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Lymphland International Lymphedema Online
| How do you treat Lymphedema?The gold standard treatment is a form of medical massage that can be called:Manual Lymph Drainage (MLD)Lymph Drainage Therapy (LDT)Complete/Complex Decongestive Therapy (CDT)The goal of therapy is to activate fluid circulation, to drain stagnant areas, stimulate the immune system, reduce pain, and keep muscle spasms to a minimum.To perform Lymphedema therapy, one must be certified and properly trained, look for your therapists credentials.Therapy feels like a massage only lighter. Your therapist will work on your body, usually head to toe. He/she will drain the nodes which again, feels like a massage. The main nodes are the waterwheel (behind earlobe), clavicle (near collarbone), axilla (under arms) and the iliac/inguinal nodes which are in the abdomen. A good deal of time is spent going back and forth to the main nodes to ensure good movement of fluids. Extra time will be spent on areas of swelling. Before you are worked on, the therapist will take your medical history and measure your areas of swelling. This is done so they can keep a record of how you progress to a smaller level.You will be taught to perform self bodywork, how to care for your skin, possibly skin brushing, do's and don'ts, special exercises to promote lymph flow, and how to wrap yourself. You usually are wrapped after each session. After you maintain the same size for a period of time, you will be ordered compression garments (sleeve, stockings) to wear instead of wraps.When NOT to go to or schedule therapy: You should not schedule or go to an appointment if: You have active or acute infectionsYou have a fever or inflammed red skin and possible infectionThrombosis (serious circulatory problems)Major heart problems (bodywork increases the cardiac load)BleedingYou are unable to urinateAlso if you have any unexplained lumps or possible malignancies, you need to check in with your doctor and therapist. NEVER forget to tell your therapist about any problems you are having, and ALWAYS have your therapist update your health records to any new medications or problems.You should always have a current prescription for bodywork. Most therapist will not treat you without a referral.ALWAYS check your therapists credentials before you have bodywork done. DIURETICS - HOW EFFECTIVE ARE THEY?Reputable health authorities advise against using diuretics in the treatment of lymphedema pointing out that the therapy is generally not effective and can be damaging when used over a long period of time. The Canadian Medical Association Journal, Clinical practice guidelines for the care and treatment of breast cancer: 11. Lymphedema (CMAJ 2001;164(2):191-9) released in January of 2001 by Susan R. Harris, Maria R. Hugi, Ivo A. Olivotto, Mark Levine, for the Steering Committee for Clinical Practice Guidelines for the Care and Treatment of Breast Cancer notes: Diuretics, which have been recommended in the past, may temporarily mobilize water, but the increased interstitial oncotic pressure exerted by the high protein concentration of lymph fluid will cause rapid recurrence of edema. The diuretic effect in the rest of the body may cause adverse side effects, such as hypotension, dehydration and electrolyte imbalance.The National Cancer Institute (NCI) points out that, " Diuretics encourage vascular fluid depletion, but do nothing for excess protein deposits and could hasten connective tissue fibrosis. Therefore, diuretics should be used with caution and only for treatment of excess vascular fluid due to other causes (1998).The 1995 consensus document of the International Society of Lymphology Executive Committee reports that although diuretics may be occasionally be useful during the initial phase of physiotherapy or in certain unique medical situations, their use on a long term basis is not generally effective. &Long-term administration of diuretics is discouraged as being of marginal benefit and potentially complicated by fluid and electolyte disturbances.Managing your lymphedema takes time and practice. You're therapist will teach you how to properly bandage or wear compressions combined with self massage. Practice makes perfect so have patience.Although there is no cure and lymphedema is usually progressive, we can hope for research and studies to arise in the future to help those with the condition and also measure to prevent others from ever having it.Therapist HygieneIf you have open wounds or leaking fluid, your therapist may wear gloves. Gloves protect contact with fluids, substances, and chemicals. If working in the mouth to drain nodes, a therapist will wear gloves. Be sure if you have any known allergy to latex you inform your therapist BEFORE bodywork with gloves Managing LymphedemaAt a GlanceYour doctor and nurse are more likely to take your symptoms seriously and be attentive to your progress if they regularly measure the circumference of your arm and compare it with your unaffected arm, documenting the measurements over time. You can usually control lymphedema by practicing good care and following basic guidelines.The health care professionals who specialize in the management of arm lymphedema are physical medicine doctors (physiatrists), physical therapists, and occupational therapists. But don't assume that anyone in these specialties is an expert in treating lymphedema. Ask about experience and references before you let anyone work on your edema problem. Most metropolitan areas have occupational or physical therapists with practices dedicated to managing the physical, psychological, and activity-related side effects of breast cancer treatment. If you can't find a therapist who specializes in breast cancer, look for a general occupational or physical therapist in a rehabilitation center or department who has experience taking care of women with breast cancer Title: Early Intervention and Treatment Intervention for LymphedemaAuthors: Gergich N,1 Washington F,2 Pfalzer3 L, Soballe P1 and McGarvey C4Affiliations: 1. Breast Care Center, National Naval Medical Center, Bethesda, MD.2. University of Maryland School of Medicine, Baltimore, MD.3. University of Michigan-Flint, Flint, MI.4.National Institutes of Health, Bethesda, MD, Physical Therapy Dept.,Abstract: DESIGN: This observational (case-control) outcome study investigated the frequencyand severity of morbidities in a population of approximately 165 patients diagnosed withbreast cancer before and after medical and surgical treatment.METHODS: A subset analysis of a cohort of women of women diagnosed with subclinicallymphedema (LE) was conducted. Pre-operative and follow-up arm volumemeasurements taken at 80% of limb length measured from ulnar styloid to tip ofacromion at 1, 3, 6, 9, 12 and 18 months by optoelectronic volumeter (Perometer®) from2001-2006. Quantitative girth measurements were collected over this period using anoptoelectric limb volumeter. The device is an framed infrared scanning system(Perometer, Pero-system MeBgerate GmbH, Wuppertal, Germany). This instrument wasdesigned specifically to measure girth (cm) and volume (ml) of the upper or lowerextremities and has been validated for use in a clinical environment by Stanton1 andothers.ANALYSIS: 2-way Repeated ANOVA with Time and Limb as factors and mean valuescalculated for Affected and Unaffected Arms. RESULTS: 43 women 34-82 years old (mean =55.3 + SD 12.1) reported symptoms ofLE including heaviness or increased limb volume. Intervention was introduced if thevolume change equated to approximately 100 ml or 3% volume change compared to preopmeasure. At intervention the volume increase in the affected arm was significant (83.0ml + 118.8 [2.1 % + 5.2] p=0.001). Baseline to onset of lymphedema and interventionaveraged 7.6 mos. Average time to follow up was 5.0 months, during which time thecohort demonstrated a significant (p=0.0000) mean volume decrease of 119.9 ml [8.6%]in their affected arm by using the sleeve.CONCLUSIONS: Pre-operative assessment, prospective surveillance and earlyintervention may have prevented the onset of irreversible LE in this small cohort.The garment significantly reduced affected limb volume to nearly that of the unaffectedlimb and therefore provides effective treatment when sub-clinical LE can be detected.Further research is warranted to confirm the long term effectiveness and costeffectiveness of this preventive model compared to a traditional impairment based model.1. Stanton AW, Northfied JW, Holroyd B, Mortimer PS, and Levick, JR. Validation of anoptoelectronic limb volumeter (Perometer). Lymphology. 1997 vol:30 (2): pp:77 -97 This page is a mix of content from Lymphology magazine in the last article, exerpts from Dr.Chikly ------------------------------------------------------------------------------------------------ MLD can be used for other things too, to speed healing after surgery. Hi Charissa, The answer is YES MLD is very successful for acne. I have done many cases here, they are all very pleased with the results. Some of them are closed to 95% clear and 1 had 100% clear skin now. Most will experience at least a 50% reduction of appearance of acne. I only have 1 resistant case due to prolong (12 years) antibiotics consumption, I realise we have to do full detox to make things work but in general everyone else responded. 99% success rate from my experience. :) Do your treatment regularly and use gentle pH balance skin care products. Harsh products will make things worse. hugs, veronica yap Vodder MLD Lymphoedema Therapist I am really interested in feedback about how successful the mld was for acne. Charissa -------------------------------------------- Alternative Systems of Medical Practice Overview Worldwide, only an estimated 10 to 30 percent of human healthcare is delivered by conventional, biomedically oriented practitioners. The remaining 70 to 90 percent ranges from self-care, according to folk principles, to care given in an organized healthcare system based on an alternative tradition or practice. Popular healthcare is the kind most people practice and receive at home, such as giving herbal tea to someone who has a cold. Community-based healthcare, which reflects the health needs, beliefs, and natural environments of those who use it, refers to the nonprofessionalized but specialized healthcare practices of many rural and urban people. Professionalized healthcare is more formalized; practitioners undergo more standardized training and work in established locations. Professionalized Healthcare Systems The professionalized healthcare practitioners often have conducted scientific studies about the causes of illness and explanations and results of treatment. Each of the major professionalized systems has certain characteristics: a theory of health and disease; an educational scheme to teach its concepts; a delivery system involving practitioners; a material support system to produce medicines and therapeutic devices; a legal and economic mandate to regulate its practice; cultural expectations about the medical system's role; and a means to confer professional status on approved providers. These professionalized medical systems include traditional oriental medicine, acupuncture, ayurvedic medicine, homeopathy, anthroposophy, naturopathy, and environmental medicine. Traditional Oriental Medicine Traditional oriental medicine is a sophisticated set of many systematic techniques and methods, including acupuncture, herbal medicine, acupressure, qi gong, and oriental massage. The most striking characteristic of oriental medicine is its emphasis on diagnosing disturbances of qi, or vital energy, in health and disease. Diagnosis in oriental medicine involves the classical procedures of observation, listening, questioning, and palpation, including feeling pulse quality and sensitivity of body parts. The professionalization of oriental medicine has taken diverse paths in both East Asia and the United States. Currently, the model in the People's Republic of China, which was established after the 1949 revolution, involves the organized training of practitioners in schools of traditional Chinese medicine. The curriculum of these schools includes acupuncture, oriental massage, herbal medicine, and pharmacology, though the clinical style of making a diagnosis and then designing a treatment plan is the one traditionally associated with herbal medicine. The graduates of these colleges are generally certified in one of the four specialty areas at a training level roughly equivalent to that of a Western country's bachelor's degree. In the United States, the professional practitioner base for oriental medicine is organized around acupuncture and oriental massage. There are about 6,500 acupuncturist practitioners in the United States. The American Oriental Body Work Therapy Association has approximately 1,600 members representing practitioners of tuina, shiatsu, and related techniques. Many American schools of acupuncture are evolving into "colleges of oriental medicine" by adding courses in oriental massage, herbal medicine, and dietary interventions. They also are offering diplomas, master's degrees, and doctor's degrees in oriental medicine. The legal sanctioning of oriental medical practice is most extensive in New Mexico, where the acupuncture community has established an exclusive profession of oriental medicine. Their legal scope of practice is currently similar to that of primary care M.D.s and D.O.s (doctors of osteopathy), and their State statute restricts other licensed New Mexico health professionals' ability to advertise or bill for oriental medicine or acupuncture services. Extensive research has been done in China through the institutions of traditional Chinese medicine, but only in the past quarter century have biomedical scientists in China characterized and identified active agents in much of traditional medical formulary. The use of traditional oriental herbal medicines and formulas in China and Japan has been studied for therapeutic value in the following areas: chronic hepatitis; rheumatoid arthritis; hypertension; atopic eczema; various immunologic disorders, including acquired immunodefiency syndrome (AIDS); and certain cancers. It would be useful to repeat these studies in the United States, assessing U.S. clinical populations according to high-quality research criteria. Acupuncture Acupuncture involves stimulating specific anatomic points in the body for theerapeutic purposes. Puncturin the skin with a needle is the usual method, but practitioners also use heat, pressure, friction, suction, or impulses of electromagnetic energy to stimulate the points. In the past 40 years, acupuncture has become a well-known, reasonably-available treatment in developed and developing countries. Acupuncture is used to regulate or correct the flow of qi to restore health. Modern theories of acupuncture are based on laboratory research conducted in the past 40 years. Acupuncture points have certain electrical properties, and stimulating these points alters chemical neurotransmitters in the body. The physiological effects of acupuncture stimulation in experimental animals have been well documented, and in the past 20 years acupuncture has become an increasingly established healthcare practice. An estimated 3,000 conventionally trained U.S. physicians have taken courses to incorporate acupuncture in their medical practices. Acupuncture is one of the most thoroughly researched and documented of the so-called alternative medical practices. A series of controlled studies has shown evidence for the efficacy of acupuncture in the treatment of a variety of conditions, including osteoarthritis, chemotherapy-induced nausea, asthma, back pain, painful menstrual cycles, bladder instability, and migraine headaches. Studies on acupuncture also have shown positive results in the areas of chronic pain management and in the management of drug addition, two areas where conventional Western medicine has had only a modicum of success. Ayurveda Ayurveda is India's traditional, natural system of medicine that has been practiced for more than 5,000 years. Ayurveda provides an integrated approach to preventing and treating illness through lifestyle states that all disease begins with an imbalance or stress in the individual's consciousness. Lifestyle interventions are a major ayurvedic preventive and therapeutic approach. There are ten ayurveda clinics in North America, including one hospital-based clinic that has served 25,000 patients since 1985. In India, ayurvedic practitioners receive state-recognized, institutionalized training in parallel to their physician counterparts in India's state-supported systems for conventional Western biomedicine and homeopathic medicine. The research base is growing concerning the physiological effects of meditative techniques and yoga postures in Indian medical literature and Western psychological literature. Published studies have documented reductions in cardiovascular disease risk factors, including blood pressure, cholesterol, and reaction to stress, in individuals who practice Ayurvedic methods. Laboratory and clinical studies on ayurvedic herbal preparations and other therapies have shown them to have a range of potentially beneficial effects for preventing and treating certain cancers, treating infectious disease, promoting health, and treating aging. Mechanisms underlying these effects may include free-radical scavenging effects, immune system modulation, brain neurotransmitter modulation, and hormonal effects. Homeopathic Medicine Homeopathic medicine is practiced worldwide, especially in Europe, Latin America, and Asia. However, even in the United States the homeopathic drug market is a multimillion-dollar industry. Homeopathic remedies, which are made from naturally occurring plant, animal, or mineral substances, are recognized and regulated by the Food and Drug Administration (FDA) and are manufactured by established pharmaceutical companies under strict guidelines. Homeopathy is used to treat acute and chronic health problems as well as for disease prevention and health promotion. Recent clinical trials suggest that homeopathic medicines have a positive effect on allergic rhinitis, fibrositis, and influenza. Basic research in homeopathy has involved investigations into the chemical and biological activity of highly diluted substances. Some homeopathic medicines are diluted to concentrations as low as 10-30 to 10- 20,000. This particular aspect of homeopathic theory and practice has caused many modern scientists to reject homeopathic medicine. Critics of homeopathy contend that such extreme dilutions of the medicines are beyond the point at which any active molecules of the medicine can theoretically still be found in the solution. On the other hand, scientists who accept the potential benefits of homeopathic theory suggest several theories to explain how highly diluted homeopathic medicines may act. Using recent developments in quantum physics, they have proposed that electromagnetic energy in the medicines may interact with the body on some level. Researchers in physical chemistry have proposed the "memory of water" theory, whereby the structure of the water-alcohol solution is altered by the medicine during the process of dilution and retains this structure even after none of the actual substance remains. Anthroposophically Extended Medicine Anthroposophically extended medicine is an extension of Western biomedicine and also incorporates approaches and therapeutics from two alternative medicine movements: naturopathy and homeopathy. Anthroposophically extended medicine is most prominent in Europe, but there are an estimated 30 to 100 M.D.s in the United States who practice it also. Hundreds of uniquely formulated medications are used in anthroposophical practice, each seeking to match the key dynamic forces in plants, animals, and minerals with disease processes in humans to stimulate healing. Much research in anthroposophically extended medicine has been connected with attempts to understand the nature of disease, assess treatments qualitatively, and understand how the essential properties of the objects under investigation could be applied in therapy. Naturopathic Medicine Naturopathic medicine, as a distinct American healthcare profession, is almost 100 years old. It was founded as a formal healthcare system at the turn of the century by medical practitioners from various natural therapeutic disciplines. By the early 1900s, more than 20 naturopathic medical schools existed, and naturopathic physicians were licensed in most States. Today there are more than 1,000 licensed naturopathic doctors in the United States. As practiced today, naturopathic medicine integrates traditional natural therapeutics - including botanical medicine, clinical nutrition, homeopathy, acupuncture, traditional oriental medicine, hydrotherapy, and naturopathic manipulative therapy - with modern scientific medical diagnostic science and standards of care. The medical research base of naturopathic practice consists of empirical documentation of treatments using case history observations, medical records, and summaries of practitioners' clinical experiences. At present, the two accredited naturopathic medical schools in the United States have active research departments. Naturopathic researchers have investigated the pharmacology and physiological effects of nutritional and natural therapeutic agents, and naturopathic physicians have been active in the investigation of new homeopathic remedies and in the natural treatment of women's health problems. The most recently completed naturopathic study in women's health tested the clinical and endocrine effects of a botanical formula as an alternative to estrogen replacement therapy. Environmental Medicine Environmental medicine, like anthroposophically extended medicine, also can be viewed as an extension of modern biomedicine. Environmental medicine traces its roots to the practice of allergy treatment and the work of Dr. Theron Randolph, in the 1940s, who identified a variety of common foods and chemicals that were able to trigger the onset of acute and chronic illness even when exposure was at relatively low levels. Environmental medicine recognizes that illness in individuals can be caused by a broad range of incitant substances, including foods, chemicals found at home and in the workplace, and chemicals in the air, water, and food. Today there are 3,000 physicians worldwide practicing environmental medicine, and there are several environmental control units in the United States and one in Canada, where patients' sensitivities are unmasked through fasting and complete avoidance of potentially incitant chemicals. Research, in this field, has been directed at clinical treatment of patients and at evaluation of the diagnostic and treatment techniques used by practitioners. Other studies have supported the use of the approaches of environmental medicine in treating arthritis, asthma, chemical sensitivity, colitis, depression, eczema, fatigue, and hyperactivity. The belief that humans can get sick from cumulative low-level environmental exposure to certain incitants is not well accepted by the conventional medical community. However, because "sick building syndrome" and other chronic conditions that cannot be explained by other phenomena are being seen with greater frequency, environmental medicine offers a theoretical groundwork for dealing with such phenomena. Indeed, environmental medicine is in a position to be a leading force in the investigation of ways to reduce the incidence of these and other disorders. Community-Based Healthcare Practices Community-based healthcare practices are varied and are found throughout the United States. Like other healthcare specialists, community-based healers may emphasize naturalistic, personalistic, energetic explanatory models or a combination. Traditional midwives and herbalists and, at the present time, pragmatic weight loss specialists are probably the best known of community-based practitioners who follow the naturalistic model. In addition, the Native American medicine man or medicine woman is a community- based traditional healer with primarily naturalistic skills, that is, the skills of an herbalist in particular. Some medicine people are also shamans, in which case they are often distinguished as holy men and women. In contrast to professionalized practitioners, community-based healers often do not have set locations such as offices or clinics for delivering care but do so in homes, at ceremonial sites, or even right where they stand. Community-based healing of the personalistic variety can also be "distant," that is, it does not require that practitioner and patient be in each other's presence. Prayers or shamanic journeys, for example, can be requested and "administered" at any time, and charm cures are sometimes delivered by telephone. Meanwhile, community-based systems also thrive in urban areas. These systems include the popular weight loss programs and other 12-step programs. Often the practitioners rent office space and emphasize contact between client and practitioner, and they may charge considerable fees. Since these practitioners depend on their healing practice for their livelihood, they advertise and so may be easier to identify and contact for study purposes. Native American Native American Indian community-based medical systems have a number of rituals and practices: sweating and purging, usually done in a "sweat lodge"; the use of herbal remedies gathered from the surrounding environment and sometimes traded over long distances; and shamanic healing involving naturalistic or personalistic healing. Tribes such as the Lakota and Dineh (Navajo) also use practices such as the medicine wheel, sacred hoop, and the "sing," which is a healing ceremony rite that lasts from two to nine days and nights and is guided by a highly skilled specialist called a "singer." Formal research into the healing ceremonies and herbal medicines conducted and used by bona fide Native American Indian healers or holy people is almost nonexistent, even though Native American Indians believe they positively cure both the mind and body. Ailments and diseases such as heart disease, diabetes, thyroid conditions, cancer, skin rashes, and asthma reportedly have been cured by Native American Indian doctors who are knowledgeable about the complex ceremonies. Latin American Latin American community-based practices include curanderismo, which is a folk system of medicine that includes two distinct components: a humoral model for classifying activity, food, drugs, and illness; and a series of folk illnesses. In the humoral component of curanderismo, things could be classified as having qualitative (not literal) characteristics of hot or cold, dry or moist. According to this theory, good health is preserved by maintaining a balance of hot and cold. Thus, a good meal will contain both hot and cold foods, and a person with a hot disease must be given cold remedies and vice versa. Again, a person who is exposed to cold when excessively hot may "take cold" and become ill. The second component, the folk illnesses, is actively in use in much of Mexico and among less educated Hispanic U.S. citizens. Studies have found that as many as 96 percent of Mexican-American households (more frequent in the less Americanized communities) treated members for Hispanic folk illnesses. Similarly, high use patterns among Mexican migrant workers have been found in Florida and Mexico. Although no formal effectiveness studies seem to have been done on this system, its wide popularity and the research suggesting the relevance of the folk diagnoses, for biomedical practice, indicate the need for further demographic and effectiveness studies. Alcoholics Anonymous Alcoholics Anonymous (AA) is an example of an urban community-based healing system for helping people, whose lives are damaged by the consumption of alcohol, to stop drinking. Founded in 1935 by Bob Smith, M.D. and Bill Wilson, two alcoholics, it is a patient-centered self-help fellowship of men and women. AA has burgeoned and today is widely considered