American Society for the Advancement of Lymphedema Management

Lymphokinetics USA Branch

NEWSLETTER

Number 14 December 1999

From the President:

NEW MILLENNIUM!

Be ready for a new era of success for us, Health Workers, who went through much turmoil during this past decade. Let’s wish that this new era would see us gain this freedom of practice and creativity that we need to help our patients.

1999 was marked by a significant event: the return of Professor Albert Leduc and Olivier Leduc. As I already explained, they will offer Confirmation and Advanced courses yearly. Their desire to improve their techniques drives them to perform experiments on an on-going basis. We are lucky to have them share their latest research in the field of physical treatment of lymphedema. Their 1999 courses were held in Piscataway, New Jersey in August. I would like to share with you some of the comments of the attendees.

"Glad to have attended." "Excellent course. Extremely informative, Helpful in clinical treatment. I am very impressed with Dr Leduc and Olivier Leduc’s Research and overall extensive knowledge." "Excellent" "Great course" "The course was fantastic, I learned a lot from All the presenters." "I really appreciated this course" "Very well worth the time and money. Learned A lot. Thanks!" "Hearing from the Master was really exciting and the material presented made the information clearer. I feel that this was very helpful to attend after a time of practice of my own." "Overall, a worthwhile learning experience."

Olivier Leduc mastered the power point presentation that triggered some positive comments regarding the audiovisual material: "Good variety – Good pictures" "It is amazing what computers add to a presentation" "Excellent, 10+" "10+++++ Fantastic slides. The video of the breast surgery was helpful, gave me a concrete image to remember"

Pt is 69 y. o. and has a history of chronic primary lymphedema in her right lower extremity since the age of 32. She is post right TKR with slight drainage from her surgical scar and staples are intact. The referring M.D. recommended a "lymphedema pump" at this time. What would be the contraindications and precautions for lymphedema management at this time?

Would a "pump" be indicated?

Would manual techniques be the only treatment indicated until the wound is completely healed?

Would a long T.E.D. be sufficient at this time?

Concerning wound healing, Professor Leduc referred the Physical Therapist to his presentation on wound healing carried out during his course. In the Newsletter No 13 (July 1999) I summarized three articles on wound healing. This will help the persons who did not attend Professor Leduc’s course.

Professor Leduc recommends avoiding the use of a compression device as long as the incision is not healed. According to him, manual lymph drainage is the best indication at the early stage.

T.E.D. stocking is supposed to prevent DVT. This was not demonstrated experimentally. At the early stage, when the patient is in bed, the use of a T.E.D. stocking may prevent DVT and limit the extension of the lymphedema. The fact that a patient is wearing TED stockings does not mean that you are not supposed to perform DVT prevention sessions: Lower extremity exercises and breathing exercises.

Pt is a 78 y.o female with a history of severe secondary lymphedema R UE post mastectomy in 1982. She is referred for physical therapy with multiple diagnosis including frozen shoulder and lymphedema R UE. She reports that her gynecologist has detected bloody drainage from her L breast nipple. Should lymphedema management be initiated on her R UE and if so, what parts of the total program?

Professor Leduc replied that it is impossible to give advice with such vague information. What is the origin of the bleeding? Traumatic? Other? Every decision regarding the implementation of the treatment must be made by the team M.D. /P.T

Some attendees asked the opinion of Professor Leduc about the Casley Smith exercises.

Professor Leduc replied that these exercises might be used.

I would like to add my own opinion: I do not appreciate the fact that these exercises are called remedial exercises because there is no research showing that they remedy lymphedema. I think that a Physical Therapist is able to create a more effective custom exercise program addressing the specific problem of a patient. It seems that this list of exercises has been designed for non-professionals who do not have the background necessary to design an exercise program.

What do you think about aquatic exercises for lymphedema patients?

Professor Leduc replied: excellent as long as the water temperature is < 30C. The water pressure is excellent for the edematous limb. Patient may walk in a swimming pool and swim. Swimming is a gentle resisted exercise.

Patient must shower carefully after the aquatic exercises and use her/his usual skin moisturizer. Recommend checking the skin daily.

Comments and suggestions. by Anne-Marie Vaillant-Newman

I would like to comment on some questions that have been asked several times:

"One of my patients who has a lymphedema post-mastectomy, exhibits an involvement of the dorsum of the hand. After the manual lymph drainage she shows a significant improvement but when I see her the following day, the edema is back."

When I questioned about the compression worn by the patient between sessions I was told that the patient was wearing a sleeve plus a glove and she was applying a bandages at night. I was surprised because Professor Leduc and myself were very clear about the fact that multilayered bandaging must be applied and monitored by the PT or OT. The person who reported the case told me that her patient had been treated in some other places before and was used to applying the bandaging herself. In fact, her lymphedema located at the dorsum of the hand never decreased during the previous treatment.

When you decide to treat a patient, you need to make a decision. If you decide to apply the method that you learned you need to do so extensively. You cannot mix several techniques or methods. If your patient had been treated previously according to another method, you will explain to her that you practice a specific treatment and would like her to try only this method in order to evaluate the effect on her. If the previous method had not been successful, it will not be difficult to convince your patient.

As I said earlier, the multilayered bandaging must be applied and monitored by the PT or OT. You all remember the story of the Ambassador, which allowed you to understand how delicate it is to apply bandaging, when you are not trained for that. Sending a patient with a daily bandaging routine to perform at home is not a success. Upon discharge the patient must have a significant decrease of volume maintained by a compression garment.

The second mistake regarding the treatment of this patient was to have provided her with a gauntlet and a sleeve. I explained that I prefer a one-piece garment: gauntlet, sleeve and shoulder strap. When a patient wears a sleeve and a glove there are two layers of garment at the level of the wrist, resulting in more pressure. This can generate a lymphedema of the dorsum of the hand. When you use several garments to apply some compression at the level of the limb, you do not benefit from the concept of degressive pressure from distal to proximal, as it occurs in the case of a one-piece garment.

I had also the opportunity to speak with one of your colleague who was disappointed by the results of her multilayered bandaging. She re [ported that she was using Cellona padding instead of foam and Rosidal instead of Durelast. What do you expect? If you change the total description of the bandaging do not expect the same results. Do not forget that the research has been done with specific types of products and you may expect to get the results reported by professor Leduc only if you use the same type of products.

If you have the opportunity to offer an in-service to your colleagues or to the Physicians of your hospital present the research as done. Describe the products used. You cannot use the results of an experiment without clearly describing the research and specifying the material used. Using the results of an experiment to justify the use of different products is dishonest and would not represent the Leduc Method.

The Leduc Method has been evolving for several years. Every technique has been proven effective by research.

Professor Albert Leduc and Olivier Leduc are conscious of the difficulty that we experience in the United States of America with the insurance companies, which restrict our potential treatment duration. Professor Leduc has been offering various strategies to fit our restrictions. However, I would like to highlight that "lymphedema management for managed care" does not exist. "American lymphedema" is the same as "European lymphedema". The treatment is the same. I think that we can be confident in a method that has been developed scientifically.

Maria Josette Mullins has been kind enough to send us a case study with photographs.. This is an interesting case which was treated successfully.

Thank you, Josette. Any candidate for publishing in the next newsletter?

The last pages of this newsletter are the brochures of the coming courses. If you think about attending the Confirmation or Advanced course, please register as soon as possible.

Anne-Marie Vaillant-Newman