… now, I don’t necessarily treat it, but it’s advanced training that an lymphedema therapist can specialize in, much like head or neck lymphedema and other areas where they can do very specific treatments to reduce the genital lymphedema and it’s very effective.

    But that’s something that’s very sensitive for patients, but it’s important to ask because a lot of them have that problem. And that’s the other thing with the pumps and diuretics. If you’re using those, especially the pumps, mobilizing that fluid begets where you’re putting it, not in a place that makes the really happy. So you got to be careful with that.

    And then tissue texture. The firmer the limb, the greater the stiffness required. Again, it’s harder to give adequate compression to something that’s firm, right, and hard and fibrotic. So again, this is why the stiffness that we’re using, the compression profiles that we’re using, the products we’re using, the textiles we’re using, so short-stretch bandages or flat knit garments are really what we want to be using for patients with a lot of fibrosis. So texture does matter.

    And then we see this a lot. These are typical presentations of patients. So the firmer the limb, the greater the stiffness that’s required. Again, that doesn’t mean you put it on tighter. You’re not going to crank it on. You’re just going to want to be using products that can manage that type of tissue well.

    So the effectiveness of the compression or garment is impacted by the tissue over which it’s applied. So there are things we can do to break down that fibrotic tissue. That’s usually the last thing to resolve for patients. It can take years. They might be reduced and plateaued in maintaining. But that fibrotic tissues can be persistent.

    But there’s specific manual techniques that can be done and there’s a lot of different types of foams, grey foams and other types of foams that we can use to really add into areas that kind of provide a micro massage under compression that really work well to manage some of the fibrotic changes, and just basic manual limb drainage can help that as well. [00:30:00]

    So neuropathy. A lot of our patients are going to be insensate and we have to be really careful putting compression on them and we want to assess their sensory status before doing compression because they’re not going to know if it’s too tight or uncomfortable or causing harm. And we need to be careful with that, especially around bony prominences. So we’re going to want to protect those areas.

    And then if somebody has systemic failures like cardiac, renal, liver, we can still compress them, but we need to be working as a team medically to understand and adjust potentially medications or monitor output or monitor ejection fractions and things along that line so that we know we’re not harming the patient.

    And it’s really important too that these patients stay active. You know, it’s very easy to just, you know, I’m tired, I don’t want to do anything. In the physical therapy, we talk about move to live, live to move, you know. And I think it’s a really important concept. And they don’t have to go to the gym. They don’t have to have an expensive membership. They can do really basic things at home just to engage pumping, diaphragmatic breathing, range of motion exercises, walking. Walking is probably one of the best things patients can do.

    And so this is just some things to consider, you know, if they have peripheral arterial disease, you really want to do a vascular work up first. Their systolic ankle pressure should be above 50 basically to make sure that they can support healing and you can use our compression safely.

    And then with a mixed presentation, you know, again, anything over 0.8, they stay static compression is appropriate. But we’re… you know, you can do it with 0.5 or higher and there’s some products in lab that you’ll see that are really effective to use in these patients with mixed presentation.

    We have to be careful with our patients that are immobile. But again, why are they immobile? Sometimes it’s just they just need physical therapy or occupational therapy or whatever the case may be. And with proximal swelling, like I said, we want to make sure we address that whole extremity. Don’t just do below the knee or just to the elbow. It’s really important we do the whole extremity.

    And then this is another thing to consider. [00:32:01] Looking at the type of edema that’s present, minimal, soft or pitting, firm pitting or fibrotic, and kind of guiding you through some of the different products that you can utilize. Remember, first and foremost, if these patients do have skin impairments, skin dysfunction, you want to manage that wound first and get them in a disposable type of product. So the inelastic type compressions, the two-layer compressions systems are exceedingly wonderful in these patients to get that edema reduced down.

    As soon as you manage that edema, those wounds are going to resolve. And then you can bump them up into different types of either compression wraps or the alternative devices, you can get them into garments or custom or over-the-counter.

    And flat knit particularly is a type… there’s circular knit or flat knit products that are more custom or over-the-counter particularly for lymphedema patients. But the flat knits are the ones… they’re a little bit more expensive, but they’re the ones that are very, very effective to manage lymphedema long term. And these are the components that we want to get our patients in ultimately.