the most successful existing method for supporting sobriety. In contrast to most community-based systems, a very large literature exists analyzing AA. Several models attempt to explain its success. One popular psychometric model interprets AA as a "cult" and the achievement of sobriety as a "conversion experience." Another model, however, asserts that members recover by integrating their own experiences with alcohol with those of others in the group and by learning and practicing some new ways to behave. Through these new ways, AA members feel as if they are living apart from the urban materialist norm; that the cause of alcoholism is not at issue; that people should share, not compete; and that the individual need not rise above the rest (spiritual anonymity). Studies have concluded that active AA membership allows up to 68 percent of alcoholics to drink less or not at all for up to a year, and 40 to 50 percent to achieve sobriety for many years. More active or dedicated members (those who attend meetings more often) remain sober longer. Bioelectromagnetic Applications Electromagnetic Fields Bioeletromagnetics (BEM) is an emerging science that studies how living organisms interact with electromagnetic (EM) fields. Electrical phenomena are found in all living organisms, and electrical currents in the body can produce magnetic fields that extend outside the body. Those that extend outside the body can be influenced by external magnetic and EM fields. Changes in the body's natural fields may produce physical and behavioral changes. Endogenous (internal) fields are distinguished from exogenous (external) fields. The latter can be natural, such as the earth's geomagnetic field, or artificial, such as power lines, transformers, appliances, radio transmitters, or medical devices. Oscillating nonionizing EM fields in the extremely low frequency (ELF) range can have vigorous biological effects that may be beneficial. Changes in the field configuration and exposure pattern of low-level EM fields can produce specific biological responses, and certain frequencies have specific effects on body tissues. Electromagnetic Research & Studies The mechanism by which EM fields produce biological effects is under increasing study. At the cutting edge of BEM research is the question of how endogenous EM fields change with consciousness. Nonionizing BEM medical applications are classified according to whether they are thermal or nonthermal in biological tissue. Thermal applications of nonionizing radiation include radio frequency (RF) hyperthermia, laser and RF surgery, and RF diathermy. The most important BEM modalities in alternative medicine are nonthermal applications of nonionizing radiation. Major new applications of nonthermal, nonionizing EM fields are bone repair, nerve stimulation, wound healing, treatment of osteoarthritis, electroacupuncture, tissue regeneration, and immune system stimulation. In the study of other alternative medical treatments, BEM offers a unified conceptual framework that may help explain how diagnostic and therapeutic techniques such as acupuncture and homeopathy may produce results that are hard to understand from a more conventional viewpoint. Diet, Nutrition, Lifestyle Changes Preventing & Treating Chronic Disease Throughout evolution, human beings adapted to a wide range of naturally occurring foods, but the types of food and the mix of nutrients (in terms of carbohydrates, fats, and proteins) remained relatively constant. Food supplies were often precarious, and the threat of death from starvation was a constant preoccupation for most early humans. However, about 10,000 years ago the agricultural revolution began making profound dietary changes in many human populations. The ability to produce and store large quantities of dried foods led to preferential cultivation of some foods, such as grains, which constituted new challenges to the human digestive system. Then, about 200 years ago, the Industrial Revolution introduced advances in food production, processing, storage, and distribution. Recent technological innovations, along with increased material well-being and lifestyles that have allowed people more freedom in deciding what and when they wish to eat, have led to even further major dietary changes in developed countries. Because changes in the dietary patterns of the more technologically developed countries, such as the United States, have been so dramatic and rapid, the people consuming these affluent diets have had little time to adapt biologically to the types and quantities of food that are available to them today. The longer term adverse health effects of the diet prevailing in these countries - characterized by an excess of energy-dense foods rich in animal fat, partially hydrogenated vegetable oils, and refined carbohydrates but lacking in whole grains, fruits, and vegetables - have become apparent only in recent decades. Because of the recent, rapid rise in chronic illness related directly or indirectly to diet, the focus of nutrition research has shifted away from eliminating nutritional deficiency to dealing with chronic diseases caused by nutritional excess. Another concern among nutrition researchers is the accumulation of evidence indicating that a less-than-adequate intake of some micronutrients, over a long period, may increase the risks of developing coronary heart disease, cancers, cataracts, and birth defects. In recent decades, the data on the relationship between certain dietary habits and nutritional intake have been growing exponentially. Designing interventions based on this wealth of research has become increasingly more difficult and complex. Dietary Supplements The Federal Government's approach to dietary intervention, formulated by boards composed of nutrition scientist, generally does not recommend supplementing the typical American diet with vitamins or nutrients beyond the recommended daily allowances (RDAs), nor does it suggest that some foods never be eaten. In contrast, many alternative dietary approaches contend that no amount of manipulation of the typical American diet is enough to promote optimum health or prevent eventual chronic illness. These alternative approaches represent a continuum of philosophies ranging from the concept that supplementing the typical American diet somewhat beyond the RDAs is necessary to promote optimum health, to the idea that supplementation well beyond the RDAs is often required to reverse the effects of long-term deficiencies. Other approaches advocate drastic dietary modification, either eliminating or adding certain types of foods or macronutrients, to treat specific types of conditions such as cancer and cardiovascular disease. Finally, there is the view that certain major staples of typical American diet, such as meat and dairy products, are basically unhealthy and should be generally avoided. There is a growing body of data supporting the notion that the RDAs for mineral, such as calcium and magnesium, may be too low and that supplementation may be necessary to prevent the onset of chronic diseases. In addition, the RDAs for a number of vitamins and micronutrients, such as vitamin C, vitamin D, vitamin E, folate, and beta-carotene, may not be adequate to prevent chronic illness. For example, recent studies have found that the RDA for folate may need to be doubled for women as well as men. Orthomolecular Medicine Orthomolecular medicine-the therapeutic use of high-dose vitamins to treat chronic disease-promotes improving health and treating disease by using the optimum concentration of substances normally present in the body. Increasing the intake of such nutrients to levels well above those usually associated with preventing overt deficiency disease may have health benefits for some people. There is at least preliminary evidence that orthomolecular remedies may be effective in treating AIDS; brochial asthma; cancer; cardiovascular disease, heart attacks, and stroke; lymphedema; and mental and neurological disorders. Alternative Diets A variety of alternative diets are offered for treating cancer, cardiovascular disease, and food allergies. Virtually all of these interventions focus on eating more fresh and freshly prepared vegetables, fruits, whole grains, and legumes. Allergy to food has become a major area of research. Food intolerance is being studied as a causal or contributing factor in rheumatoid arthritis, and there is evidence that food-elimination diets may help many hyperactive children. Some alternate dietary lifestyles are believed to offer a greater resistance to illness. These include several variations of the vegetarian diet, such as those consumed by Seventh-Day Adventists and proponents of the macrobiotic diet. Studies have found a significant lowering of risk factors for heart disease and certain forms of cancer in these two groups. Recent studies have also reported that certain cultural eating styles, such as the Asian and Mediterranean diets, appear to lower risk factors for heart disease and certain forms of cancer as well. Although there have been few controlled studies of the benefits of many traditional diets, such as those originally consumed by Native American Indians, diseases such as diabetes and cancer were not a problem for these populations until their diets became more Western, or affluent. Because dietary and nutritional therapy interventions affect an array of biochemical and physiological processes in the body, evaluating their effectiveness may require equally complex methods. Furthermore, developing a comprehensive healthcare policy that incorporates diet and nutritional interventions may require taking into account Federal feeding programs and dissemination strategies that might present barriers to the effective propagation of adequate nutritional knowledge. Herbal Medicine Folk Medicine Traditions All cultures have long folk medicine traditions that include the use of plants and plant products. Even in ancient cultures, people methodically collected information on herbs and developed well-defined herbal pharmacopoeias. Indeed, well into the twentieth century, much of the pharmacopoeia of scientific medicine was derived from the herbal lore of native peoples. Many drugs commonly used today are of herbal origin. Indeed, about one-quarter of the prescription drugs dispensed by community pharmacies in the United States contain at least one active ingredient derived from plant material. The World Health Organization (WHO) estimates that 4 billion people, 80 percent of the world population, presently use herbal medicine for some aspect of primary healthcare. Herbal medicine is a major component in all indigenous peoples' traditional medicine and a common element in Ayurvedic, homeopathic, naturopathic, traditional oriental, and Native American Indian medicine. Drug Regulation Although, the discovery of useful therapeutics from plants has changed the face of medicine and the course of civilization, many people, especially some in the Federal Government, evaluate herbal remedies as though they were either worthless or dangerous. Today in the United States, herbal products can be marketed only as food supplements. An herb manufacturer or distributor can make no specific health claims without FDA approval. A growing number of Americans are interested in herbal preparations. Two features of European drug regulation make that market more hospitable to natural remedies. First, it costs less and takes less time in Europe to approve medicines as safe and effective. This is especially true of substances that have a long use history and can be approved under the "doctrine of reasonable certainty." European guidelines for the assessment of herbal remedies follow up on WHO's Guidelines for the Assessment of Herbal Medicines, which state that a substance's historical use is a valid way to document safety and efficacy in the absence of scientific evidence to the contrary. France, where traditional medicines can be sold with labeling based on traditional use, requires licensing by the French Licensing Committee and approval by the French Pharmacopoeia Committee. Germany considers whole herbal products one active ingredient; this makes it simpler to define and approve the product. The German Federal Health Office regulates products such as ginkgo and milk thistle extracts so that potency and manufacturing processes are standardized. England generally follows the rule of prior use; that is, years of use with apparent positive effects and no evidence of detrimental side effects constitute enough evidence - in lieu of other scientific data - that the product is safe. In Japan, China, and India, patent herbal remedies composed of dried and powdered whole herbs or herb extracts, often in tablet form, are the rule. Traditional herbals are the backbone of China's medicine. Japan's traditional medicine, kampo, is similar to and historically derived from Chinese medicine but includes traditional medicines from Japanese folklore. Herbal medicines are the staple of medical treatment in many developing countries and are used for many types of ailments. European Phytomedicines European phytomedicines are among the world's best studied medicines, researched in leading European universities and hospitals. Some have been in clinical use, under medical supervision, for more than ten years, with tens of millions of documented cases. This form of botanical medicine most closely resembles American medicine. In Europe there have been credible research studies reporting positive effects on a variety of chronic illnesses for herbs such as Silybum marianum (milk thistle), Ginkgo biloba (ginkgo) Vaccinium myrtillus (bilberry extract), and Ilex guayusa. Many herbs in China have been studied extensively by methods that are acceptable from the Western perspective; among these herbs are ginseng, fresh ginger rhizome, Chinese foxglove root, baical skullcap root, wild chrysanthemum flower, and licorice root. A number of Ayurvedic herbs also have recently been studied in India under modern scientific conditions, including Eclipta alba, Indian gooseberry, neem, turmeric, and trikatu. Reports of positive effects of herbal preparations in developing countries and Native American Indian herbs are primarily anecdotal. However, since much modern-day medicine is directly or indirectly derived from such folklore sources, it seems illogical to conclude that there are no more significant treatments or cures for major diseases to be found, in the world, from plant sources. Manual Healing Overview Touch and manipulation, with the hands, have been in use in health and medical practice since the beginning of medical care. Physicians' hands were once their most important diagnostic and therapeutic tool. Today, however, many medical and health practitioners tend to retreat from physical contact with the patient, distanced by diagnostic equipment and legal and time constraints. Manual healing methods are based on the understanding that dysfunction of a part of the body often affects secondarily the function of other discreet, not necessarily directly connected, body parts. Consequently, theories and processes have been developed for correcting secondary dysfunctions by manipulating soft tissues or realigning body parts. Overcoming misalignments and manipulating soft tissues bring the parts back to optimal function, and the body returns to health. Osteopathic Medicine One of the earliest U.S. healthcare systems to use manual healing methods was osteopathic medicine. In 1993 more than 32,000 American-educated and -licensed D.O.s were practicing in the United States. More than 60 percent of osteopathic physicians are involved in primary care - family medicine, pediatrics, internal medicine, and obstetrics-gynecology. An extensive body of work supports the use of osteopathic techniques for musculoskeletal and nonmusculoskeletal problems. Nearly all osteopathically oriented research has been funded from the private sector. Chiropractic Science Chiropractic science is concerned with investigating the relationship between structure (primarily of the spine) and function (primarily of the nervous system) of the human body to restore and preserve health. Chiropractic medicine applies such knowledge to diagnosing and treating structural dysfunctions that can affect the nervous system. Chiropractic physicians use manual procedures and interventions, not surgical or chemotherapeutic ones. In 1993, more than 45,000 licensed chiropractors were practicing in the United States. Chiropractic specialty areas are extremely pertinent to other medical specialties, such as radiology, orthopedics, neurology, and sports medicine. Current chiropractic research interests include back and other pain, somatovisceral disorders, and reliability studies. Massage Therapy Massage therapy, one of the oldest methods in healthcare practice, is the scientific manipulation of the soft body tissues to return those tissues to their normal state. Massage consists of a group of manual techniques that include applying fixed or movable pressure and holding and causing the body to move. Primarily the hands are used, but sometimes forearms, elbows, and feet are used also. These techniques can affect the musculoskeletal, circulatory-lymphatic, and nervous systems. Massage therapy encompasses the concept of vis medicatrix naturae - helping the body heal itself - and is aimed at achieving or increasing health and well- being. Touch is the fundamental medium of massage therapy. Massage therapists are licensed by 25 States, the District of Columbia, and several localities. Most States require 500 or more hours of education from a recognized school program and a licensing examination. Massage therapy techniques include Swedish massage, deep-tissue massage, sports massage, neuromuscular massage, and manual lymph drainage. Other physical healing methods include reflexology, zone therapy, tuina, acupressure, Rolfing, Trager, Feldenkrais method and Alexander technique. Biofield Therapeutics Biofield therapeutics - laying on of hands - is also a very old form of healing. The earliest Eastern references are in the Huang Ti Nei Ching Su Wen (The Yellow Emperor's Classic of Internal Medicine), dated between 2,500 and 5,000 years ago. The underlying rationales cluster around two views: first, that the healing force comes from a source other than the practitioner - God, the cosmos, or another supernatural entity - and second, that a human biofield directed, modified, or amplified in some way by the practitioner is the operative mechanism. During biofield treatment, the practitioner places hands directly on or near the patient's body to improve general health or treat a specific dysfunction. Treatment sessions may take from 20 minutes to an hour or more; a series of sessions is often needed to treat some disorders. There is consensus among practitioners that the biofield permeates the physical body and extends outward for several inches. Extension of the external biofield depends on the person's emotional state and health. Biofield practitioners have a holistic focus. About 50,000 practitioners provide 18 million sessions annually in the United States. At least three forms of biofield therapeutics are used in medical care inpatient and outpatient settings: healing touch, therapeutic touch, and SHEN therapy. No generally accepted theory accounts for the effect of these therapies. Mind-Body Control Overview Most traditional medical systems make use of the interconnectedness of mind and body and the power of each to affect the other. During the past 30 years there has been a growing scientific movement to explore the mind's capacity to affect the body. The clinical aspect of this enterprise is called mind-body medicine. Mind and body are so integrally related that it makes little sense to refer to therapies as having impact just on the mind or the body. Mind-body interventions often help patients experience and express their illness in new, clearer ways. Distinctions between curing and healing have little place in contemporary medical practice but are important to patients. Perceived meaning has direct consequences to health. The placebo response is one of the most widely known examples of mind-body interactions in contemporary, scientific medicine, yet it is also one of the most undervalued, neglected assets in medical practice. That the placebo response relies heavily on the relationship between doctor and patient says a great deal about the importance of the doctor-patient relationship and the need to provide further medical training on understanding and using this relationship. The therapeutic potential of spirituality, as well as religion, also has been neglected in the teaching and practice of medicine. Interest in the mind's role in the cause and course of cancer has been substantially stimulated by the discovery of the complex interactions between the mind and the neurological and immune systems, the subject of the rapidly expanding discipline of psychoneuroimmunology. The profound differences in the psychological stances taken by people who survive cancer suggest that there is extreme variation both among cultures and within cultures. Specific mind-body interventions include psychotherapy, support groups, meditation, imagery, hypnosis, biofeedback, yoga, dance therapy, music therapy, art therapy, and prayer and mental healing. Psychotherapy Psychotherapy directly addresses a person's emotional and mental health, which is, in turn, closely interwoven with his or her physical health. It encompasses a wide range of specific treatments from combining medication with discussion, to simply listening to the concerns of a patient, to using more active behavioral and emotive approaches. It also should be understood more generally as the matrix of interaction in which all the helping professions operate. Conventional psychotherapy is conducted primarily by means of psychologic methods such as suggestion, persuasion, psychoanalysis, and reeducation. It can be divided into general categories. All of the therapies can be undertaken either individually or in groups. Research indicates that psychotherapeutic treatment can hasten a recovery from a medical crisis and is in some cases the best treatment for it. Psychotherapy also appears to be valuable in the treatment of somatic illnesses in which physical symptoms appear to have no medical cause. These symptoms are often improved markedly with psychotherapy. In addition, psychotherapy has been shown to speed patients' recovery time from illness. This, in turn, leads to smaller medical bills and fewer return visits to medical practitioners. Support Groups Support groups, as the research literature demonstrates, can have a powerful positive effect in a wide variety of physical illnesses, from heart disease to cancer, from asthma to strokes. Indeed, one study found that women with breast cancer who took part in a support group lived an average of 18 months longer (a doubling of the survival time following diagnosis) than those who did not participate. In addition, all the long- term survivors belonged to the therapy group. Support groups have two other major benefits: they help members form bonds with each other, an experience that may empower the rest of their lives; and they are low cost or even "no cost" (for example, Alcoholics Anonymous). Meditation Mediation is a self-directed practice for relaxing the body and calming the mind. Most meditative techniques have come to the West from Eastern religious practices, particularly India, China, and Japan, but can be found in all cultures of the world. Until recently, the primary purpose of meditation has been religious, although its health benefits have long been recognized. During the past 15 years, it has been explored as a way of reducing stress on both mind and body. It is often recommend it as a way of reducing high blood pressure. Some studies have found that regular meditation can reduce healthcare use; increases longevity and quality of life; reduces chronic pain; reduces anxiety; reduces high blood pressure; reduces serum cholesterol level; reduces substance abuse; increases intelligence-related measures; reduces post-traumatic stress syndrome in Vietnam veterans; reduces blood pressure; and lowers blood cortisol levels initially brought on by stress. Imagery Imagery is both a mental process (as in imagining) and a wide variety of procedures used in therapy to encourage changes in attitudes, behavior, or physiological reactions. As a mental process, it is often defined as "any thought representing a sensory quality." It includes, as well as the visual, all the senses - aural, tactile, olfactory, proprioceptive, and kinesthetic. Imagery has been successfully tested as a strategy for alleviating nausea and vomiting associated with chemotherapy in cancer patients, to relieve stress, and to facilitate weight gain in cancer patients. It has been successfully used and tested for pain control in a variety of settings; as adjunctive therapy for several diseases, including diabetes; and with geriatric patients to enhance immunity. Imagery is usually combined with other behavioral approaches. It is best known in the treatment of cancer as a means to help patients mobilize their immune systems, but it also is used as part of a multidisciplinary approach to cardiac rehabilitation and in many settings that specialize in treating chronic pain. Hypnosis Hypnosis and hypnotic suggestion have been a part of healing from ancient times. The induction of trance states and the use of therapeutic suggestion were a central feature of the early Greek healing temples, and variations of these techniques were practiced throughout the ancient world. Modern hypnosis began in the eighteenth century with Franz Anton Mesmer, who used what he called "magnetic healing" to treat a variety of psychological and psychophysiological disorders, such as hysterical blindness, paralysis, headaches, and joint pains. Since then, the fortunes of hypnosis have ebbed and flowed. Freud, at first, found it extremely effective in treating hysteria and then, troubled by the sudden emergence of powerful emotions in his patients and his own difficulty with its use, abandoned it. In the past 50 years, however, hypnosis has experienced a resurgence, first with physicians and dentists and more recently with psychologists and other mental health professionals. Today, it is widely used for addictions, such as smoking and drug use, for pain controls, and for phobias, such as the fear of flying. One of the most dramatic uses of hypnosis is the treatment of congenital ichthyosis (fish skin disease), a genetic skin disorder that covers the surface of the skin with grotesque hard, wartlike, layered crust. Hypnosis is, however, most frequently used in more common ailments, either independently or in concert with other treatment, including the management of pain in a variety of settings, reduction of bleeding in hemophiliacs, stabilization of blood sugar in diabetics, reduction in severity of attacks of hay fever and asthma, increased breast size, the cure of warts, the production of skin blisters and bruises, and control of reaction to allergies such as poison ivy and certain foods. Biofeedback Biofeedback is a treatment method that uses monitoring instruments to feed back to patients physiological information of which they are normally unaware. By watching the monitoring device, patients can learn, by trial and error, to adjust their thinking and other mental processes in order to control bodily processes heretofore thought to be involuntary--such as blood pressure, temperature, gastrointestinal functioning, and brain wave activity. Biofeedback is used to treat a very wide variety of conditions and diseases, ranging from stress, alcohol and other addictions, sleep disorders, epilepsy, respiratory problems, and fecal and urinary incontinence to muscle spasms, partial paralysis, or muscle dysfunction caused by injury, migraine headaches, hypertension, and a variety of vascular disorders. More applications are being developed yearly. Yoga Yoga is a way of life that includes ethical precepts, dietary prescriptions, and physical exercise. Its practitioners have long known that their discipline has the capacity to alter mental and bodily responses normally thought to be far beyond a person's ability to modulate them. During the past 80 years, health professionals in India and the West have begun to investigate the therapeutic potential of yoga. To date, thousands of research studies have been undertaken and have shown that with the practice of yoga a person can, indeed, learn to control such physiologic parameters as blood pressure, heart rate, respiratory function, metabolic rate, skin resistance, brain waves, body temperature, and many other bodily functions. Regular yogic meditation also has been shown to reduce anxiety levels; cause the heart to work more efficiently and decrease respiratory rate; lower blood pressure and alter brain waves; increase communication between the right and left brain; reduce cholesterol levels (when used with diet and exercise); help people stop smoking; and successfully treat arthritis. Dance Therapy Dance therapy began formally in the United States in 1942, and in 1956 dance therapists from across the country founded the American Dance Therapy Association, which has now grown to over 1,100 members. It publishes a journal, the American Journal of Dance Therapy, fosters research, monitors standards for professional practice, and develops guidelines for graduate education. Dance/movement therapy has been demonstrated to be clinically effective in the following: developing body image, improving self-concept and increasing self-esteem; facilitating attention; ameliorating depression, decreasing fears and anxieties, expressing anger; decreasing isolation, increasing communication skills and fostering solidarity; decreasing bodily tension, reducing chronic pain, and enhancing circulatory and respiratory functions; reducing suicidal ideas, increasing feelings of well-being, and promoting healing; and increasing verbalization. Music Therapy Music therapy is used in psychiatric hospitals, rehabilitation facilities, general hospitals, outpatient clinics, day-care treatment centers, residences for people with developmental disabilities, community mental health centers, drug and alcohol programs, senior centers, nursing homes, hospice programs, correctional facilities, halfway houses, schools, and private practice. Studies have found music therapy effective as an analgesic, as a relaxant and anxiety reducer for infants and children, and as an adjunctive treatment with burn patients, cancer patients, cerebral palsy patients, and stroke, brain injury, or Parkinson's disease patients. Art Therapy Art therapy is a means for the patient to reconcile emotional conflicts, foster self-awareness, and express unspoken and frequently unconscious concerns about his/her disease. In addition to its use in treatment, it can be used to assess individuals, couples, families, and groups. It is particularly valuable with children who often cannot talk about their real concerns. Research on art therapy has been conducted in clinical, educational, physiological, forensic, and sociological arenas. Studies on art therapy have been conducted in many areas including with burn recovery in adolescent and young patients, with eating disorders; with emotional impairment in young children, with reading performance, with chemical addiction, and with sexual abuse in adolescents. Prayer and Mental Healing Prayer and mental healing techniques fall into two main types. In Type I healing, the healer enters a prayerful, altered state of consciousness in which he views himself and the patient as a single entity. There need be no physical contact and there is no attempt to "do anything" or "give something" to the person in need, only the desire to unite and "become one" with him or her and with the Universe, God, or Cosmos. Type II healers, on the other hand, do touch the healee and describe some "flow of energy" through their hands to the patient's areas of pathology. Feelings of heat are common in both healer and healee. These healing techniques are offered only as generalities. Some healers use both methodologies, even in the same healing session, and other healing methods could be described. Many published reports exist, of experiments, in which persons apparently were able to influence a variety of cellular and other biological systems through mental means. The target systems for these investigations have included bacteria, yeast, fungi, mobile algae, plants, protozoa, larvae, insects, chicks, mice, rats, gerbils, cats, and dogs, as well as cellular preparations (blood cells, neurons, cancer cells) and enzyme activities. In human "target persons," eye movements, muscular movements, electrodermal activity, plethysmographic activity, respiration, and brain rhythms have been apparently affected through direct mental influence. These studies assess the ability of humans to affect physiological functions of a variety of living systems at a distance, including studies where the "receiver" or "target" is unaware that such an effort is being made. The fact that these studies commonly involve nonhuman targets is important; lower organisms are presumably not subject to suggestion and placebo effects, a frequent criticism when human subjects are involved. Many of these studies do not describe the psychological strategy of the influencer as actual "prayer," in which one directs entreaties to a Supreme Being, a Universal Power, or God. But almost all of them involve a state of prayerfulness - a feeling of genuine caring, compassion, love, or empathy with the target system, or a feeling that the influencer is "one" with the target. Conclusion In addition to preventing or curing illnesses, these therapies by and large provide people the chance to be involved in their own care, to make vital decisions about their own health, to be touched emotionally, and to be changed psychologically in the process. Many patients today believe their The mind-body approach is potentially a corrective to this tendency, a reminder of the importance of human connection that opens up the power of patients acting on their own behalf. More work needs to be done, but there is already a growing amount of evidence that many of the mind- body therapies discussed in this report, if appropriately selected and wisely applied, can be clinically as well as economically cost-effective, that they work, and that they are safe. Pharmacological and Biological Treatments Pharmacological and biological treatments are an assortment of drugs and vaccines not yet accepted by mainstream medicine. A sampling of biological and pharmacological treatments currently being offered by alternative and medical practitioners includes the following: Antineoplastons Peptide fractions originally derived from normal human blood and urine, presently being used to treat certain kinds of tumors as well as AIDS. Cartilage Products Derived from cattle, sheep, sharks, and chickens, which are being used to treat cancer and arthritis. Ethylene Diamine Tetraacetic Acid (EDTA) Chelation Therapy Used to treat heart disease, circulatory problems, and rheumatoid arthritis and to prevent cancer. Immunoaugmentive Therapy An experimental form of cancer immunotherapy consisting of daily injections of processed blood products. 714-X A nitrogen-providing compound injected into the lymph system near the abdomen to treat cancer and AIDS. Coley's Toxins A mixture of killed cultures of bacteria from Streptococcus pyogenes and Serratia marcescens, used for treating cancer. MTH-68 A vaccine that uses an attenuated strain of the Newcastle disease virus of chickens (paramyxovirus), which may interfere with cancer-related viruses. Neural Therapy A therapy that involves injecting local anesthetics into nerve cell bodies, peripheral nerves, scars, and elsewhere to treat chronic pain. Apitherapy The medicinal use of various products of the common honeybee to treat a variety of diseases: rheumatic diseases such as arthritis; neurological diseases such as multiple sclerosis, low back pain, and migraine; dermatological conditions (for example, eczema, psoriasis, herpesvirus infections); chronic pain; and cancer. Iscador A liquid extract from mistletoe plants used to treat tumors. Biologically Guided Chemotherapy A major impediment to full investigation of alternative pharmacological and biological treatments is the high expense of conducting the trials. Most alternative treatments lack sponsors and funding for clinical trials of safety and effectiveness. Many potentially useful alternative drugs or vaccines are supported by data indicating they may be useful in treating cancer, AIDS, heart disease, hepatitis, and other major health problems. Source: National Center for Complementary & Alternative Medicine For More Information Visit the National Center for Complementary & Alternative Medicine Visit the U.S. Food and Drug Administration ------------------------------------------ COMPLIMENTARY HOLISTIC REMEDIES FOR LYMPHEDEMA TREATMENT by Diana Brady, Holistic Nutritionist Ultimate Health Center, Asheville, N.C. 1/06 Please note that the following article discusses holistic nutritional supplementation that may be useful in supporting a patient's daily regime of self-care. This is not an endorsement by the NLN, nor do we promise results from the use of any of these items listed below. We are committed to presenting all avenues of possibility for improvement of the condition and quality of life for all lymphedema patients. Any and all claims or opinions expressed in this article are solely of the author. Ed. -------------------------------------------------------------------------------- There are many holistic remedies that can support and enhance CDP and manual lymph drainage therapy. Some of these therapies have been around for a dozen or so years, with much clinical research to back them. Others are just now being reviewed in scientific journals, while still others are being used in clinical practice based upon empirical results alone. All of the remedies are non-prescription and consist of enzymes, vitamins, herbs and homeopathic compounds. They are best used in conjunction with the patient's treatment regime and will vary from person to person. I will briefly describe a few of the more popular remedies and reference the clinical research. Suppliers and their phone numbers will be provided at the end of the article. INFLAMZYME FORTE From American Biologics, Chula Vista, CA This product is a specific combination of digestive enzymes, antioxidants and co-factors designed to reduce the accumulation of protein and fats in the lymphatic system and connective tissue. It has similar effect to benzopyrenes without the side effects. It contains: pancreatin, bromelain, papain, trypsin, chymotrypsin, lipase, amalyse, rutin, zinc, superoxide dismutase, catalase and l-cysteine. It must be taken on an empty stomach, with the dosage of three to six tablets three times a day. It is recommended for use before, during and after treatments; until the limb or affected area is close to normal size. At that point, the inflammation and proteins, fats, etc., causing it will be under control. Inflamzyme Forte was created by and for the American Biologics Medical Center in Tiajuana, Mexico. It has been used there very successfully for the past ten to twelve years. Clinical research has been performed by the Bradford Research Institute, Chula Vista, CA. LYMPHOTEND From American Biologics, Chula Vista, CA This is a homeopathic remedy designed to relieve lymphatic congestion. It works well in combination with inflamzyne forte. Lympotend is a specific combination of classic homeopathic remedies manufactured according to the process defined by Dr. Samuel Hahnemann. Although each of the component ingredients has been used since the 19th century, this particular combination is fairly new. Lymphotend has been used in clinical practice worldwide for the past year and a half with excellent results. This product should also be used before, during, and after treatments until the inflammation is reduced. The Bradford Research Institute, Chula Vista, CA is currently accumulating research data. HORSECHESTNUT HERB In a recent study of chronic diseases of the veins, the herb, horsechestnut, was found to be very effective. Horsechestnut was compared to that of compression stockings in 240 patients with chronic venous insufficiency. Patients were randomly assigned to receive either compression treatment, horse chestnut (providing 50 mg of active component escini twice daily), or a placebo for twelve weeks. Horsechestnut was found to be as effective as compression treatment, as determined by the reduction in swelling in the legs. Both treatments were significantly more effective than the placebo. Research was conducted by C. Diehm, and reported in the Lancet, 1996; 347:292-294. This remedy is currently being used in clinical practice. More information will be provided at a later time. DANDELION LEAF EXTRACT From Herbalist & Alchemist, Inc. Herbalist all over the world have considered dandelion a valuable herb for centuries. It has a long folk use throughout the world for a variety of ailments. Dandelion root (Taraxacum officinale) is regarded as one of the finest liver remedies, both as food and as a medicine. The dandelion contains much more nutritional value than many other vegetables, being particularly high in vitamins, minerals, protein, choline, inulin and pectins. Dandelion leaf has been used historically as a natural diuretic aiding in excess fluid loss. Due to its high content of potassium and other electrolytes, there is little, if any side effects to the use of this natural diuretic. Recommended dosage is 30-60 drops, two or three times per day either before or after meals. This can be used indefinitely, but should be used for several months, stopped for a week or so and then started again. It is more effective this way, as the body does get used to the herb and it loses its potency. BURDOCK/RED ROOT COMPOUND From Herbalist & Alchemist, Inc. This is a special formula designed to thin the lymphatic fluid, allowing it to flow more easily, as well as cleansing the lymphatic system itself. It is useful for many conditions of stagnation in the body including congested lymphatics, swollen lymph nodes and low resistance to infections. It contains burdock root (Arcticum lappa), red root (Ceanothus spp.), figwort herb (Scrophularia nodosa), violet herb (Viola odorata), red clover blossoms (Trifolium pratense) and echinacea root (Echinacea angustifolia). Recommended dosage 10-30 drops daily for up to a year or two depending upon the severity of the condition. Breaks should be taken from this compound periodically to ensure effectiveness VITAMINS, MINERALS, ANTI-OXIDANTS It is important to ensure the use of a good multiple vitamin along with potent anti-oxidants like pycnogenol for an indefinite period of time. There are many good products on the market. Some of the manufacturers that we prefer are: Phyto Pharmacia, Enzymatic Therapies, AMNI, Solgar, Twin Labs, etc. SUPPLIERS American Biologics, Chula Vista, CA Consumers..............................800-227-4473 Health Care Professionals...800-332-9345 Phyto Pharmacia, Green Bay, WI 800-553-2370 Herbalist and Alchemist, Inc. N.J. 800-611-8235 AMNI, CA 800-356-4791 Ultimate Health Center, N.C. 800-268-6905 PATIENTS with light to moderate lymphedema may use this supplement program starting several weeks before treatment and then continue it through treatment, says lymphedema expert, Peter Glasser, L.M.T. Before Treatment: Flor Essence tea (2 oz twice daily, 30 minutes before meals); for gentle detoxification when there is a history of infections. Harmony Multi Herbal Cleanse (1-6 capsules twice daily, 60 minutes before rneals; increase water intake to 4 - 12 glasses daily); for colon and body cleansing when there is no history of infections. Add two teaspoons of colloidal silver twice daily to prevent an infection. * Colon Formula (1-6 capsules twice daily, 30 minutes before meals): use if you're not having one bowel motion daily; when once-daily regularity begins, then switch to Harmony Multi Herbal Cleanse. Basic Preventive (two capsules three times daily, at meals); a well-rounded multivitamin with minerals. PCO Phytosome (one capsule twice daily, at meals); grape seed extract as an antioxidant. Dandelion leaf/root extract (30 drops three times daily, at meals); increases urination (works as a diuretic). Garlic extract, colloidal silver, echinacea (per directions); natural antibiotics in cases of infection. At Start of Treatment: Infla-Zyme Forte (3-5 capsules three times daily, 30 minutes before meals on empty stomach): enzymes to break up fat and protein deposits in the lymph and tissues. Lymphotend (ten drops three times daily, on tongue, taken just before Infla-Zyrne Forte); homeopathic remedy to cleanse the lymph. Burdock/red root herbal extract (10-40 drops three times daily; start at ten drops, then increase); to cleanse the blood and lymph. Garlicin Pro (one capsule twice daily); an internal disinfectant. Lymphatic System Cleanse (10-30 drops three times daily, at meals; take for six days, omit seventh day, then resume); contains cleansing herbs. Horse chestnut seed capsules (one capsule twice daily with meals); to reduce swelling and strengthen lymph vessel walls. Vitamin C with bioflavonoids (1,350 mg, at meals); strengthens vascular system. Rutin (500 mg twice daily); to be taken with horse chestnut seed; a bioflavonoid or vitamin C helper, helps reduce swelling and strengthens lymph vessel walls. Optional: Flaxseed oil (1,000 mg daily, with a meal); reduces inflammation. Optional: Echinacea,/red root herbal extract (30-40 drops three times daily); cleanses blood and lymph. Optional: CurcuMax (three capsules three times daily, 30 minutes before meals); contains enzymes, herbs, vitamins, and minerals to reduce inflammation. Optional: GingerMax (two capsules twice daily, before meals); improves blood circulation. * Using Harmony cleanse can sometimes trigger an infection in lymphedema patients by moving toxins faster than the sluggish lymphatic system can eliminate them, says Glasser. For that reason, he always includes a course of colloidal silver to be used with it. ------------------------------------------------ http://www.cancer.org/docroot/NWS/content/NWS_3_1x_Coumarin_and_Lymphedema.asp Coumarin and Lymphedema Study Determines Coumarin Does Not Reduce Lymphedema Article date: 1999/03/04 The drug coumarin is not effective therapy for women who develop arm lymphedema after being treated for breast cancer, according to a study reported in the February 4, 1999, issue of The New England Journal of Medicine. Lymphedema can be a serious consequence of therapy for breast cancer, and coumarin has been reported to be effective in treating lymphedema. In this latest study, researchers studied 140 women with chronic lymphedema in order to confirm results of a previous study, which showed that coumarin reduced lymphedema. "In our study we found coumarin did not alleviate lymphedema, and coumarin-related hepatoxic effects [liver toxicity] were more common than has been previously reported," the authors wrote, adding they cannot explain the differences in the results of the two studies. All of the women studied had lymphedema after treatment for breast cancer and characteristics of the women in both studies were similar. Standards for the study were arm and hand measurements and women’ s perceptions about their symptoms. Although coumarin is marketed in several foreign countries, the Food and Drug Administration (FDA) has not approved its medical use in the US, said Charles L. Loprinzi, MD, of the Mayo Clinic and one of the researchers in the study, though he said women have been able to get the drug through pharmacies formulating it locally as well as from other countries. Dr. Loprinzi also noted during his study coumarin was removed from the market in at least two countries because of death from liver toxicity. The new study should reassure women who are frustrated because coumarin is not available here that they aren’t missing out on an important therapy, said Debbie Saslow, PhD, director of breast and cervical cancer for the American Cancer Society. In the study, women in both groups gave similar responses when asked about their symptoms of arm swelling, pressure, tightness, heaviness, loss of mobility, and the frequency of infections. Women who have lymphedema should see a doctor who recognizes the condition and who is educated about it, Dr. Saslow said. Other recommendations from Dr. Saslow: For mild lymphedema, visit a trained physical or occupational therapist. For the early stages, compression sleeves are suggested, but compression pumps are controversial. For more severe lymphedema there are trained people in this country who can provide more elaborate treatment. Recommendations The most important thing for women who are at risk – women who have had radiation therapy or had any of their lymph nodes removed – is to be aware there is a risk for lymphedema and to follow some of the recommendations below, Dr. Saslow said. The recommended preventative measures are suggestions from women who have had lymphedema. Avoid infection by keeping the arm clean, avoiding cuticle cuts and using gloves for washing dishes and gardening. Avoid extreme temperatures from activities such as taking a sauna or putting hands in ice. Avoid carrying anything heavy such as a heavy purse with a shoulder strap. Never have blood pressure taken or have blood drawn from the arm at risk. Avoid anything constrictive such as a tight wristband or tight jewelry on the arm at risk. Avoid heavy lifting including heavy repetitive weight lifting. Dr. Saslow said some women associate the onset of lymphedema with the change in pressure linked with air travel, and women should wear a compression sleeve when traveling by air. Another suggestion is to examine the arm frequently for any redness, swelling, warmth, heaviness, or bloatedness. The key, Dr. Saslow said, is to catch lymphedema early Coumarin is a dietary supplement that has been studied as a treatment for lymphedema. In the United States, dietary supplements are regulated as foods not drugs. Supplements are not required to be approved by the Food and Drug Administration (FDA) before being put on the market. Because there are no standards for manufacturing consistency, dose, or purity, there may be considerable difference from one lot of dietary supplements to the next. Coumarin was once used in some foods and medications in the United States. It was found to cause liver damage, and its use in foods and medications in the United States has been banned since the 1950s. Coumarin is available in several countries, but has not been approved for use in the United States or Canada. http://www.cancer.org/docroot/NWS/content/NWS_3_1x_Coumarin_and_Lymphedema.asp ----------------------------------------------------------- Horsechestnut Herb in the Treatment of Lymphedema by Diana Brady, Holistic Nutritionist Please note that the following article discusses holistic nutritional supplementation that may be useful in supporting a patient's daily regime of self-care. This is not an endorsement by the NLN, nor do we promise results from the use of any of these items listed below. We are committed to presenting all avenues of possibility for improvement of the condition and quality of life for all lymphedema patients. Any and all claims or opinions expressed in this article are solely of the author. Ed -------------------------------------------------------------------------------- The swelling and edema characteristic of lymphedema is the result of damaged lymph nodes/vessels, often combined with radiation in the case of secondary lymphedema (secondary), or as a result of inborn missing lymphatics or partially functioning lymphatics (primary) which leads into protein accumulation in the interstitial tissue, causing swelling. This manifests itself in various parts of the body, most commonly the arms and legs. Bandaging and compression garments are used successfully to reduce and control edema through pressure. Plant compounds that improve tissue integrity are also used to treat edema, but work in a different manner. One particular herb, horsechestnut seed, contains a plant compound (escin) that strengthens the tissues of the lymph vessels, capillaries and veins. When these tissues are strengthened, there is less leakage of fluid into the surrounding tissue. Edema is therefore reduced at its source. A recent study at the Department of Internal Medicine in Germany proved the efficacy of this herb in clinical testing. Results were published in the February 1996 issue of the Lancet, by D. Diehm (vol. 347, pp.292- 4). The effectiveness of horsechestnut seed extract was compared to that of compression stockings in 240 patients with chronic venous insufficiency. Patients were randomly assigned to receive compression treatment, horsechestnut extract (containing 50 mg. of escin twice daily) or placebo for twelve weeks. Horsechestnut seed was found to be as effective as compression treatment, determined by the reduction in swelling in the legs of the patients. Both treatments were significantly more effective than the placebo. Based upon this study, Peter Glasser, LMT, MLDT, ICMT, began incorporating horsechestnut into his treatment program with encouraging results. His patients were at different stages of treatment when the horsechestnut was introduced, and results have varied from patient to patient. Here are a few of the results reported by just a few of his patients: The first patient to include horsechestnut in her regime was a 69 year old woman with secondary lymphedema of the left arm. She had 11 CDP/Manual Lymphatic Drainage treatments nine months ago, along with Mr. Glasser's complete program of herbs, vitamins and enzymes. She also had one maintenance treatment every two weeks for five months before starting the horsechestnut herb. In addition, she was bandaging nightly or using CircAid garment, and wearing a Juzo compression sleeve with custom hand piece. By this time her affected arm was measuring the same and even less in some areas than her affected arm. After a few days of taking 10 drops of horsechestnut once a day, she stopped bandaging, using CircAid and the compression garment. When she came in for her next bi-monthly treatment, there was very little increase in swelling from her last visit (0.1 cm to 0.4 cm). The patient continued this routine for over three months, but the dosage was increased to 10 drops twice a day. Each time she came in for a treatment, her arm measurements were the same or slightly higher with the increase ranging from 0.1 cm to 0.4 cm. There was only one time when she overexerted herself and her measurements increased between 0.1 cm to 1.3 cm. Her dosage was increased to 30 drops two times daily to try and compensate for her active lifestyle. This appears to be the appropriate dosage for her. When she overexerts herself now, she simply relaxes for a while and allows the swelling to reduce itself without compression garments. The only time she uses the compression garment and CircAid is when she flies. She is extremely happy with these results. A patient with secondary lymphedema of both legs and into the abdominal area began treatment seven months ago. At this time she came in only for maintenance treatments but was enthusiastic about trying a holistic protocol. Along with this, she was treated in the clinic once or twice a month for two months, and then once a month. At that time she was put on 10 drops of horsechestnut twice a day. It took two weeks for any noticeable improvement in the edema, but after two weeks, the edema began to decrease and she was able to stop wearing her compression garments. However, when the weather became warm, the edema increased. Her dosage was increased to 30 drops twice a day and that controlled the swelling. She reported feeling much better on the increased dosage and is very happy with the results. Three months ago, a gentleman with primary lymphedema of the left leg started on five drops of horsechestnut twice a day. At the time he was wearing a full thigh stocking with a knee-high stocking over this for better compression. His work requires him to be on his feet all day. With the addition of the horsechestnut, his leg does not get as hard at the end of the day as it did before the herb was added. He reports that the tissue is soft and supple, even after a long day on his feet. His dosage has been increased to 10 drops twice a day in an attempt to achieve the same results without having to wear the extra knee high stocking. Other patients who have tried the horsechestnut herb have all reported that they feel better, that their edema is reduced and is maintaining. It does take some time to ascertain the correct amount of horsechestnut herb for each individual. However, it is well worth the effort, according to patient reports thus far, as well as physical measurements. Mr. Glasser is currently experimenting with a topical ointment containing aloe vera gel and horsechestnut herb. The type of horsechestnut used by Mr. Glasser is manufactured by GAIA herbs. It is important to get the highest quality product on the market. GAIA can be purchased at many health food stores or can be ordered directly from the manufacturer at: 1-800-831-7780. Emerson Ecologics also distributes the herb. They can be reached at: 1-800-654-4432. http://www.uhealth.net/article6.htm Life Extension Magazine March 2005 PROFILE features people who exemplify the Life Extension Foundation way of life: a commitment to enhanced health and nutrition, as well as an abiding respect for body and mind. Developing a Successful Treatment for Lymphedema By Paul Gains PROFILE: PETER GLASSER "Lymphedema causes massive swelling, usually in the arms and legs. left untreated, it can lead to hypertension and stroke." Millions of Americans suffer from lymphedema, a debilitating condition in which lymphatic fluid accumulates in the interstitial tissues. Lymphedema causes massive swelling, usually in the arms and legs. Left untreated, it can lead to hypertension and stroke. Lymphedema sufferers are often sent home and told to apply bandages and compression garments to the extremities. Although this helps to squeeze fluids out and reduce the swelling, it is a temporary fix at best. Fortunately, a holistic treatment pioneered by Peter Glasser, a North Carolina-based massage therapist, is proving successful with lymphedema patients from across the continent. The treatment involves the administration of supplements and herbs, most notably horse chestnut (Aesculus hippocastanum), in combination with a specific massage technique called manual lymph drainage. An Accidental Discovery In 1995, Glasser moved to Asheville, NC, where he opened a practice called the Ultimate Health Center (www.uhealth.net) with his wife, Diana Brady, a holistic nutritionist. A New Jersey native, Glasser learned about lymphedema while studying massage, and became intrigued by the lack of information about the condition. "I saw a news broadcast one evening on lymphedema and they mentioned massage as part of the treatment program. It's called manual lymph drainage and it piqued my interest," Glasser recalls. "I called and asked what lymphedema was and what they knew about it. I went for an interview and then for two weeks of training to be certified in the treatment of lymphedema." Glasser, a licensed massage therapist, has established himself as something of an authority on lymphedema, which has a variety of origins. It can be caused by a genetic condition, though some people develop secondary lymphedema because of surgery, radiation treatment, or injury. In many cases, it is directly related to cancer surgery. A lot of women get it when they have breast cancer and their lymph nodes are removed," Glasser explains. "With radiation treatment, there's more stress on your lymphatic system. You see it with hysterectomies, which can cause lymphedema in the legs. In men, prostate surgery can cause it in the legs. These are the main causes of secondary lymphedema." While treatment centers have sprung up around the country in recent years, Glasser believes his is the only facility that specializes in the holistic treatment of lymphedema. He criticizes the mainstream medical establishment for failing, through either ignorance or complacency, to warn patients that surgery might cause the condition. "It's a case of the lesser of two evils." Glasser says. "Many patients complain that their doctors never tell them there is a possibility they will develop lymphedema. When they come back and complain to their doctors, they're told, 'you're still alive, aren't you?' "The doctors should be up front and tell patients that there is that possibility, but a lot of doctors don't know much about lymphedema. There is very little training on the lymphatic system in medical school, so a lot of doctors don't know what to do for the swelling. People will go out and get a pump or get compression garments, and they're told to wait and it will get better." As Glasser's hands-on experience in treating lymphedema has grown, so has his practice. In addition to his wife, the Ultimate Health Center now employs several other massage therapists, a physiotherapist, a physician's assistant, and a medical doctor who doubles as the center's medical director. "I was always interested in finding a better way for patients," Glasser recalls. "I would hear a lot of complaints from patients on the amount of bandaging they had to do every night on their arms and legs. They didn't want to do it for the rest of their lives. "I started reading more about herbs and came across an article in The Lancet about horse chestnut being used in Germany and Austria for varicose veins and hemorrhoids. I thought that if it could improve blood vessels, then it could help lymphatic vessels. So I started experimenting with horse chestnut extract, which was then still hard to find in this country. Soon I found that my patients' conditions were improving." Life Extension products figure prominently in Glasser's practice. He recommends that his patients take two capsules of Venotone (horse chestnut) with a quarter teaspoon of Life Extension's Rutin Powder twice a day. This strengthens their lymphatic vessels and helps reduce the edema. "We also recommend Life Extension's two-per-day multi-vitamin and Super Digestive Enzymes, which help reduce fibrotic tissue and edema," says Glasser. Patients' Lives Transformed The Ultimate Health Center's reputation has spread quickly throughout the US. Although most of the center's patients are from North Carolina and bordering states, Glasser has treated lymphedema sufferers from as far away as California and Canada. "I had lymphedema for almost 20 years, but the doctors couldn't tell what it was," says 52-year-old Susan Philips, one of the center's long-time patients. "Finally in 1999, I went to a major teaching hospital in Winston-Salem, NC. They started working on me and could get the liquids squeezed out of my legs, but my legs would fill right back up. I had gotten to the point where I could hardly walk. My calves were larger than my waist." Philips was referred to the hospital's occupational therapy department, whose staff was well aware of Glasser and his treatment protocol. But getting an appointment at the Ultimate Health Center proved difficult, as Glasser was taking on more patients. "He had a long waiting list, so I originally saw him in July 1999 but didn't start manual lymph drainage treatment until that October," says Philips. "I did begin taking horse chestnut in July. I had already lost inches of swelling off my legs by the time I saw him in October, just from taking the supplements." Like many of his other patients, Philips is now on what Glasser calls a maintenance program, which involves taking horse chestnut daily. She also applies it to her skin each day. While she originally took treatments at the center six times a week, those have been scaled back to twice a month. Over the years, Philips has lost most about 150 pounds. Glasser believes from that this has extended her life. Philips says that while her legs have returned to normal size, they are still deformed from enduring 20 years of lymphedema. Doctors now almost believe her condition is hereditary, since her younger brother and sister also suffer from lymphedema. Another long-time patient, 69, year-old Vicki Stokes, developed lymphedema after a radical hysterectomy. Doctors discovered she had cervical cancer, thus necessitating the surgery. According to Stokes, however, the doctors went too far. "My oncologist was not familiar with the lymphatic system at all," Stokes explains. "I diagnosed myself. He removed an unreasonable amount of lymph nodes from each side, saying that he was trying to prevent a recurrence. "So I got on the Internet and found out about lymphedema. "I belong to an online support group with people from Israel, India, South America, and all over the world. That's where we share information. The doctors remove lymph nodes. Mine were all healthy. That causes lymphedema." Twice a year, she makes the journey to Asheville from her home in San Diego for a weeklong maintenance treatment, and she showers praise on Glasser and his team. Despite his success to date, Glasser continually seeks ways to improve his treatments. Although he tells patients to follow his protocol for six months to a year, he often sees them improve much more quickly. He ascribes that rapid improvement to the quality of the horse chestnut and other supplements he prescribes. "I started using Rutin Powder along with the horse chestnut," Glasser explains. "Rutin is a bioflavonoid that works well in combination with horse chestnut. When I first started, horse chestnut was an extract. I would tell patients to take 30 drops with a little bit of water, twice a day. Then it started coming in capsules, so I started advising patients to take one capsule, twice a day, and I found that it works better." Because horse chestnut is a powerful herb that can cause nausea and other gastrointestinal problems, Glasser advises his patients to take it with meals. Glasser recommends that patients who are already on blood thinners to forego horse chestnut. He also advises pregnant women not to use horse chestnut. As Glasser and his staff continue to treat lymphedema patients, they are learning more about its prognosis and adjusting their treatment protocols accordingly. Glasser believes there are millions of people with lymphedema who can be treated with horse chestnut and relieved of this crippling condition. While his patients have Glasser to thank for regaining their health, he is quick to share the credit. "The way my wife and I see it, Life Extension is the leader in the philosophy that aging and disease can be prevented or corrected," Glasser says. "That's a philosophy that I happen to share." Medline: http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-horsechestnut.html. Horse chestnut appears to be fairly safe, as long as it is standardized and does not contain significant levels of esculin (constituent of horse chestnut that is toxic except at low or moderate doses). The same caution is sounded by James A. Duke, a leading world authority on herbs, in his book The Green Pharmacy. http://healthlibrary.epnet.com/GetContent.aspx?token=e0498803-7f62-4563-8d47- 5fe33da65dd4&chunkiid=21758 Safety Issues Whole horse chestnut is classified as an unsafe herb by the FDA. Eating the nuts or drinking a tea made from the leaves can cause horse chestnut poisoning, the symptoms of which include nausea, vomiting, diarrhea, salivation, headache, breakdown of red blood cells, convulsions, and circulatory and respiratory failure possibly leading to death.19 However, manufacturers of the typical European standardized extract formulations remove the most toxic constituent (esculin) and standardize the quantity of aescin. To prevent stomach irritation caused by another ingredient of horse chestnut, the extract is supplied in a controlled- release product, which reduces the incidence of irritation to below 1%, even at higher doses.20 Properly prepared horse chestnut products appear to be quite safe.21 After decades of wide usage in Germany, there have been no reports of serious harmful effects, and even mild reported reactions have been few in number. In animal studies, horse chestnut and its principal ingredient aescin have shown a low degree of toxicity, producing no measurable effects when taken at dosages seven times higher than normal.21,22 Dogs and rats have been treated for 34 weeks with this herb without harmful effects. Individuals with severe kidney problems should avoid horse chestnut.23-25 In addition, injectable forms of horse chestnut can be toxic to the liver.26 The safety of horse chestnut in young children and pregnant or nursing women has not been established. However, 13 pregnant women were given horse chestnut in a controlled study without noticeable harm.29 Furthermore, studies in pregnant rats and rabbits found no injury to embryos at doses up to 10 times the human dose, and changes of questionable significance at 30 times the dose.21 Horse chestnut should not be combined with anticoagulant, or blood-thinning, drugs, as it may amplify their effect.27,28 -------------------------------------------------------------------------------- Interactions You Should Know About If you are taking aspirin, clopidogrel (Plavix), ticlopidine (Ticlid), pentoxifylline (Trental), or anticoagulant drugs such as warfarin (Coumadin) or heparin: Do not use horse chestnut except under medical supervision. ---------------------------------- Self-Care: Massage Introduction Living Well With Lymphedema Performing self-massage is an important role that you play in managing your lymphedema! The primary purpose of self-massage, also known as lymphatic massage, is to improve the flow and drainage of lymph by stimulating the lymphatic vessels. Your lymphedema therapist will instruct you in a program of daily self-massage. Since this is an important and your should perform self-massage regularly as directed by your therapist. [1] Self-Massage Basics If you have an infection, or any indication that you are developing an infection, you may need to modify or skip your self-massage until the infection is under control. Self-massage is a gentle technique that should never hurt or make the skin red. Self-massage is not the same as conventional muscle massage. Do not allow anyone, other than a trained lymphedema therapist, to instruct you in how to perform massage using deep strokes on lymphedema affected tissues. Self-Massage is best performed first thing in the morning before bandaging or exercising, and at other times as specified by your therapist. Self-massage should be performed in a time and place where you can be relaxed and will not be disturbed. The time devoted to self-massage varies depending on your condition and the instructions of your lymphedema therapist. Most self-massage strokes use very little pressure and the hands do not slide over the skin. Instead they move and stretch the skin to stimulate the lymphatic capillaries located just under the skin. Therefore, oils and lotions that make the skin slippery are not used during self massage. Self-massage movements are repeated from five-to-seven times in the same position. This matches the subtle pumping motion of the lymphatic vessels in a rhythm of five-to-seven pulsations per minute. Self-massage begins at the terminus. This clears the terminus so that lymph flowing upward from other parts of the body can move freely into the terminus where it will rejoin the circulatory system. ------------------------------------------ Aloe The gel extracted from aloe (Aloe vera) leaves is a cost-effective, natural way to treat a variety of seasonal ailments: it can be used topically for the treatment of windburn, skin irritations or inflammation, and rashes. Look for a whole, living plant at your local garden store, cut open the leaf and apply the gel generously as needed. Or, choose a lotion (look for those with a high percentage of aloe gel) or a gel product. Although aloe is great for minor heat burns, you should always contact trained medical personnel to treat burns with significant blistering. -------------------------------------------- avoid deep massage strokes on pregnant womens legs, also lymphedema There is truth to this, the really deep pressure can damage nodes on someone with lymphedema or pregnant, keep in mind alot of people do get deep tissue massage on their limbs and legs BUT they are not people with lymphedema, those are more sports oriented. Deep cross fiber friction work, speading and other techniques are good to break up scar tissue, relax spasmed muscle which do block lymph flow are good techniques BUT only done by a knowledgeable, qualified person, they have to be done the right away. Avoid Deep Massage Strokes on Pregnant Women's Legs! A Spa Site Guest Article by Elaine Stillerman, LMT, the author of "MotherMassage: A Handbook For Relieving the Discomforts of Pregnancy" and "The Encyclopedia of Bodywork" and the developer and instructor of the professional certificate program MotherMassage: Massage During Pregnancy, taught at massage schools and spas across the country. Contact Elaine Stillerman, L.M.T. Massage Therapist 108 E. 16 Street Suite 401 New York, NY 10003 Tel: (212) 533-3188 Fax: (212) 533-3148 http://mothermassage.net/ Related Resources • Elaine Stillerman's NY Massage Practice • MotherMassage®: Massage During Pregnancy Professional Certification Course Description • Breech Presentation, a Spa Site Guest Article by Elaine Stillerman, L.M.T. • Spas that Offer Maternity Treatments Related Books MotherMassage The Encyclopedia of Bodywork Several weeks ago, I got a frantic call from a colleague and former student. She was distressed about a pregnant client she had just massaged.The client wanted her to massage her sore legs deeply, but my colleague explained to her that she couldn't because of several physiological changes in her circulation. The disgruntled client then called me up to complain. I assured her that her massage was administered correctly. "Well," she said in a huff, "I don't care what you think, I'm going to find someone who will work deeply on my legs." I told her that anyone who would do so probably didn't understand the changes in her body and if she did, would be acting irresponsibly. During pregnancy, several physiological changes in her circulatory system caution the use of deep massage work. As a way to prevent hemorrhaging during labor, her body increases her coagulating activity (the creation of fibrin) 4-5 times. The potential of developing blood clots is 5-6 times greater than when she is not pregnant. In some cases, these thrombi cause pain, heat, muscle spasms and are symptomatic. However, sometimes the presence of thrombi is asymptomatic: there is no over-riding pain or discomfort. These clots are generally found where the blood is most stagnant - the iliac, femoral and saphenous veins of the legs. Deep massage strokes, ischemic compression (i.e. acupressure, shiatsu), deep vibration, tapotement or friction could dislodge these clots are send them coursing through the circulatory system. The result could be a stroke, or coronary or pulmonary thrombosis. Another equally important consideration is the increase in interstitial fluid. By the third trimester, the fluid within her tissues can increase as much as 40%. It is no wonder, then, that her legs are tired and sore. But the only way to effectively increase removal of the fluid is through lymphatic drainage technique. This massage technique is light to enhance the lymphatic drainage of the superficial lymph vessels. The direction of this light pressure is always towards the heart and the massage starts at the proximal portion of the leg (knee to hip) to open the channels and then continues from ankle to knee to hip and finally from the feet (distal) up the leg to the hip. Traditional Swedish massage strokes, or any other deep technique, can actually inhibit lymphatic drainage. These strokes (i.e. deep effleurage) cause an increase in arterial blood flow. You can see this when the skin turns red after an area has been massaged (hyperemia). This increase of arterial blood flow causes an increase in blood capillary pressure and subsequent increase in ultra filtration of water. Therefore, more water accumulates within the tissues causing an increase in lymph load and lymphedema. Another reason to avoid deep Swedish massage strokes on pregnant women's legs is that the superficial lymphatics are vulnerable to external pressure and damage can be done to the anchoring filaments and endothelial lining of the lymph vessels. As a spa director or massage practitioner, you want to do what is right and best for the client. When a pregnant client tells you her legs bother her, the best way to treat them is to address the cause of the problem: fatigue and soreness from swelling. Even if her legs aren't swollen, it is still important to massage them following lymphatic protocol to avoid dislodging potential blood clots: lightly. The fact that the lymph load is decreasing from this safe and appropriate care will provide her with much needed and welcomed relief." Elaine Stillerman, LMT is the author of MotherMassage: A Handbook For Relieving the Discomforts of Pregnancy (Dell, 1992) and The Encyclopedia of Bodywork (Facts On File, 1996). She is the developer and instructor of the professional certificate program MotherMassage: Massage During Pregnancy, taught at massage schools and spas across the country. ----------------------------------------- Instructions to drain the face: start at forehead middle, drain both sides towards the temple keep going down and over as indicated by arrows. You want to drain all areas. After each arrow set, drain the waterwheel (nodes behind the ears) and clavicle (collarbone area nodes) and axilla (underarm) nodes. Do each area with 20 strokes (each line). When you finish, make sure to drain the thoracic duct sides of the body, iliac nodes and inguinal nodes. the thoracic duct is the sternum area between your breasts. Iliac nodes are each side of the bellybutton and inguinals are groin, crease of the leg nodes. --------------------------------------------- THE IMPORTANCE OF BODY AND LYMPHATIC DETOXIFICATION IN THE TREATMENT OF LYMPHEDEMA by Diana Brady, M.A., Holistic Nutritionist Please note that the following article discusses holistic approaches and/or alternative nutritional/herbal supplementation that may be useful in supporting a patient's daily regime of self-care. This is not an endorsement by the NLN, nor do we promise results from the use of any of these items listed below. We are committed, and at request of our members, to presenting all avenues of possibility for improvement of the condition and quality of life for all lymphedema patients. Any and all claims or opinions expressed in this article are solely of the author. Ed. -------------------------------------------------------------------------------- "Every tissue in the body is fed by the blood, which is supplied by the intestines. When the intestines are dirty, the blood is dirty and so are the organs and tissues. It is the intestinal system that must be cared for first before any effective healing can take place," according to Dr. Bernard Jensen, D.C., Ph.D. This thought was echoed by Joseph D. Beasley, M.D. and Jerry Swift, M.A. authors of the 1989 Kellogg Report, "In today's conditions, most adult patients have to be detoxified and nutritionally restored before specific diagnosis can be formulated" 1. Today's conditions refer to the amount of external and internal toxins bombarding us every day. External toxins were quantified in 1989 by U.S. Environmental Protection Agency, Office of Toxic Substances 2 to be the following: * 551,034,696 pounds of industrial chemicals were dumped into public sewage storage. * 1,180,831,181 pounds of chemicals were released into the ground, threatening our natural aquifers. * 188,953,884 pounds of chemicals were discharged into surface waters. * The total amount of air emissions pumped into the atmosphere was 2,427,061,906 pounds. * A grand total of 5,705,670,380 pounds of chemical pollutants were released into the environment in 1989. Toxic chemicals easily find their way into our body through the air we breath, the food we eat and the water we drink. Obviously these toxins must be eliminated before they can disrupt normal metabolic systems and processes. Yet, although the body is designed to eliminate toxins, it cannot always handle the overload present in today's environment. In addition to external toxins, our own bodies produce internal toxins through normal metabolic processes such as digestion, muscle movement and cellular activity. Consequently, annual and bi-annual detoxification is routinely recommended by many health care professionals regardless of health status. However, healthy detoxification takes on an even more important role in a disease, lymphedema, characterized by a breakdown in the detoxification mechanism itself. Lymphedema is characterized by edema and blockage of the lymphatic system. The lymphatics have three very important functions, according to Dr. Gerald M. Lemole, Chief of the Department of Thoratic and Cardiovascular Surgery, Deborah Heart and Lung Center, Browns Mills, New Jersey: "First of all, the lymphatics return protein to the bloodstream. As much as 50 percent of our serum protein can leak out of our bloodstream during a 24-hour period, and it is the job of lymphatics to return this protein to the blood. Second, the lymphatics clear the spaces between our cells and carry away toxins and foreign particles such as bacteria, large proteins, cholesterol, and viruses. We were taught that the liver and kidneys clear away toxins, but it is actually the lymphatics that clear away the fluid that bathes each cell of our body. Third, the lymphatics are an integral part of our immune system. The white cells, called lymphocytes, circulate in and out of the lymphatics and help destroy foreign particles like bacteria, viruses and parasites. "The trouble begins when the lymphatic system becomes blocked or the flow of lymph slows down appreciably. It's like the kitchen sink: if the drain is clogged but you leave the water running, the water will eventually run all over the floor." Not only is the lymphatic fluid blocked, but so are all the toxins, bacteria and viruses that the lymphatic fluid normally drains from the body. It is no surprise that lymphedema patients suffer from other varied health ailments. The stagnant lymph fluid is a breeding ground for bacteria, parasites and viruses; and a cesspool of toxic waste. Peter Glasser, MLDT, LMT, ICMT of Ultimate Health Center, Asheville, N.C. uses herbal cleanses as an integral part of his treatment for lymphedema. The results show improvement, not only in the lymphedema, but also in the overall health and well being of the patient. Peter has also found that when an herbal cleanse is initiated before treatment begins, treatment time itself is shortened and results improved. His typical treatment period is between two to four weeks, with 90% of his patients requiring only two weeks of one treatment per day. It is critical to undertake an herbal cleanse under the care and scrutiny of a qualified health care practitioner. Each individual may react different to the cleansing process itself, and to the herbs contained within the cleanse. A cleansing program needs to be established for the circumstances and needs of the individual patient, and closely monitored for any adverse reactions. The herbal cleanses remove some of the toxins in the blocked lymphatic fluid and start the process of lymphatic drainage. Patients have reported a decrease in swelling of affected limbs and a softening of hardened tissue before treatment even begins. Some patients chose to use an herbal cleanse after their CDP treatments, and still noticed improvements in their lymphedema and overall health. The herbal cleanses preferred by Mr. Glasser include both a commercial tablet and a specially prepared liquid formula. The commercial tablet is available in most health food stores as Nature's Secret A.M./P.M. Multi-Cleanse. The liquid formula is specifically created for Mr. Glasser by Herbalist and Alchemist of New Jersey and GAIA herbs. The A.M./P.M. herbal cleanse contains: alfalfa leaf, black cohosh root, burdock root, cayenne fruit, cascara sagdrada bark, chickweed herb, dandelion root, echinacea angustifolia leaf extract, fennel seed, fenugreek seed, ginger root, guar gum, hawthorn berries, horsetail herb, marshmallow root, milk thistle extract, mullien leaf, papaya leaf, peppermint leaf, plantain root, psyllium seed, red clover leaf, safflower oil, slippery elm bark, yarrow flower and yellow dock root 4. The herbal cleanse works by cleansing the body , blood and lymphatics. Waste is eliminated by stimulating additional bowel movements. The amount and type of bowel movements needs to be monitored so that they do not exceed two to three per day, and do not become too watery. Additionally, because toxins and bacteria are being mobilized, some symptoms of detoxification should be expected . They include: flu like symptoms, fatigue, flatulence and in some cases, a slight rash. Mr. Glasser normally recommends going very slowly with the cleanse, monitoring progress and including what is considered a "natural antibiotic," such as colloidal silver, in the regime. The "natural antibiotic" is to ensure that as the bacteria are mobilized from the system, they are destroyed before they can multiply. Also, included in the regime is a good multi-vitamin, pycnogenol and dandelion root/leaf. The multi-vitamin provides necessary vitamins and minerals to strengthen and revitalize the body, pycnogenol combats free radical production in the blood and lymph system, and dandelion helps the liver and kidneys deal with the elimination of toxins while also aiding in edema reduction. The custom liquid formula contains herbs historically used to cleanse the lymphatic system 3: echinacea, cleavers, golden seal and poke root. This formula is taken three times a day with the usual starting dose of between 10 to 30 drops. To date, no side effects have been reported using the liquid formula. Either one or both of the herbal cleanses is and excellent way to start the process of lymphatic drainage. The benefits obtained can shorten the treatment time and help the patient achieve a greater level of overall health and well being. REFERENCES 1. Beasley JD, Swift JJ. The Kellogg Report. Institute of Health Policy and Practice, The Bard College Center. 1989;Ch 4:171. 2. U.S. Environmental Protection Agency, 1991. Toxics in the Community: National and Local Perspectives. The 1989 Toxics Release Inventory National Report. Office of Toxic Substances, Washington, D.C. 3. Hoffman, David. The Holistic Herbal. Element Books, Inc. Rockport, 1995; 32. 4. Herbal Research Publications. Naturopathics Handbook of Herbal Formulas. Herbal Research Publications, Inc., Ayer, Massachusetts. 1996; 133-15 ------------------------------------------------- TIPS FOR HEALTHY EATING WHILE TRAVELING: Bring your own sandwiches and fresh fruit in a cooler or picnic basket. Keep an assortment of dried fruit handy for snacking, it will satisfy your sweet tough while providing disease fighting antioxidants. Better yet make your own trail mix with dried fruit, mixed nuts, sunflower seeds. Pack single servings of precut baby carrots, celery, or bell peppers in resealable bags to snack on. Use small plastic containers to pick dips such as low fat ranch dressing, peanut butter or hummus. Freeze grapes the night before so they are chilled for your trip. They make great bite sized snacks and taste great with small cubes of low fat cheese. For convenience, pick up prepackaged fruit slices or vegetables at the grocery store. Some even come in their own containers with utensils and dipping sauces. You can also buy peanut butter in a squeezable tube. It tastes great on apple slices or granola bars. Many fast food restaurants offer fruit and vegetable options instead of fries. You can also usually request a fruit cup or side salad for an additional service of fruits or vegetables. *Note McDonalds now has a fruit and nut salad!. Switch from soda to low fat milk or water or experiment with various flavors of herbal teas. As an appetizer, order a salad with low fat dressing or oil and vinegar. Opt for tomato juice, vegetable juice or water on the airplane. Order a small fruit smoothie at the juice bar. Don't necessarily skip your favorite dessert or fried foods. Eat smaller portions of these and make them treats, not regular menu items. Watch portion sizes. Share an appetizer or antree or choose two appetizers instead of an entree. Prepare half of your meal yourself and snack on fruits and vegetables Diet Reading With so many diet programs and pills on the market today you may be asking yourself which dieting plan you should consider purchasing. Our goal is to provide you with the most unbiased diet reviews for both the good diet programs as well as the bad diet programs on the web. Celebrity film stars are different from people around, with cooks, fitness trainers and continual other people to assist them, they lead a life which is completely different. So the Celebrity Diets aught to be different too! To the celebrities their million-dollar image is so important that the Celebrity Diets can go to any extent, no matter how bad the diet is, to sustain that Star look. Celebrity Diets can be very strict and can even extend to long fasts, which otherwise can be harmful to the common workingman. Looking curiously at some of the secret Celebrity Diets, one very popular one is Hampton diet. It's a plan designed by Dr. Fred Pescatore (M.D) and is basically a low carbohydrate eating plan centered upon whole and organic foods and good fats such as macadamia oil. Every famous celebrity is associated with a book, a DVD, infomercial, and other publicized diet plans. And others keep appreciating the Atkins and the Hampton diet. One thing should be very clear. Celebrities can advice about acting maybe and its also acceptable, but advice about a diet plan should come from a health care professional such as a registered dietician. Most Celebrity Diets are faked and as per the reputation of the so-called Celebrities to promote. The words might appear harsh, but they are very true. Following a celebrity diet just out of mere appreciation for the Star can cause detrimental results. Also, Celebrity Diets promote very quick programmes, which are hard to follow, and ballyhoo all types of ideas in the diet plan. And if people who are not technically trained to do so design these so called Celebrity Diets, then the results can be really detrimental. Again, Celebrities are paid huge cash in order have that good look and can thus meet the expense of hiring personal chefs, masseur and other people to do whatever they wish. Ordinary people, or common men, must seek help of a diet plan that is affordable, practical and also includes food that are available. There is no need to feel awful and depressed because one has to cut out upon the Celebrity Diets, its simply because the Celebrity Diets are not worth following. The Celebrity Diets, just like their celebrities, are good to look at and lucrative from far away, what remains inside these Celebrity Diets and their celebrities is an abysmal mystery, otherwise why do they are always on the get to a simple lifestyle at every opportunity. Celebrity Diets, be happy where you are among the Stars! ----------------------------------- Non-Surgical Weight Loss ST. LOUIS (Ivanhoe Newswire) -- For the first time in this country, doctors are performing a weight loss procedure without a single incision. It's a new experimental option for obese patients who want to drop the pounds without having major surgery. A nine pound weight loss in two weeks amazes Carrie Williamson. The 30-year old has been overweight since she was a child. "I had done Meridia, Weight Watchers," Williamson recalled to Ivanhoe. "You name it, I did it." That's why she volunteered to be the first American patient to undergo a new form of stomach stapling surgery without incisions. It's called transoral gastroplasty, or TOGA. "The thing that's unique about this is that it's all done through the mouth," J. Christopher Eagon, M.D., an assistant professor of surgery at Washington University School of Medicine in St. Louis, told Ivanhoe. Washington University surgeons 'stapled' Williamson's stomach by passing flexible instruments down her esophagus, to the stomach where a restrictive pouch was created. "The jaws open up, pull a portion of the stomach into the jaws, and then close it down and fire the stapler and that creates that tubular type of anatomy," Dr. Eagon explained. The pouch collects food as it enters the stomach, giving the patient a feeling of fullness after a small meal. "Because you take in so little food, you have to make sure you take enough protein -- enough nutrients," Williamson said. In the pilot study, patients on average lost 40 percent of excess body fat within a year of the procedure. Doctors say that's slightly less than gastric bypass, but patients recovered quickly and had a low risk of complications. Williamson is blogging about her experience in the TOGA study. She writes: "I did the bike for 30 minutes … more than I ever thought I could do!" "I had surgery on Wednesday and went back to work on Monday," Williamson said. A schedule-friendly procedure that has many of the weight loss surgery benefits without a single incision. Researchers in Mexico and Belgium successfully tested TOGA weight loss over the past year. TOGA patients stayed overnight in a hospital after the procedure, but doctors believe it will eventually be performed on an outpatient basis. The TOGA study is investigating 275 cases across the United States. Volunteers who want to enroll must be 18 to 60 years old and be at least 100 pounds overweight. FOR MORE INFORMATION, PLEASE CONTACT: Toga Clinical Study http://www.togaclinicalstudy.com ------------------------------------------------------------ The Fat Flush Diet can be subdivided into three phases. In the ultimate phase the Fat Flush Diet recommends 40 percent carbohydrates, 30 percent protein and 30 percent fat, a ratio that is best suited when most toxins are out of the human body. However in the incipient stages, first two stages, there remain a lot of restrictions to achieve proper functioning of the Fat Flush Diet plan. Discussing the phases one by one, beginning with the toughest and the strictest...the first phase.This first phase of the Fat Flush Diet is like a purification phase, cleansing the liver and nourishing it in the proper way to achieve effective weight loss. Restrictions include strictly upon not using herbs or spices except for the fat flushing herbs and spices outlined in The Fat Flush Plan, margarine, alcohol and sugar too are restricted. Leaving aside flaxseed oil, all oils and fats are restricted too. Even vegetables like grains, bread, cereal or starchy vegetables such as beans, potatoes, corn, parsnips, carrots, peas, and pumpkins are removed from the first phase of the Fat Flush Diet. Neither dairy product is spared in the plan. Coming down to the second phase of the Fat Flush Diet, it incorporates more food preferences, including the option of adding some small amount of carbohydrates. Finally coming round to the third phase of the Fat Flush Diet, some dairy products as well as starch containing vegetables are included along with some grains too. This is the final phase of the Fat Flush Diet plan where the human body is effectively trained for the Fat Flush process enhancing weight control and keeping healthy in the same time. The Fat Flush Diet is a progressing diet plan that continues from a very strict plan onto a trained and later conventional diet in its final phases. However people following this Fat Flush Diet plan reportedly have had a lot of health benefits and this assures the success of the Fat Flush Diet. Anyways, the diet remains to be popular among people irrespective of its strictness thereby proving that discipline is the foundation of a healthy empire named LIFE! The grapefruit diet promises that you can lose up to 50 pounds in as little as two and a hald months time. Are you kidding? Not only is this type of weight loss very unhealthy, but is also nearly impossible without totally depriving your body of nutrients.The grapefruit diet consists of eating four meals throughout each day. Meal 1 would consist of a half grapefruit, 3 eggs(any style), and two slices of bacon! Healthy? I don't think so. Meal 2 would consist of another half grapefruit, any piece of meat you want, and a salad with any type of dressing. Is salad dressing healthy? No. Meal 3 consists of the exact same thing as meal 2, but add 1 cup of coffee into your meal. Finally Meal 4 consists of either 1 eight ounce glass of tomatoe juice or 1 eight ounce glass of skim milk. This is one of those diets that many of you may have tried in the past and found that it didn't work. Although the grapefruit diet seems very easy, it doesn't produce results and is far from a healthy and permanent way of dieting. The reason why the Mediterranean Diets are being so popular is because research reveals that the people of the Mediterranean live the longest of lives! Starting from Italy, Crete, Spain to France. The imperative portions of the Mediterranean Diets are perhaps the spectral blend of a variety of component foods like lofty quantities of cereals, olive oils, dry fruits, garlic, herbs and also sea food. Poultry is also included in the Mediterranean Diet more often than red meat; also Wine is moderate component of the Mediterranean Diet. In total the Mediterranean Diet is a different mixture of nutrient foods. The Mediterranean Region covers 3 continents with above 17 countries and for years all these countries have had their influences upon the Mediterranean Diet whose age old recipes are a stupendous mingle of all the cultures of these countries. From Turkey, Portugal, Spain, Egypt and Arabia all with different ways of living and thinking have contributed to the making of this great Mediterranean Diet that outshines all other diets in it's diversity. The Arabs brought the richness of spices to the Mediterranean Diet. They also added the Mediterranean Diet with nuts, saffron, rice and fruits. Taking a closer look at the Mediterranean Diet, it can be observed that this diet is a perfect and wholesome natural diet without the dependency upon manufactured foods. The followers of the Mediterranean Diet, on principle, take reduced amounts of saturated fats and whatever fats the Mediterranean Diet provides the body with are monounsaturated in nature that primarily does not elevate cholesterol levels in the blood. Thus Mediterranean Diets have the miracle of reducing the rates of heart diseases and subsequent death rates. The credit to this can be partially admitted to the Mediterranean Diet without dispute. The consumption of the so called monounsaturated fats, fruits, dry fruits and high quantities of cereals makes the Mediterranean Diet a good plan to supply the human body with essential nutrients, vitamins and no foul components and thereby the Mediterranean Diet prevents diseases very efficiently. However not enough is known whether these goods are only due to the Mediterranean Diet or due to the climatic factors and lifestyles of the Mediterranean Countries too, and to what extent. Thus the Mediterranean Diet is not officially suggested very often as much of the research still lays ahead, however there no denying that the Mediterranean Diet does have some good effects. Hence the Mediterranean Diet remains to enthrall people around the world with the wonders it can do to the human race. The name Subway Diet seems a bit puzzling to the common reader, but it is certainly a twister in it's own way! Also Subway Diets have a great story behind them. It's a popular story about a college student named Jared Fogle, who weighed around 410 pounds. He, Jared Fogle, one day noticed an advertisement in Subway about low fat subs. He followed the idea and the meals really helped him drastically. This was the story about Subway diet. Now looking at the facts about Subway diets. The key idea is a good selection of low-calorie subs that can comprise a person's lunch, frequent snacks during even weight loss plans in order to reduce junk food intake and dinner. However only the subs are not sufficient. People need to include vegetables and fruits, for instance, to supplement the Subway diet and make it complete. The only fact that proved it is that Subway diets are not properly planned and are the least scientific of all diets. Neither does the Subway diet plan follow any calorie-measured path. Thus it is an intuition-based program that can cause a lot of problems with people with diseases such as heart problems and diabetes, which really need a specialized and properly planned diet and not just Subway diet. Subway diets are good to follow casually, but if followed seriously them they should be properly supplemented with other foods to provide the correct calorific intake a human body requires. Otherwise the Subway diet instead of helping weight loss plan would cause a person to lose strength and energy. Hence no fruitful results would come out of the Subway diets in any way. The most active ingredients in Trim Spa are ephedrine and caffeine. Like other ephedrine/caffeine-based products, Trim Spa works by inducing thermogenesis (the production of heat), which speeds up your metabolism and burns calories. It also has an appetite-suppressing effect, so you feel less hungry and therefore eat less Trim Spa now offers an ephedra free version of their popular ephedra pills. -------------------------------------------------------- DO's and Don'ts: DO'S and DON'TS of LYMPHEDEMA: Outdoors DO protect your arm from sunburn. Always wear sunscreen. DO avoid insect bites. Wear something to guard yourself from insect bites whether it be bug repellent or long sleeves and pants. DO wear gloves when gardening, shovelling, and yard work. DO exercise and do stretches before outdoor work. Be careful you don't over exert. DO NOT allow outdoor pets to scratch or bite you. Be sure if you do happen to get scratched, you clean it properly and quickly to avoid infection and make sure your tetnus shots are up to date. DO NOT expose your affected areas in outdoor hot tubs. DO NOT play sports that can injury you with falling, bumps, bruises, etc. Indoors DO wear gloves when doing housework or cooking. If you do happen to get cleaning products on yourself, wash immediately and look for irritation. Apply antibacterial or necessary ointment to prevent infection from any breaks in the skin. This also applies to burns. The OVGlove works wonders for taking pans out of the oven for those with arm/hand lymphedema. DO NOT allow pets to bite you or scratch you even in play. Always be careful when handling any pets. DO NOT iron or sew without proper hand protection whether it be a thimble or glove when ironing. Hygiene DO make sure you keep your affect areas clean and use moisturizing lotions to keep the skin supple. DO make sure you wash and apply any ointments, lotions, and antibacterial remedies immediately after a cut or scratch. DO dry your body thoroughly after bathing, and be sure the water is warm, not hot. It is good practice to do skin brushing wet work or dry work before or after bathing. Skin brushing helps remove dead dry skin and also stimulates the superficial lymph nodes under the skin to promote lymph flow. While in the tub, you can make it a practice to save time (for women) to do breast exams. Everyone can also check their body over for any odd moles or patches of skin (skin cancer check). You can also save time by doing some self massage as well. Grooming and Accessories DO wear a well fitted bra. There are actually bra's made for lymphedema, one company makes a compression bra. The company is named Bellise. Be sure the straps on your bra do not cut in your shoulders and the edges of the bra don't have anything to irritate the skin (sharp edges on lace, etc). Some prefer to go bra-less. Some also use stick on patches. Be careful of the adhesive on these as it can irritate the skin. If you wear a prosthetic, be sure it's a light weight one. DO NOT use a disposable razor if you can help it. Electric razors give a smoother shave which is less likely to harm the skin with little cuts or abrasions. Be careful with cutting finger and toe nails as well. Cutting the cuticles isn't advised with arm/hand lymphedema. If you have hard, brittle nails (Toe or Finger) please see your doctor or podiastrist. You may have a fungal or some type of infection that should be treated. (Lamisol is the treatment of choice). DO NOT wear tight jewelry of any kind on your affected areas. For abdominal lymphedema, body piercing is not an option, it's a danger. Anklets, bracelets, rings and other jewelry can cause irritation and become tight with swelling. It is also advised not to carry a heavy purse, bag, laptop bag or briefcase over the shoulder of an affected arm. Travel DO wear compression garments when travelling. Make sure you get up and move around as much as you can. Remember to stretch and do range of motion exercises if possible, and to deep breathe. Also remember to take your special supplies (Soap, creams, bandages, etc) with you. Medical DO NOT allow blood to be taken from any arm affected with lymphedema, nor allow vaccines or shots to be given in the arm. IV's are also troublesome, as well as blood pressure cuffs. The vaccine or shot causes a prick in the skin which is a risk for infection as well as trauma to the area. The blood pressure cuff exerts a force on the area traumatizing it as well. ---------------------------------------------- COMPREHENSIVE TREATMENT GUIDELINES Establishing Disease Management Guidelines for LYMPHEDEMA Cyndi Ortiz Contributing Authors: Phyliss Tubbs-Gingrich, RN, LANA-CLT Wade Farrow, MD, CWS, FCCWS Cheryl L. Morgan, PhD Lawrence L. Tretbar, MD, FACS Benoit Blondeau, MD Disease Management Practice Guidelines Lymphedema Cyndi Ortiz, with Phyliss Tubbs-Gingrich, RN, LANA-CLT, Wade Farrow, MD, CWS, FCCWS, Cheryl L. Morgan, PhD, Lawrence L. Tretbar, MD, FACS, Benoit Blondeau, MD COPYRIGHT 2005 All Rights Reserved Lymphedema: Goals and Objectives: Goals and objectives in current medical practice for lymphedema are concentrated on assisting affected individuals with successful treatment and long-term disease management of chronic intractable lymphedema, with a focus on patient independence. Lymphedema is a chronic disease due to an obstruction, interruption, or malformation of the lymph system. Currently, there is no cure for lymphedema. The physical results are chronic edema caused by excess fluid that accumulates in the interstitial tissue. This fluid is high in protein content, which distinguishes it from other types of swelling. This fluid also has not yet been filtered and has a high content of bacteria and other waste products not normally found in this tissue. Health risks include progressively degenerative edema, tissue fibrosis, fibrotic skin changes, blisters, wounds, re-occurring cutaneous and sub-cutaneous infections (cellulitis), osteomylitis, deformed limb(s), decreased mobility due to inactivity, repeated hospitalizations for infections, severe weeping of lymphatic fluid from swollen wounds (lymphorrhea), and in severe cases can even result in amputation, or death due to sepsis. The psychological affects due to appearance, pain, reduced function, can be devastating to the quality of life of affected patients. As with many chronic diseases, untreated lymphedema tends to worsen over time, resulting in increased complications and morbidity over time without treatment. When this chronic diseases are not effectively managed, the disease process progresses causing significant and expensive health complications. Collateral affects resulting from physical limitations and complications can interrupt a patient’s normal lifestyle activity including employment, family relationships, social activities, and exercise activity. Patients report a lack of desire to socialize due to appearance, difficulty purchasing clothes and shoes that fit properly, which in turn, causes depression. The change in physical abilities contribute to depression causing a feeling of being needy or worthless. Prior to experiencing lymphedema, many individuals report being able to perform normal daily functions as well as actively assisting friends and family in meeting their needs. Once the disease progresses to a point of affecting function, they are no longer able to participate in normal daily activities such as cleaning their home, shopping for groceries, caring for children or family, or other menial but important activities healthy individuals take for granted. Goals and objectives must include the education of medical practitioners in properly diagnosing upon early onset, education of medical professionals in properly identifying risk of onset, early diagnosis, appropriate treatment, and educating patients about the management of this life long disease. Treatment and disease management that are geared towards individual needs will create an environment for successful long-term management. This environment should consider and provide treatment and tools that facilitate effective results, compliance, independence, exacerbation prevention, and complication prevention. Treatment and management that is individual needs based not only should include effective treatment, but providing an individualized treatment plan allows patients to enjoy a psychological view that gives them control over their disease. This improves compliance by increasing their ability to maintain normal lifestyle activities, while implementing disease management into their daily regime. Because 20 to 45% of cancer survivors who are treated with surgery, radiation, and/or lymph node removal develop lymphedema at some time in their lives, patient education and early intervention for “at risk” cancer patients is essential. Some develop lymphedema immediately after treatment, and some years later. Many cancer survivors never develop lymphedema; therefore, those who do may have an existing obstruction or minor congenital defect of the lymph system prior to treatment, which predisposes them to experiencing lymphedema. Education for at risk cancer survivors provides them with the necessary information for early recognition, so they are able to obtain treatment immediately upon symptom onset. Early intervention is essential in achieving treatment success. As with any chronic disease with early intervention, desired goals are achieved at an accelerated rate, thus reducing the need for lengthy treatment, preventing expensive and debilitating health complications, and better enables patients to continue with normal lifestyle activities. Failure of medical practitioners in properly diagnosing early on, ordering the proper treatment, and long-term disease management can facilitate disease progression that can not only lead to health complications but facilitates employment loss, and other devastating life changing events. In order to achieve effective results and better enable long-term success, several factors must work together in order to ensure longterm disease management success: education, early intervention, effective treatment, and effective needs based home management tools that will allow independent, successful, and long-term home disease management. Treatment and management should include a comprehensive approach that addresses each individual’s physical, mental, and social objectives. Considerations during the treatment and long-term management planning should not only include the patient’s objectives, but their level of motivation, physical abilities, system of support, employment and social activity schedules. A realistic approach to disease management should include the evaluation of each patient’s ability and motivation to implement management into their daily regime, and should involve the necessary tools that are realistic in independent application. Prevalence In the United States: Lymphatic obstruction resulting in lymphedema can be caused by a congenital malformation, a surgical procedure(s), trauma, a benign or malignant tumor, radiation, lymph node removal, sentinel node biopsy, and disease. Because those affected are considered an underserved population, a lack of knowledge in the medical community has resulted in many individuals who experience lymphedema to remain undiagnosed. Estimated figures are available however, they may be significantly lower than those who truly experience lymphatic disease. Current Cases Estimated in the United States due to reasons other than cancer or cancer treatment: An estimated 2.5 Million current cases of lymphedema that exist in the United States resulting from congenital malformation, trauma, surgical procedures, or disease. Approximately 26% of cancer survivors treated with surgery and/or radiation will develop lymphedema at some time in their lives. The National Cancer Institute reports in a survey of 1151 women treated with radiation for breast cancer, 23% reported lymphedema at zero to two years after treatment and 45% of these women developed lymphedema at fifteen or more years after treatment. In patients treated with surgery alone, 20% developed lymphedema at zero to two years and 30% at fifteen or more years after surgery. The National Cancer Institute further documents patients with lymphedema reported an impaired quality of life. Lymphedema is seen more prevalently in cancer affecting the stomach, colon, anal/rectal system, urinary tract, respiratory system, biliary and gallbladder systems, bones and joints, soft tissue, skin, breast, genital (both male and female) system, lymph system as is seen in lymphoma, and sometimes the brain, other nervous system, or endocrine system. There are approximately between 2.02 million to 4.5 million cancer survivors in America who experience lymphedema, with 156,214 to 351,481 new cases of lymphedema in cancer survivors yearly. As cancer treatment improves and more individuals survive cancer, these numbers will continue to rise. Total Americans estimated to experience lymphedema as of 2006 is an estimated 5.1 million to 7.5 million Americans: Due to cancer or cancer treatment: 2.1 million to 4.5 million due to cancer or cancer treatment Due to trauma, infection, surgery, or disease: 2.5 Million Due to congenital malformation: 500,000 We suspect these numbers may be higher due to discrepancies in the definition and a lack of uniform diagnostic criteria. Information concerning cancer patients, for example, is somewhat limited to breast cancer while lymphedema resulting from other types of cancer and from other causes have not been well reported and documented. Economic Impact: As the disease process continues to remain untreated and therefore progressively worsens, individuals who experience lymphedema become less mobile, less active, and are eventually unable to maintain employment. Individuals who were gainfully employed are able to contribute to the government’s economy via income tax, and to the American economy in purchases of consumer goods above and beyond items that meet the needs of minimal survival. When lymphedema is not effectively treated and managed, allowing the disease to progress to severe levels affecting mobility, affected individuals who are unable to maintain gainful employment and are forced to use disability benefits. Thus, they are no longer contributing to the government’s economy via income tax and instead are now being supported by government sponsored long-term disability benefits for both income and medical care, and are limited to purchasing only items needed for survival. Americans who are not receiving effective treatment have proven to experience obesity due to a lack of mobility and exercise. Untreated lymphedema leads to isolation, impairs patient’s ability to perform activities of daily living, and exercise, leading to weight gain and obesity. Obesity has proven to significantly increase the cost of health care. In an article published in 2004 by Reuters Health News, results of a study showed a reduction in compliance with disease management medications when health insurance benefits reduced coverage. When a lack of health insurance coverage prevents or hinders individuals who experience a chronic disease from implementing effective disease management, and the disease process continues to exacerbate, individuals experience health complications that are much more expensive to treat, increasing the overall national cost of health care. The rise of health care costs is passed on to American consumers via higher insurance premiums and tax dollars, and increased deductibles and co-insurance. This, in turn, affects spending in the economy, as expenditures turn towards health care expenses, and away from consumer goods. All of this can be avoided by taking a common sense approach to health care by implementing improved coverage and treatment guidelines for effective disease management of chronic diseases including lymphedema. This common sense approach is similar to effective vehicle maintenance in utilizing the thought process of regular vehicle maintenance that may prevent a more expensive vehicle accident in the future. Using the same thought process of repairing a vehicle brake system will prevent an expensive vehicle accident that can occur with brake system failure, we must also apply a common sense approach to health care delivery. Lymph System Overview: The lymph system is an integral part of the circulatory system and its function is to collect and return interstitial fluid, defend the body against disease, and absorb lipids from the intestine and transport them to the blood. The lymph system consists of the spleen, lymph nodes, lymph ducts, lymphatic vessels, and lymphatic capillaries. The lymph system runs parallel to the blood capillaries and extends into most tissues, and while it does not communicate directly with the vascular system, it is connected to the vascular system by filaments that are attached to the outer surface of the capillary wall. The lymph system is present in almost all tissue, but is not present in some, such as the central nervous system and cartilage. With arterial inflow, protein plasma, a blood component, is released into the interstitial tissue to deliver moisture, nutrients, and oxygen. Some excess fluid is collected during vascular outflow. At the lymphatic capillary end, the lymph system collects what the vascular system does not collect, which consists of larger molecules including proteins, fat, and debris. The capillary end contains overlapping endothelial cells that form “swinging tips” that open and close by constant interaction of the capillary blood pressure, the plasma colloid oncotic pressure, the interstitial fluid pressure and the interstitial colloid oncotic pressure. A pressure gradient is created by fluid pressure differentials. The overlapping endothelial cells, open allowing fluid intake but not fluid outflow. Once fluid enters the lymph system, the fluid becomes lymph fluid. The head and neck drain into the jugular then the supraclavicular trunk. The upper extremity drains into the axillary nodes, which then drain into the subclavian trunk. The foot and lower leg drain into the popliteal and then inguinal nodes. The pelvic, abdominal wall, and viscera return to the bloodstream primarily through the thoracic duct. The major node group that drains the body wall are external iliac, common iliac, internal iliac, and visceral groups. The lymph flow is produced by respiratory movements, muscle contraction, and the stretching of lymph vessels. In the normal lymph system, as the vessels become stretched with lymph, the smooth muscle wall of the vessel then contracts, pushing fluid into the next segment. Diagnosing Lymphedema and Determining the Cause: One or several factors can cause imbalance in extracellular fluid volume. When one or more of the pressure differentials is disrupted, the fluid does not adequately eliminate from the interstitial tissue and edema results. Edema due to lymphedema arises from a chronic failure in lymphatic function caused by malformation, obstruction, or interruption of the lymphatic system that results in the disruption in fluid differential. Excess fluids, proteins, immunological cells, and debris in the interstitial tissues cause inflammation. If untreated, the disease progressively becomes worse. The accumulation of proteins result in tissue fibrosis or hardening and thickening of the interstitial tissue, which makes elimination more difficult. Obvious signs and symptoms indicative of insufficient lymphatic transport include progressive chronic edema, stasis dermatitis, blisters, weepy wounds, and reduced extremity function. Some individuals experience pain, while others do not. When chronic edema is present, other possible causes are ruled out. These include: congestive heart failure, deep vein thrombosis, kidney failure, venous insufficiency (sometimes is seen concurrent with lymphatic dysfunction), abnormal hormone levels, side affects of some prescription drugs, and occasionally other temporary obstructions, i.e. ovarian cysts. A Venous Doppler may be administered to rule out DVT, arterial insufficiency, and vascular insufficiency. Lymphangiography may show where the lymphatic blockage is and the extent of the blockage, however not all labs offer this diagnostic test, nor are they readily available in all major cities. There are two types of lymphedema; primary which is caused by congenital or hereditary defect, and secondary, which is acquired resulting from secondary factors such as surgery, trauma, disease, radiation, or other reasons. Primary Lymphedema is caused by developmental abnormalities, which may be part of chromosomal abnormalities (i.e. Turner’s Syndrome) or inherited single gene defects, or by other malformations during gestation. Other congenital abnormalities resulting in lymphatic dysfunction can include Downs Syndrome or Spinal Bifida, or other developmental malformation. Onset occurring at birth is congenital lymphedema, onset after birth but before age thirty-five is Lymphedema Praecox. Onset occurring after age thirty-five is called Lymphedema Tardum. Some patients present with symptoms of lymphedema as adults after an incident of trauma is reported. Congenital abnormalities may have been present at birth but not significant enough to present symptoms until trauma, severe illness, or other event (some report after flying on an airplane) occurred. These individuals report no symptoms prior to the incident, but recall paternal or maternal relatives having symptoms. Obtaining previous medical history and family history can assist in diagnosing the patient who may have a congenital malformation, but no symptoms until adulthood. Secondary Lymphedema is acquired and results from obstruction, interruption, or obliteration of the lymphatics. Cancer, trauma, severe infections, disease, lymph node dissection, lymph node removal, radiation, sentinel node biopsy, lymphoma, filariasis, and thrombosis can result in secondary lymphedema. Some medical professionals also attribute lymphatic dysfunction to other diseases, such as fibromyalgia, and reflex sympathetic dystrophy, although further evaluation of this is warranted. An evaluation was conducted on patients with unilateral lower extremity lymphedema using a color Duplex Doppler scanner and the results published in Lymphology 1999 March;32(1):11-4. Results showed soft tissue edema from lymphatic stasis gradually impedes venous return. Chronic venous insufficiency, if not treated, may also cause fluid overload resulting in lymphedema. This further complicates the treatment and outcome. Patients with both chronic venous insufficiency and lymphedema are more at risk of amputation because due to a reduced blood flow, the skin begins to die, and infection is more of a risk. Complications include re-occurring infections which include fungal, cellulitis, streptococci and/or staphylococci, and osteomylitis. Infections result from lymph stasis, decreased local immune response, tissue congestion, accumulated proteins, and other debris. Excess edema causing is high in bacteria, which places affected individuals at high risk of severe cutaneous and subcutaneous infections. This excess fluid furthers the obstruction of healing as it prevents blood capillaries from delivering oxygen and nutrients to keep the skin healthy and respond positively to topical wound treatments. Lymphorrhea or weepy wounds occur with severe lymphedema and result from permanent tissue damage, and the skin’s inability to accommodate excess fluid. Excess lymph fluid begins to weep through the damaged skin causing a blister that then results in a weepy or a heavily draining non-healing wound. Other complications affecting the skin include lymphoceles, papillomas, and hyperkeratatosis. Staging of lymphedema as reported in the Lymphology 36, 2003, The International Society of Lymphology (ISL) Consensus Document, reviews the staging of lymphedema in four stages as follows: Stage 0 – “refers to a latent or sub-clinical condition where swelling is not evident despite impaired lymph transport.” Stage 1 – “represents an early accumulation of fluid relatively high in protein content (e.g. , in comparison with “venous” edema) and subsides with limb elevation. Pitting may occur. “ Stage II – “signifies that limb elevation alone rarely reduces tissue swelling and pitting is manifest. Late in Stage II, the limb may or may not pit as tissue fibrosis supervenes. “ Stage III – “encompasses lymphostatic elephantias is where pitting is absent and trophic skin changes such as acanthosis, fat deposits, and warty overgrowths develop.” “Within each Stage, severity based on volume difference can be assessed as minimal (<20% increase) in limb volume, moderate (20-40% increase), or severe (>40% increase).” Lymphedema can affect any part of the body. It most often affects either the upper or lower extremities. It can, however, also affect the head, neck, chest, back, abdomen, hips, buttocks, and both male and female genitalia. Congenital defects can result in edema affecting the part of the body where the lymphatics are malformed. Secondary lymphedema can occur as follows: Head and Neck: regional lymph node removal and/or radiation. Surgical removal of a tumor possibly interrupting lymphatic flow. Disease, infection and regional trauma may also cause regional lymph damage. Upper Extremity: regional lymph node removal, sentinel node biopsy, lymph node dissection, surgical interruption of lymphatic vessels, and the application of radiation. Disease, infection, and regional trauma may also cause regional lymph damage. Back and Chest: Lymphedema can affect the chest and back area due to radiation, congenital deformation, regional lymph node removal, trauma and disease. It is most often seen in post-mastectomy patients. Abdomen, Hips, Waist and Buttocks: Abdominal surgical procedures including hysterectomy in which inguinal vessels and/or nodes were incised, and/or nodes removed. Lymphatic interruption may occur without lymph node removal. Disease, infection, and regional trauma may also cause interruption to the inguinal lymphatics resulting in chronic lymphedema. Male and Female Genitalia: Occurs primarily due to the application of radiation, but can also result from rectal surgery interrupting medial vessels of the thigh, disease or infection. The female genitalia tissue does contain superficial inguinal vessels that drain into the supermedial superficial inquinal nodes. Surgical interruption may also contribute to female genital lymphedema. Lower Extremity: Because the lower extremities drain into the popliteal and inguinal nodes, any surgical interruption of those vessels and nodes can cause lymphedema. Regional trauma of the inguinal vessels and nodes, or popliteal nodes, disease infection, or radiation may result in and interruption in lymph flow. Surgical procedures, such as vein harvest, knee surgery, tumor excision, hysterectomy, or any surgical procedure interrupting lymphatic vessels and/or nodes can cause an interruption severe enough to result in lymphatic dysfunction. Because intercostals and vertebral nodes are located in and around the spine, some patients who have undergone surgical procedures involving the spine result in lower extremity lymphedema. Long term lower extremity paralysis can be complicated by lymphedema due to the lack of a muscle pump assisting in gradient fluid differential due to reduced venous return, the involvement of gravity, and sometimes a trauma contributing to the paralysis result in lymphatic dysfunction. Not all individuals who experience surgical procedures, radiation, trauma, disease, or infection develop lymphedema. The explanation for this may be due to a previous unknown factor of reduced lymphatics which would interfere with the normal increase in lymphatic uptake compensation for damaged or interrupted lymphatics. If there is an undisclosed predisposition of reduced lymphatics, this would result in remaining lymphatics to be insufficient in increased uptake performance, when trauma to the body occurs. Early Intervention and Prevention: Patients who have undergone treatment of cancer, surgical procedures, and those who have been diagnosed with venous disease should receive a consultation for educational purposes for prevention and to ensure treatment during early onset of lymphedema. Patients whose cancer treatment included the following procedures are at high risk of developing lymphedema: 1. Lymph node dissection 2. Sentinel node biopsy 2. Lymph node removal 3. Radiation 4. Major surgical procedures Prevention of lymphedema includes: 1. Keeping the skin clean and moisturized 2. Avoid having blood drawn from the affected extremity. 3. Avoiding hot showers, saunas, or steam rooms. 4. Avoiding bug bits by using insect repellents. 5. Protecting the skin from sun burn. 6. Avoid lifting heavy objects and over strenuous activity. 7. Wearing a compression stocking when flying on an airplane. 8. Use an electric razor to shave affected extremity. 9. Education on signs and symptoms of onset and complications. 10. Avoid sleeping on the “at risk” side of the body. The sooner treatment begins with a chronic disease, the less likely serious health complications will occur. Teaching “at risk” individuals to watch for signs and symptoms of lymphedema will better ensure early treatment intervention. Treatment applied immediately after onset has proven to achieve more effective longterm results, exacerbation of the disease process, and expensive health complications. Treatment: Criteria Used for Review: Various treatment modalities and technologies exist and are very effective. Current clinical studies published to date have been conducted on many treatment options, however, much of the information in these studies is subjective and not objective, there are too few subjects included in the studies, subjects are not evaluated over a long enough period of time, some published studies show conflicting results Some studies fail to disclose important variables and factors in the studies. Some of the important variables and factors not reported in current medical studies include length of time the disease has been present, condition of tissue, whether or not radiation was applied directly to affected edematous areas which may result in the requirement of increased therapy, level of patient compliance, and additional therapies that were applied to some subjects and not others during the study. This overview will seek to address objective information and review the physiological affects and benefits of various treatments versus subjective information provided in some of the available published data. Initial Evaluation: Once the proper diagnosis has been obtained, the treating therapist should gather the following information during the patient’s initial evaluation: health history, signs and symptoms, disease etiology, history of complications including current, social demographics, employment status, the system of social and emotional support, nutritional status, and specific treatment goals. Treatment should be adjusted to meet the patient’s physical needs while considering level of motivation of compliance, and ability to be compliant. Daily schedule, social activities, financial status, and mental capacity should be considered when developing a treatment plan, and setting specific reasonable and attainable goals. Contraindications should be ruled out, which include deep vein thrombosis, renal failure, and active cancer unless providing palliative care, active infection, and congestive heart failure. Allergies to creams, foam, and bandaging products should be obtained and alternatives considered when allergies are present. Treatment may not be applied to areas with localized trauma, and hyperthyroidism prohibits neck treatment. Treatment should be applied by a licensed medical professional who have received at least 135 hours of specialized training in the disease etiology and treatment of lymphedema which includes combined decongestive therapy. Combined decongestive therapy includes the application of manual lymph drainage and external compression. Because lymphedema is accompanied by health complications, specialized training is required. When a non-medical and/or insufficiently trained individual attempts to treat a medical disease, further complications can ensue causing physical harm to the affected individual. A two phase treatment approach that includes an intensive treatment phase, followed by a long-term disease management phase is optimal. The first phase involves direct one on one application of manual lymph drainage and short-stretch banding. Manual Lymph Drainage: In the overview of normal lymphatic function, fluid enters the lymph system in two ways: pressure gradient dynamics, and as the lymph vessel are stretched with lymph fluid, it is pushed into the next deeper segment. When the lymph system is dysfunctional, this action can be done manually by the application of manual lymph drainage. Manual lymph drainage is a specialized massage technique, in which lymphatic receptors are manually stretched. Because the lymph system operates by the outward pressure differential pushing the fluid into the lymph collectors, manual therapy physically manipulates the lymphatic collectors by manually doing what the lymph system is unable to do on its own. Manual lymph drainage further assists the body in redirecting fluid away from damaged or impaired lymphatics and towards working lymphatics. Fluid can be redirected around scarring that may be “blocking” lymphatic flow. Therapy begins proximally in order to clear a path for distal fluid, allowing for a place to send excess fluid. The jugular/subclavian vein junction at the base of the neck is cleared first as this is the main pathways of lymph elimination. Deep breathing exercises performed during this therapy assist in stimulating deep lymphatic flow. Lymphatic flow is increased with lymphatic output of the thoracic duct and lymphatic trunk by deep diaphragmatic breathing exercises. This also contributes to peripheral lymphatic increased flow. Exercise is also beneficial in moving lymph fluid as the intrinsic contraction of muscles and movement of veins during exercise helps to mobilize lymph flow. External Compression: Stimulation of the lymph system with manual lymph drainage does assist in clearing, redirecting fluid, and stimulating stagnant lymphatic flow, it does not actually significantly reduce edema due to excess fluid. External compression must be applied in order to produce significant reduction and maintain reduction. Tissue compression helps prevent fluid refill, softens hardened tissue, and aids in fluid re-absorbtion by acting as a resistive force. External compression assists in edema reduction by helping to move fluid out of the interstitial tissue and into the vessel system for elimination. Phase One – Intensive Therapy Phase: The initial treatment phase should include direct one on one therapist’s application of manual lymph drainage. Optimally, therapy is applied for twenty consecutive days or more if needed to achieve reduction goals. Some individuals who have very mild lymphedema and are treated immediately at onset may require less however, treatment plans should be -6-developed to meet each individual’s needs. Patients with severe cases who may have hardened fibrotic tissue that is more difficult to eliminate, wounds, or other health complications may require more therapy. It is essential to address the disease adequately during the intensive therapy phase so that complications do not arise and home disease management is achievable for the patient. The therapist should treat the disease in its entirety during the intensive phase, and assist the patient in keeping the disease maintained at home. Failure to adequately treat affected patients during the intensive therapy phase will result in treatment failure because when significant reduction is not achieved, wounds are not healed, and a patient is left to complete treatment on their own. This is much like a surgeon handing a patient the scalpel halfway through surgery, and asking the patient to complete the surgery, and suture their own incision. Unfortunately, inadequate insurance coverage many times results in the non-completion of necessary and essential therapy. This causes treatment failure and the result almost always is the requirement to return to therapy after a exacerbation of edema and/or serious and expensive health complication has occurred. During therapy, each visit should consist of at least the following: 1. Therapist application of manual lymph drainage. The therapist should not only apply manual lymph drainage on the affected extremity, but it is essential to first apply therapy to stimulate the jugular/subclavian vein. This is needed to stimulate and prepare it for receiving fluid. Therapy is then applied proximal to distal. When bilateral extremities are affected, therapy focuses on one extremity at a time, with treatment starting with the worst extremity first. After the most severe extremity is adequately treated, therapy begins on the second extremity. 2. Diaphragmatic breathing exercises. 3. Application of Short-stretch bandaging - gradient. 4. Exercises specifically designed to assist in promoting working pressure against the bandages can be done to increase lymphatic flow. Modifications can be made in bandaging techniques to address phlebolymphatic components of the disease as well. 5. During the intensive treatment phase, the therapist is also educating their patient on this process, so that therapy can continue self-application of therapy during the home management phase. Patients should also be educated on the importance of good skin care, prevention of complications such as exacerbation and complications. Time of application: Each therapy visit for combined decongestive therapy is based on the severity of the patient’s condition. Considerations include whether or not there is a wound present that will need addressing, the stage of the lymphedema, and whether or not there is hardened fibrotic tissue to address. Fibrotic tissue is difficult to eliminate and requires more attention during manual lymph drainage. More severe and advanced stages of lymphedema require longer therapy times, while early stage lymphedema may not require more than forty- five minutes of lymph drainage. Other considerations include areas of the body that are affected. Some affected individuals experience lymphedema in more than one region, therefore, more time is required to address all affected areas. For example, a patient who experiences lymphedema in the chest, back, and upper extremity will require more therapy time than a patient who experiences lymphedema affecting only the upper extremity. The average treatment time for lymphedema is typically as follows, but should be adjusted according to the patient’s specific health needs: Manual Lymph Drainage (MLD): 60 minutes Diaphragmatic breathing exercises 5 minutes/intermittently during MLD Application of short-stretch bandage 15 to 30 minutes Exercise 15 to 30 minutes Education 15 minutes Wound Management in Presence of Severe Oedema: Severe oedema due to chronic lymphedema or severe venous insuffieiency with secondary lymphedema results in massive buildup of interstital fluid. Swollen limbs are more prone to loss of skin integrity and skin breakdown. In the case of ulceration or trauma, the excess interstitial fluid must be reduced in order for wound healing to occur. There are several reasons why reduction of excess interstitial fluid is critical to wound healing. First, fluid buildup leaks into open wounds, following the path of least resistance. The ulcer then becomes an outlet for reducing the interstitial fluid, similar to a faucet being turned on. Draining ulcers are much less likely to heal due to the fact that the leakage of the fluid actually creates a hemodynamic steady-state situation. Therefore, without reduction of interstitial edema, healing cannot occur as the ulcer is an outlet for fluid. Secondly, there is dramatic decrease in oxygen delivery to wound beds in the presence of significant interstitial edema. The reason is simple. Oxygen and nutrients must diffuse from the capillaries and then through the interstital fluid, in order to reach cells. There is increased metabolic rate in wounds needed for healing, including collagen production and cross-linking. Further oxygen is processed by the body's immune cells to kill bacteria by the oxidative burst method. Furthermore, cell waste products and toxins must be removed by diffusion back into the capillary system. Without reduction of the interstitial edema buildup, bacteria are not killed and are more likely to travel into the interstitial fluid planes where they can multiply, dramatically increasing the risk of infection. In summary, reduction of edema achieves several vital functions related to wound healing: 1) Allows capillary seal in the wound bed, which speeds healing. 2) Reduces fluid in wound bed, reducing bacterial colonization and infection rates. 3) Increases oxygen deliver to speed wound healing. 4) Reduces risk of infection. 5) Prevents skin macerationof periwound skin. 6) Increases removal rate of toxins and cellular byproducts, CO2. Optimal wound care includes: 1. Wound cleaning. Sterile saline is the preferred agent using gentle pressure. In simple wounds, a blunt cannula with syringe can be used. The gentle pressure of 8-15mm has been demonstrated to reduce bacterial load on the wound bed. In more extreme cases, pulse lavage is needed. Cytotoxic agents such as hydrogen peroxide and betadine and most commercial cleansers should be avoided except in wounds heavily colonized with bacteria. 2. Skin barrier. Since the affected area will be bandaged, a skin barrier needs to be applied to the limb to ensure proper skin care. Typical products used have 2% dimethicone, which prevent skin drying and chaffing, and also help prevent maceration. For the periwound skin near draining ulcerations, a more moistureresistant barrier dressing is needed, such as one with high zinc content. 3. Moist wound healing. Wound healing is much improved in the presence of a moist wound bed. A properly moistened wound bed facilitates autolytic debridement, which speeds the bodies own healing mechanism. Moistened wound beds are much quicker to epithelize, and scabs and eschars slow healing rates and increase scarring. Scarred wounds do not have the same skin integrity as properly healed wounds, and have some increased likelihood of reulceration. Much of modern wound care focuses on adequate control of drainage. For heavily draining wounds, special dressings need to be used to wisk away the drainage from the wound bed and periwound. A good example of such a dressing is Exudry, which is a dressing made of similar design as a diaper. This is the preferred dressing by many professionals for ulcers draining lymphedema fluid (lymphorrhea). For more modrately draining wounds, ABD (abdominal) pads can be used. For lightly draining wounds, gauze is adequate. For wounds that are not draining, often a telfa dressing is useful to cover the topical medicine applied to the wound bed, to prevent drying. For very dry wound beds, a dressing which contributes moisture to the wound bed is needed, such as hydrocolloid dressings. The highest moisture donor medication is a hydrogel, which contains over 90% water and can rehydrate eschar. 4. Appropriate medication selection. Use of antimicrobial dressing is often desired. Silvadene, used long for burn care, is cytotoxic and has no place in wound care outside of burn care. It is still preferred for burns due the ability of Sulfamylon to penetrate eschar with silver ions which are antimicrobial. Preferred dressings are not cytotoxic, but wound have antimicrobial properties or facilitate active wound healing. There are many hundreds of products and their discussion and efficacy is out of the scope of this document. Examples include Aquacel Ag, Acticoat, and Silvasorb hydrogel. Needless to say, proper dressing selection and application techniques often makes a significant difference in the outcome rate of wound healing. 5. Removal of nonviable tissue. Necrotic and nonviable tissue should be removed from the wound bed to stimulate healing. This can sometimes be done through use of enzymatic debriding agents. For wounds with significant slough, mechanical or sharp debridement is recommended. Use of topical anesthetics such as EMLA cream or 2% lidocaine are sometimes used as topical numbing agents as needed. 6. Dressings may need to be changed daily. Heavily draining wounds need to be changed more often. Adequate use of compression can greatly reduce drainage levels over time. Often, bandages need to be changed daily for wounds with severe lymphorrhea. As compression reduces the interstitial fluid, dressing changes can be spaced out less often. Use of antimicrobial dressings allows less frequent dressing changes. In modern wound care clinics, dressing changes once to twice weekly are possible after interstitial edema is reduced through proper technique and dressing selection. 7. Compression bandaging. The gold standard for lymphedema management is short-stretch bandages. These bandages have unique properties that make them ideal for lymphedema management. These bandages are usually applied over cotton batting. The number of layers and technique of application is specialized, and requires special training. This requires extensive training, such as is given only in specialized classes focusing on lymphedema treatment. For lower compression, a spiral bandage is applied. For more compression, a figure 8 application is used. Often, bandages with less width are used on the distal limb, and then wider bandages are used on the more proximal limb. Technique can be used to apply the bandage with gradient compression, by varying the stretch of the bandage and altering technique and number of bandage layers. Multilayer compression wraps or limited reusable garments such as the FarrowWrap WoundOp(TM) line are possible. Completely nonelastic bandages such as the Unna boot are other options, although they lose compression as edema reduces and so are not as ideal as short-stretch bandages with some elastic compression. 8. Foam padding. Foam padding is often necessary for lymphedema patients. There are several foam types used in lymphedema management. White foam is softer (lower inflection load density of approximately 30) and used to pad sensitive areas such as the ankle bones and tendons over the top of the foot. More dense foam with IDL of around 60 is often used to create small pads with waffle-like configuration. This configuration is used over areas with chronic fibrotic changes due to lymphedema. The foam can help reduce fibrotic areas and restore more normal limb function. Padding is also necessary between skin folds. In severe lymphedema, there are often large crevices that form between massively swollen limb portions. These crevices often become macerated and are a haven for fungal infections, ulcerations, and bacterial infections to form. These skin folds must be properly cleaned, appropriate skin barriers or antifungal creams applied, and then foam wedging used to provide gentle compression to the area to reduce lymphatic swelling. Gradient Pumps or Manual Lymph Drainage Pumps During Therapy: Gradient pumps may be applied during therapy as an adjunct to treatment. There are newly developed and FDA approved compression devices that apply both external compression and manual lymph drainage mechanically. While mechanical devices should not take the place of therapist applied manual therapy, they may be used in addition to therapist manual therapy. These devices assist in achieving further reduction when a patient has reached a plateau, but requires more reduction in order adequately treat the lymphedema. Gradient pumps may be applied for half an hour to an hour after manual lymph drainage, followed by the application of bandaging. Some therapists continue to apply therapy during application of the gradient pump. Therapy is applied towards regional nodes proximal to the affected extremity. Phase Two – Independent Home Management Phase: The independent home management phase occurs after treatment goals have been accomplished which includes significant edema reduction, approximately 30 to 60% depending on the disease stage, and wounds are healed. Patients should be supplied with a daytime compression stocking or garment. Prior to discharge, each patient should have a good understanding of proper application of manual lymph drainage, diaphragmatic breathing exercises, extremity exercise, skin care, nutrition and proper application of compression bandage systems. Because compliance during the maintenance phase is essential, evaluation for long-term external compression is essential. Long-term many patients are not able to be compliant with bandaging, possibly due to other physical limitations such as arthritis, back injuries, or other conditions that prevent their ability to properly apply bandages. Patients report a lack of confidence in their ability to properly apply bandages, they are not physically able to apply, or they simply refuse to wear them because they are time consuming and tedious to apply and uncomfortable. In order to adequately address long-term goals, a realistic approach to disease management compliance and independence must be applied with consideration to long-term use of external compression. This can be accomplished by evaluating the patient’s physical abilities, system of support, lifestyle, motivation to apply treatment, and the psychological value in allowing each patient to control their disease management tools. A Pre-Discharge Questionnaire assists in determining what external compression alternatives might be most effective based on the individual patient’s needs. The “Bandage Only” approach: Patient feedback indicates some practitioners have advised patients that the only way to effectively manage their disease is by application of short-stretch bandage. This approach is limiting and not realistic. Patient feedback specifically shows a window of application for about two weeks. After about two weeks, the bandaging ceases application by most patients, therefore, their condition exacerbates. Once the disease progresses to a place that is intolerable for the patient, they are forced to return for therapy. This occurs repeatedly for years. Patients must be offered realistic external compression that they are able and motivated to apply daily. Proper evaluation, proper education as to all the external compression tools available and patient choice not only assists with realistic application, but gives control back to the patient. Most people are more compliant with treatment that they choose for themselves. Since they are the ones who must live with the disease and the treatment, they should be the decision maker. The medical practitioner’s job is to educate patients on available treatments, the function of each external compression device, and the proper use of the external compression device once the item has been provided. It is then up to the affected individual to make the final decision as to what they believe they can live with, and be compliant with. Types of External Compression: The compression applied externally can apply either resting pressure or working pressure. Working pressure refers to pressures that increase with activity. Working compression is temporary and allows for superficial vessel refill. This compression is rigid compression and offers the most resistance against expanding muscles. It is most effective when a patient is walking or exercising. Examples of working compression are short-stretch bandage, Unna boot, rigid bandages, adhesive bandages, moderate short-stretch bandages short-stretch compression stockings. Resting pressure refers to external compression that pressures increase with rest. This compression is constant pressure and involves the use of strong, very elastic bandages. Since resting compression is constant, it does not allow for superficial vessel refill. Examples of resting compression include, ace wraps, long-stretch bandages, and long-stretch stockings. Pressure Gradient is essential in the application of external compression. Since one goal in treating lymphedema is to restore pressure gradient fluid differentials, uniform compression can result in pressure disturbance. Non-gradient compression can result in compression of proximal vessels and thus, blood being trapped in the periphery. This in turn, compromises venous return in from the distal part of the limb. Because the venous in-flow increases lymphatic flow, lymphatic dynamics are reduced. It is much like squeezing a tube of toothpaste in the middle. Fluid back up can cause pain, and exacerbate edema. Because the body operates on a pressure gradient system, treatment should physiologically mimic the body’s system as close as possible. Dr. Smith, Scurr published an article in Surgery 1990;108:874, in which they discuss the criteria used for external compression used in their study. They used Doppler ultrasonography to review the affects on the veins when using uniform compression versus gradient compression. Uniform compression was shown to collapse the proximal veins first with the wave of vessel collapse moving in the distal direction, while gradient compression was seen to collapse the distal veins first with the wave of vessel collapse moving proximal. Uniform compression, in collapsing proximal to distal resulted in a “trapping” of blood in the distal veins, whereas gradient compression resulted in a more complete emptying of the distal veins. Patients have reported nongradient compression causes severe paid and exacerbation of edema. This may be attributed to the distal trapping of blood when uniform compression is applied., as it operates against the body’s natural pressure gradient system. Bandaging Alternatives Overview: External Compression Devices should be applied by either a trained therapist, or a certified compression therapist who has received at least 40 hour of training specific to disease management of lymphatic and vascular disease. Durable medical equipment companies providing these devices through delivery personnel or shipping to patients with little or no instructions can allow for misuse, or placement in spite of the existence of contraindications. Because these items are medically prescribed by a physician, failure to provide proper instructions by trained therapists can lead to serious health complications, just as providing prescription drugs through the mail with little or no instructions. Trained professionals should always be involved in the setup and instructional phase of providing medical equipment and supplies for lymphedema. Foam Compression Garments: Foam compression garments include the Reid Sleeve, Circ-Ai, and Leg Assist Garments. These garments work by applying high low pressure points. Foam, when compressed against edematous fibrotic tissue works by physiologically by applying increased pressure, providing a more even pressure distribution, helps to provide as foam moves against the skin, it assists in stretching the skin thereby stimulating lymph function. When foam is applied with gradient compression, it assists with the breakdown and softening of hardened fibrotic tissue. This facilitates the elimination of fibrotic tissue that would not otherwise eliminate. These devices utilize a system of Velcro straps and/or an outer spandex type garment that simulate bandaging. Patients are much more compliant with these devices as they are easier to apply and more comfortable to wear over lengthy periods of time. Foam compression devices may be worn for nighttime compression and the devices that are not accompanied by Velcro straps can be used with gradient pump therapy. The compression applied by foam compression garments provide protection for the superficial lymphatics, while applying resting compression. Directional Flow Garments: Directional Flow garments, such as the Jovi Pak and the Solaris Tribute Garment use a similar technology as the multi-density foam compression garments, but are designed with seams that assist in directing lymphatic flow towards proximal lymph nodes for elimination. Various foam densities and the shapes of foam chips enhance lymphatic circulation and assist fibrotic tissue for elimination. These garments are used with a compressive outer garment that assists with increased compression. Bandaging can be applied over these devices as can gradient pumps. These devices provide compression for affected areas of the body such as the face and neck, the genitals, the chest, the hips and abdominal region. These devices are a thinner than foam compression garments, and patients compliance is extremely high because of their ease of use. These devices offer technology that assists the body in stretching superficial lymphatics, thereby stimulating lymph flow in the proximal direction for elimination. FarrowWrap(TM) Classic Arm-Wraps and Leg-Wraps: This technology uses short-stretch compression technology to simulate short-stretch function in a garment. The garment has similar compression to two layers of short-stretch. The garments can be used to simulate bandaging. The short-stretch function augments the muscle pump to augment venous return. The low active compression prevents garment slippage and allows accomodation to limb size. Physiologically, the short-stretch function is very effective in removing excess fluid, creating the "pumping" action that that it is not able to provide on its own. The garment has been demonstrated to be easier to don than compression stockings, and can be used in patients with low Activities of Daily Living (ADL) scores to give them more independence in controlling their swelling. The FarrowWrap (TM) is the only garment in the world with short-stretch technology. FarrrowWrap WoundOp (TM) Arm-Wraps and Leg-Wraps: This line of FarrowWrap products is designed for Wound care and post-Operative use. It uses short-stretch technology to provide safer compression garments.technology uses short-stretch compression technology. The WoundOp product line has slightly lower resting compression levels than the Classic model. The product, however, is breathable and easy to dry, and more suitable for use on active wounds. This limited reusable garment has expected life expectancy of at least three months. Since it is reusable, it is cost-effective over many disposable garments, such as multilayer compression wraps, which must be reapplied at least once per week and in many cases several times per week. Circ-Aid Silhouette: This unit is made using soft foam technology and assists patients with bandaging. Foam is applied under bandaging in order to prevent slipping, to assist with increased local pressure and in fibrotic tissue breakdown. Many patients have difficulty bandaging with individual pieces of foam. Holding the foam in place while wrapping the bandage around the extremity is difficult, especially when bandaging the upper extremity. This device better facilitates bandaging as it provides the foam in one easy “slide-on” unit. This device also reduces the patient’s expense of having to continually re-purchase new foam. Circ-Aid Non-Elastic Legging: This technology non-elastic sustained compression device consists of a series of straps that simulate bandaging. With the application of gradient compression, this device uses working pressure to assist in stimulating venous return and as the patient walks, the superficial lymphatics are stretched assisting in increased lymphatic flow. They are easy to apply and compliance due to ease of use, is very high. Physiologically, this device is effective by assisting the body in removing excess fluid, by creating the “pumping” action that it is not able to provide on its own. Foam Pads: Reid and Solaris Tribute provide foam pads or crescent shaped pads that assist with hardened areas of over large lipomas or fatty lumps, to assist in break down and elimination. Pads, using applicable shape, can be placed around ankles or just under the lipoma and bandages applied over them in order to address the edematous and fibrotic tissue. Lipomas are extremely difficult to bandage and bandages tend to slip. Application of foam pads assist in addressing these tough areas by adding soft high low pressure directly to the problem area. Pumps: Pumps in particular have been widely misapplied, and misrepresented within the medical community. These devices can either cause lymphedema to exacerbate when not applied properly, or when applied properly they are an invaluable tool for many affected individuals who have achieved significant disease management success over a long period of time. Pumps are not recommended for everyone, and the mechanism of compression of some pumps can cause harm. Due to the lack of education and standard of care with these devices, this document seeks to establish a model of application for sequential pumps when treating lymphedema. There are three different types of pumps: 1. One chamber intermittent: This pump by applying uniform compression works against the body’s natural physiological pressure gradient system. In doing so, it causes a reflux of fluid in the distal veins, thereby increasing pain upon compression, and increasing edema. This device may reduce edema initially, however long term use can cause further damage to the lymph system. Patients who use a one cell or one chamber pump cease use after a few months due to pain, and as edema becomes worse instead of better. These devices are contraindicated for the treatment of lymphedema. 2. Sequential non-gradient: This pump applies compression using three to six chambers. These devices also in applying uniform compression sequentially, have shown to cause severe pain upon compression and increased edema. Since treatment of lymphedema seeks to restore the pressure gradient differentials, application of compression that works against pressure gradient differentials are contraindicated for the treatment of lymphedema. Short term use may show some reduction, however long-term use has shown to cause exacerbation. Compliance becomes an issue as the patient sees his or her condition exacerbating. -11-3. Gradient Sequential: Pumps that apply gradient sequential compression are more closely mimicking the body’s pressure gradient system, and more accurately assist in edema reduction, by helping to restore pressure gradient differentials. Gradient compression pumps contain six to twelve chambers, depending on the model. Compression is applied distal to proximal with more pressure distally than proximal. Gradient sequential pumps that apply compression using a shorter cycle time, more closely mimic venous inflow during walking. Since the venous inflow occurs from the planter veins to the femoral vein in approximately thirty seconds, a thirty second cycle time is preferred. By applying compression at the plantar veins, venous inflow is increased through the deep venous system. When compression is applied to the plantar veins, venous out-flow increases at a higher rate of speed. Some medical practitioners believe that this sheer force against the endothelial cells releases a natural anti-coagulant into the blood stream, which prevents or reduces the occurrence of deep vein thrombosis. As the gradient pressure continues its sequence distally the peripheral venous inflow increases, and excess edema causing fluid is pushed back into the vascular system for elimination. Peristaltic Wave: Since larger lymphatics have a peristaltic rhythm, a gradient pump that applies peristaltic compression is optimal. In utilizing a gradient compression pump that utilizes the maximum number of non-overlapping chambers, as compression is applied sequentially, one chamber is compressing as proximal chambers are releasing compression. This action results in a slight pulling of the skin as compression moves distally, which stretches the superficial lymphatics causing an increase in lymphatic flow. This technology more closely mimics manual lymph drainage. As the chambers deflate, they allow for capillary refill. This cycle compresses distal to proximal every thirty to sixty seconds during compression pump therapy. Compression setting: External compression has shown with the use of a laser Doppler probe, showed micocirculatory flow velocity and concentration of moving blood cells reduced when pressures were too high. Vascular flow increased upon application of external compression until 60mmHg, at which time, microcirculatory flow began to decrease. Pressure settings between 45 mmHg and 55mmHg, depending on patient tolerance are optimal to achieve significant reduction of edema. Duration: The duration of gradient compression when used in a clinic setting should be applied for about one half hour after the application of manual lymph drainage. Manual lymph drainage may also be applied in the region of drainage during gradient compression therapy. For long-term disease management two hours BID is optimal, as one hour of use only address “new” fluid, and does not allow time for addressing “old” fluid or fibrotic tissue. Once significant edema reduction is achieved, and wounds are healed if present, gradient compression may be applied as needed to maintain edema reduction and manage lymphedema. Gradient Compression Pumps are not recommended when a patient experience severe renal failure, active infection, active cancer unless used for palliative care, deep vein thrombosis, or with congestive heart failure. If a patient has a history of congestive heart failure, has been clear for six months or more and is compliant with diuretics, a pump may be applied; however application may be reduced to one hour BID. A pump may not be appropriate for patients who experience limited lymphatics in regional nodes where drainage occurs, such as the inguinal region for lower extremity drainage, or the back or chest wall, for upper extremity drainage. Application of a pump may further complicated edema by pushing fluid to already affected areas. Some compression devices provide garments that extend over the back and chest wall, and/or over the hips, waist, abdomen, and even the female genital region that are appropriate in these cases, and will address edema in these drainage regions, however, gradient compression should not be applied without extensions to address edema in areas affected. Gradient pumps are also not appropriate for use when male genital edema is present, unless the device is accompanied by an appliance, such as the device that addresses the hips waist and abdomen, and when a foam pad is included. These appliances look more like pants, and allow for compression to begin distally, to just under the chest, addressing affected regions as described above. Pumps should always be used in conjunction with manual lymph drainage. Foam Compression for Use with a pump: Foam compression garments, such as the Reid Optiflow, Jovi Pak, or the Solaris Tribute garments may be used with gradient sequential compression devices. The application of foam garments with compression therapy assists by providing addition compression, breaking down fibrotic tissue that would otherwise not be eliminated, protecting the superficial lymphatics from over compression, and reducing pain. The application of foam with external compression devices is similar to bandaging over foam, and because of the comfort and ease of use, compliance is significantly higher than the application of the pump or banding alone. Compression stockings: Despite the fact that compression stockings are considered by many as a “conservative method of treatment”, compression stockings are not a “treatment” at all. When used during early onset, in conjunction with manual lymph drainage and exercise, they may assist in effective disease management. However, compression stockings do nothing to actually treat lymphedema. Compression stockings are a must for use as a daytime garment to maintain reduction achieved with manual lymph drainage, bandaging, and other compression devices. Stockings that apply 20 to 30 mmHg of graduated compression should be applied as a part of the disease management plan in order to continue reduction during daily activity. -12- Miscellaneous treatment overview: Diuretics: Diuretics must be used when prescribed by the examining physician, and are needed to treat various health conditions, however, when they are used solely for treating for lymphedema, they can do more harm than good. Diuretics work by removing water from the subcutaneous tissue. In doing so, they leave behind proteins and bacteria, now in a higher concentration. This places the patient at a greater risk of infection, and long-term use causes fluid to become hard and fibrotic, making elimination more difficult. Furthermore, once the tissue is starved for water, it pulls more water to the tissue, making the edema worse long-term. Reduction achieved by diuretics, unless edema results from causes other than lymphedema, is shortlived. Diuretics further deplete the system of potassium which can cause lower extremity pain. Elevation: Elevation assists in edema reduction by eliminating gravity, and allowing edema causing fluids to flow towards regional drainage nodes, however, as soon as elevation ceases, edema returns. This also is not a long-term effective method of treatment. It further hinders the patient’s ability to maintain an active and productive lifestyle. Pool therapy: Pool therapy is an effective adjunct to lymphedema treatment as the water applies external compression. External compression during exercise assists in stretching the lymph vessels improving flow. Pool therapy also assists in protecting from muscle strain which can exacerbate lymphedema, by preventing quick strenuous movements and allowing for more slow precise exercise movements. By itself, however, it is not an effective long-term disease management tool. When included with manual lymph drainage and effective external compression, pool therapy is an effective exercise technique. Set-Up Procedures for External Compression: External Compression Devices should never be shipped to patients unless a patient has been properly trained in its use, and multiple follow-up visits have been conducted to ensure this is the case. Just as antibiotics or any other physician prescribed medical treatment requires proper use, so does external compression used to treat lymphedema. When used appropriately, these devices can provide an effective adjunct to disease management however they can also cause health complications when not used appropriately. It is recommended that external compression devices be provided by a licensed medical professional with training specific to treating lymphatic disease, or a properly trained certified compression therapist. Each patient should receive the following with the set-up of home medical supplies or external compression devices: 1. Home Set-up 2. Measurements starting at the ankle or wrist, unless edema involves another area of the body, measuring every four centimeters distal to proximal. These measurements can be entered into various available computer programs in order to determine volume of edema, and reduction. 3. The patient should be shown how to apply the device, and then allowed to apply the device themselves. 4. Have the patient use the device while reviewing other information, such as: a. Confidence level in their independent application of MLD b. Knowledge of proper exercise technique. c. Knowledge of breathing exercises. d. Knowledge of proper skin care. e. Knowledge of proper diet. f. System of support g. Confidence level in their independent application of daytime compression garments. All information reviewed above should be reviewed again, when needed, and written information should be left for the patient at their home with external compression devices. 5. After the device has been applied for no less than half an hour, measurements should be taken again and reviewed with the patient. Problem areas can be addressed that may require special attention. 6. Review questions and concerns, and refer the patient referrals to the treating therapist, may be suggested when there is any question or lack of confidence in self application at all. Follow-Up: Follow-up is essential for successful long-term disease management. When external compression is provided, a seven day phone call should be made to ensure patient comfort, ability to consistently and independently apply, and to address any questions, concerns, or complications they may be experiencing. Six to eight week measurements should be taken in order to monitor continued reduction after external compression devices have been provided. In severe cases, three to four subsequent follow-up evaluations may be needed. Improvements in edema reduction, skin presentation, and mobility should be noted and shown to the patient during each follow-up visit. Subsequent six month follow-up visits should be provided to ensure continued reduction and maintenance throughout the patient’s lifetime. Any life changing event or lifestyle change warrants a review of daily disease management as these occurrences typically alter a patient motivation and ability to implement their daily disease management regime. A career change, a divorce, children leaving the home or entering the home, loss of a loved one, relocation or other such events can completely interrupt the daily habits of treatment, therefore, assisting patients with re-implementation ensures continued long-term care. Conclusion Lymphedema is a chronic disease, and currently there was no cure. Technology and treatment exists, however, that effectively treats and manages this disease long-term. Disease management failure occurs when inexperienced practitioners do not properly apply treatment, educate patients on self-care, and the proper longterm disease management tools are not provided. Each patient’s needs are unique and therefore require an individualized long-term plan of care. Long-term, successful and independent management can be achieved when practitioners who are properly trained, assist those affected in the daily and proper implementation of daily management. Improved long-term management increases mobility, quality of life, and reduces the risk and occurrence of expensive health complications. The optimal standard as outlined in this document will help to reduce the overall cost of health care by setting a national model and standard of care, thus reducing complications that lead to hospitalizations and additional medical care. Implementing proper treatment also reduces the need for long-term disability and better enables affected individuals to continue an active and healthy lifestyle. REFERENCES: 1. American Cancer Society 2. National Cancer Institute 3. The American Society of Lympholgy 4. The United States Centers for Disease Control – Health and Human Services 5. J. Smith, LePalliative Care Oxford 2004 Final Chapter 14 6. Solomon, Schmidt, Adragna, Human Anatomy & Physiology – Second Edition, Harcourt Brace College Publishers, 1990 7. M. Foeldi, E. Foeldi, S. Kubic, Textbook of Lymphology, Urband & Fisher 2003 8. Gardner & Fox, The Return of Blood to the Heart, John Libbey & Company, LTD. 1989 9. Abu-Own, Shami, Chittenden, Farrah, Scurr, Colerdige Smith, Microangiopathy of the Skin and the Effect of Leg Compression in Patients with Chronic Venous Insufficiency, Journal of Vascular Surgery 1994;19:1074-1083 10. Wilson and Bilodeau, Current Management Concepts for the Patient with Lymphedema, Journal of Cardiovascular Nursing 1989: 4(1) 79-88 11. Coleridge-Smith, Sarin, Hasty, and Scurr, Sequential Gradient Pneumatic Compression Enhances Venous Ulcer Healing: A Randomized Trial, Surgery 1990; 108:871-875 12. The Diagnosis and Treatment of Peripheral Lymphedema, Consensus Document of the International Society of Lymphology: Lymphology 36 (2003) 84-91 13. Individual Vendors listed provided information regarding products listed. CONTRIBUTING AUTHORS: 1. Phyliss Tubbs Gingrich, RN, BSN, CLT – LANA 2. Wade Farrow, MD, CWS, FCCWS 3. Cheryl L. Morgan, PhD 4. Lawrence L. Tretbar, MD, FACS 5. Benoit Blondeau, MD Winter Tips for Lymphers by Tina Most of us have seen the preventative tips and heard what we should and should not do regarding our limbs and swollen areas. We all must be careful in the summertime about overheating, sunburn, and warmth along with humidity. But what about winter? Winter is an equally important season in which we must be careful. After trial and error I have come up with a list of things I’d like to share: 1. Be very careful of ice. Remember you can’t always see ice, it can be what they call black ice, a very fine coat. Walk on surfaces very carefully. You don’t want to fall. 2. Dress appropriately. Keep your limbs comfortably warm but not too warm or too tight. Remember that you can swell in wintertime as well. Think of the hot malls when out shopping and dress appropriately. 3. Always wear appropriate footware. Make sure you have worn and broken in your boots, sneakers or your winterwear before you tread out. Awkward foot gear can cause falls, and again on ice it’s dangerous. 4. Moisturize! Remember in wintertime skin can be extremely dry with the furnace air blowing. 5. Make sure if you happen to get your garments or socks wet, change them as soon as possible. Remember we lower lymphers are prone to fungal infections as well as skin irritations from wet materials. Waterproofed and insulated boots keep the feet drier than plain rubber ones. 6. Remember the sensible tips for avoiding illnesss, if you can get inoculated for flu/pneumonia. Wash your hands after touching things someone sick has touched. Try not to have sick people breathe in your face. Wearing a scarf helps warm the air for those of us who have breathing problems as well as keep out germs. 7. Eat a healthy well balanced diet as usual. 8. Remember that hypothermia and frostbite are dangerous. Note that wind speeds can make for dangerously cold conditions even if the temperature is not below freezing. 9. If you can wear mittens, they provide more warmth than gloves. Gloves can also become tight on the fingers if you swell. 10. Get lots of rest, drink plenty of fluids, and if you think you are or someone else is experiencing hypothermia, avoid caffeine. Warm up slowly with a blanket and by drinking fluids slowly. 11. Keep a lymphedema and winter survival kit in your car. Try to carry extra medications, bandages, extra blanket, batteries, flashlights, etc with you in case you are stranded somewhere. 12. Keep a list on you in a wallet or purse of emergency contacts, medications you are on and your doctors name and number. Lymphedema Gardening Tips Wear gloves that actually fit, make sure they are not too loose or too tight. Leather gloves with a cloth back are a good general purpose glove. If you plan to work in wet soil, select rubber gloves with cotton lining Wear Neoprene gloves to use when spraying or working with pesticides. If you are pruning or trimming shrubbery, wear gloves that have long wrist protectors. If your gloves get muddy you can washing the gloves while on your hands! If you wear your compression garments under the gloves, make sure you don't get them wet, if wet, change immediately. Avoid direct sunlight, even Spring sunshine can cause sunburns. Always wear sunscreen. Wear comfortable clothing. If you get overheated, take a shower in cool water, not cold, you don't want to cool off too fast. Make sure you don't get dehydrated! Drink lots of water and/or gatorade. Work at a steady pace with frequent breaks, switch gardening chores often to avoid repetitive injuries. Warm up before you garden. Use as many ergonomic tools as possible. Wear shoes that will protect you from hazards such as nails, sharp objects on the ground. If you do get scratched, wash the area right away, apply an antibacterial cream or zinc. For any puncture wounds, make sure your tetnus shot is up to date, wash thoroughly, depending on how deep they are, clean/bandage, or go to the emergency room. Make sure you put tools away when finished to avoid later injuries. Some good warm ups: From Tina, who gardens. Use hands to squeeze stress balls or balls with seed like materials in them. Do 10 each hand. Stretch your hands straight out, link your fingers and pull lightly to feel a stretch in hands, elbows and arms. Do 10 times. Stretch your hands above your head, again link your fingers and stretch. Do 10 times. Bend at the waist downward letting your arms dangle in a relaxed position, this stretches the upper back. Put your right hand on your left shoulder, turn your body slightly to the left until you feel a stretch. Reverse to left hand on right shoulder, turning right. Switch back and forth, 10 times, so it will be 5 stretches to each side. Put your hands on your hips and lean backward, arch your back, this stretches the ribs. Do 5. To stretch your low back, lay down, bend your legs. Put your right foot up to left knee, take a hold of your knee and lightly pull to feel a slight stretch. Do the other side. Do each side 5 times. Never do exercises until you check with your doctor. -------------------------------------------- Skin Brushing Benefits Tightens Skin Helps digestion Removes Cellulite Stimulates Circulation Increases Cell Renewal Cleanses Lymphatic System Removes Dead Skin Layers Strengthens Immune System Improves Exchange between cells Stimulates the Glands, thus helping All of the Body Systems to perform at peak efficiency!! Easy and Inexpensive The Basis for Dry Skin Brushing The skin is our largest route of elimination, excreting more than 2 pounds of waste each day, and taking in air and sunshine. Our skin breathes! And yet, in most people, this vital route of detoxification is operating far below it's capacity, because it is clogged with dead skin cells and the un-removed waste excreted through perspiring. Dry skin brushing is a simple, inexpensive way of removing the waste from the skin and breaking down old toxic deposits through it's unique action on the lymph vessels and capillaries. Our bodies make a new top layer of skin every 24 hours - skin brushing removes the old top layer, allowing the clean new layer to come to the surface, resulting in softer, smoother skin. Draining the Lymph The lymph is the interstitial fluid that bathes our cells, bringing them nutrients and removing their waste - all detoxification occurs first and foremost through the lymph. Our bodies contain far more lymph than blood, and yet the lymph is dependent upon outside forces for it's circulation around the body; the lymph has no heart to pump it! Consequently, the lymph relies upon exercise and massage for it's vital circulation, two things that are lacking in most people's everyday lives. For many years, the only way to drain the lymph was through lymph drain massage or manual lymphatic drainage, a powerful massage technique credited to have originated from ancient Chinese Medicine. Dry skin brushing prompts the body to release its’ toxic deposits into the lymph, whilst simultaneously cleansing the lymph itself, through it's return to it's two plexuses, or centers, near the heart. Because of it's ability to release the skin's detoxification potential and to cleanse mucoid deposits from the cells directly into the colon, dry skin brushing is considered by many (including such luminaries as Bernard Jensen and Robert Gray) to be an essential part of any intestinal cleansing program. Dry Skin Brushing Technique Start with a natural bristle brush 1. Skin Brush before showering, bathing or sauna 2. Do not wet skin 3. ALWAYS brush towards heart 4. Begin with the soles of feet, then ankles, calves, and thighs. 5. Then Brush across abdomen and buttocks. Use circular counter-clockwise strokes on the abdomen 6. Now brush your hands and arms and gently the underarms 7. Reach for that back and neck 8. Lightly brush the breasts 9. Brush each part of the body vigorously, completely several times. 10. Wash your brush every few weeks in water and let it dry. http://www.racingsmarter.com/skin_brushing.htm article by doctors on skin brushing, this ones copyrighted and no permission granted to use it, sorry gotta go to their site to read it! When you brush the pores of your skin clear, your skin is able to absorb nutrients and eliminate toxins. Clogged pores are not just a cosmetic concern. Healthy, breathing skin contributes to overall body health. To dry brush, use a soft natural fiber brush (available from health food stores), a loofah sponge, or a rough towel. It is important to use a natural bristle brush, or a loofah sponge, or even a coarse bath glove. Nylon and synthetic fiber brushes are too sharp and may damage skin. Always dry brush before you shower or bathe because you will want to wash off the impurities that you scrape up from the brushing action. Begin with your feet and brush vigorously in circular motions. Brush away from your extremities and toward your heart. Continue brushing up your legs, then proceed to your hands and arms. Brush your entire back and abdomen area, shoulders and neck. Do not brush any sensitive, irritated, infected or damaged areas of the skin and avoid facial skin as well. After brushing, rinse off in the shower. Paavo Airola, author of Swedish Beauty Secrets, recommends alternating temperatures in the shower from hot and cold. This will further invigorate the skin and stimulate blood circulation, bringing more blood to the outer layers of the skin. Don’t forget to clean your dry skin brush or sponge regularly, using soap and water. After rinsing, dry your brush in an open, sunny spot to prevent mildew from developing More specific Instructions: Dry skin brushing tones the immune and circulatory systems. It may reduce the duration of infection and accelerate the clearing of toxins. It will reduce cellulite, help support the immune system during cancer and other chronic illness treatment. Best of all, it feels really good! Using your right hand, gently slide the brush along your right jaw line starting from your earlobe to the underside of your chin 7 times. Place the brush at the hairline on your neck and gently pull around the right side of your neck to the Adam's apple 7 times. Hold the brush with your right hand at the bottom of your neck (where it joins the top of your back) and bring it around your neck to the right and down along your right collar bone and end up between your collar bones. Stroke your breastbone in a circular fashion to stimulate the thymus gland. Carefully brush the breast in a circular motion. Do all of Step 1c 7 times. Repeat steps a, b and c on your left side holding the brush with your left hand. 2. To stimulate the pituitary gland, hold the brush on the back of your head near the base of your neck and rock the brush up and down, then side to side, both 14 times. Hold the brush in your left armpit with your right hand and rotate it counter clockwise 7 items, then clockwise 7 times. Repeat on your right armpit with your left hand. Brush upward 7 times from your upper right thigh to your right armpit. Repeat process on your left side. Women may need to hold their breast out of the way with their free hand. Brush back and forth over your belly button and around your waistline 14 times (like passing a basketball behind your back). Brush in a circular motion over your belly-button, counter-clockwise 7 times then clockwise 7 times. Finish brushing the front of your body in any direction starting at the bottom and brushing all the way up 14 times. Very little pressure needs to be applied to the genitals and women's breasts because the skin is sensitive and will redden if irritated. Brush up and down your spine from the base of your neck and down as far as you can 14 times Finish your upper back by stroking it around toward your 11 sides. Brush your spine from tailbone up as high as you can reach 14 times, holding the brush with two hands or with the detachable wooden handle. Finish your lower back by stroking it around toward your sides). Brush up from right ankle to right knee and work all the way around your leg, brushing up towards your heart This improves blood circulation, firms skin and gets rid of cellulite. Hold the brush in the right groin with both hands and rotate it 7 times counter-clockwise, then 7 times clockwise. Repeat with the left groin. Brush from right knee to right hip 7 times. Work all the way around your leg continuing to brush upwards (towards the heart). Brush up from right ankle to right knee and work all the way around your leg, brushing up towards your heart (Figure 11). This improves blood circulation, firms skin and gets rid of cellulite. Brush around your right ankle 7 times. Brush back and forth over the top of your right foot from toes to ankle. Brush across your right toes on top and underneath 7 times. Brush the bottom of your right foot heel to toe 7 times. Repeat numbers 11-12 for your left thigh, left leg and foot. Brushing upward from right elbow to your armpit and shoulder, cover that entire area 7 times. Brush from your right wrist to the elbow in the same manner 7 times. Repeat number 14 for your left arm. Lightly brush the webbing (or junction) between your left thumb and index or pointer finger on the palmside 14 times, then on the non-palmside 14 times (Figure 15). Brush your left palm from wrist to fingertips and back 7 times. Brush the back of your left hand the same way 7 times. Brush each left hand finger individually back and forth 7 times on the areas that have not been brushed yet. Repeat steps 16-17 for your right hand. NOTE: YOU CAN DO THE BRUSHING HEAD TO TOE OR TOE TO HEAD. SOME THERAPISTS RECOMMEND TOP TO BOTTOM YET OTHERS PREFER BOTTOM TO TOP. This article was featured on Cleansing Waters website which no longer exists, The article is worthwhile and valuable to lymphedema patients so I chose to keep it up here, it has been edited by the Lymphland Editoral Team, 10/08. Before doing any skin brushing, check with your doctor, we are not medical professionals and cannot give medical advice. Some lymphedema therapists recommend brushing, others do not. Skin brushing is one of the better self-help health care methods available to us today. It be can be performed on your self while the skin is dry or wet. Stimulation of the skin activates natural healing pathways within your body and it removes toxins from pores and other external surface areas. It also stimulates nerve beds within its structure that in turn activate normal healing pathways and healing processes throughout your body. There are no drugs involved, no toxic reactions or contraindications to be concerned about, only the commitment to yourself to perform it on a regular basis. Skin brushing can be used over the entire body or just to special local areas to stimulate the body’s normal inflammatory healing response. The skin is the largest eliminative organ of the body and one of the four major intake and eliminations systems. The digestive tract, kidneys, and lungs are the other three. Over the course of a regular inactive day the skin eliminates over a pound of waste products mixed in with its sweat. In individuals who are active or in athletes who are very active the skin eliminates many times more. Sweat glands are located through out the skin's surface and automatically eliminate unwanted metabolic waste produced. *Never do brushing during active cancer, sunburn, or infection. For maximum lymph drainage both the sequence and direction of the brushing are important. The area closest to the drainage point is treated first. Brush the armpit region before the chest and both before the head and neck. The groin region is brushed before the abdomen. To reduce the resistance of gravity, brush the upper body before the lower body. Use 7 brush strokes for each step. Brush up the arms from the hands to shoulders. Armpit: Use 7 circular clockwise strokes and 7 counterclockwise strokes. Chest: Brush from the breastbone to each armpit, 7 times on each side. Women avoid direct brushing to the breasts, use curving strokes below the breast. Brush sides upward from the waist to armpit. Back: Brush upward and outward from spine, 7 strokes on each side, starting at the base of the neck. The upper back and shoulder blades drain into the armpit. Neck and throat: Start at the back and brush outward and upward from the spine, then forward over the shoulder to the soft hollow at the base of the throat. Turn head to right when working on left side and vice versa. Place brush vertically at the base of the skull and brush along the jaw line to throat and down over the collar bone to the chest. Lower and mid-back and buttocks: Holding the brush horizontally with both hands, start at the lower sacrum, pull brush upward with firm pressure to the bottom of the shoulder blades. Use 7 strokes each up the center, left and right of the back. Buttocks: firm, upward and outward strokes. Begin at the top, circle around hip to groin region. Gradually work down to the gluteal fold where the buttocks join the thigh, and then back up to the top. Leg Region: Brush left leg first, using firm gliding strokes rush upward 7 times on the inside, outside, front and back, front and back, from knee to the top of the thigh, brush from the ankle upward to the knee. These instructions were given to me by my lymphedema therapist who no longer practices. I am not a medical professional and cannot give advice, I am only sharing knowledge in the event it can help another patient manage lymphedema. Check with your doctor before you do any skin brushing. Tina Budde 10/08. ---------------------------------- Remember that the sun can damage more than the skin. The eyes are six times more sensitive to UV rays than the skin. UV radiation increases the likelihood of cataracts, a condition which clouds vision. If not properly treated, it can cause blindness. Wearing proper eye protection can reduce the likelihood of developing cataracts. Overexposure to UV radiation can suppress the immune system. It can cause decreased response to immunizations, increased light sensitivity and reactions to some medications. SUNBURNS...HOW TO TREAT When, why and how to treat for sunburn. Sunburn should be treated before it happens, when it might and after it does happen. This can be in winter or in summer, on land or on water, wherever direct sun or highly reflected light may reach and therefore threaten bare skin. Sunburn should be treated for the healing of current sunburn pain, skin damage and potential skin cancer as well as to prevent further sunburn. Here are the several ways we may do this. Use Aloe Vera. Aloe Vera comes from the aloe vera plant and may be squeezed from its leaves. Purchasing and learning to care for an Aloe Vera plant through the summer can be a wonderfully relieving investment. This healthful moisturizer is frequently used for sunburn and is applied to the affected areas of the skin as a rub to re- moisturize the dried and burnt surfaces. You can also purchase aloe vera creams and ointments that may include other moisturizers or treatments for dry or burned skin. General Moisturizers. A general skin moisturizer such as Noxzema can be applied to sun burned areas to cool and sooth the painfully itchy malady. Baby oil is a good moisturizer but don’t use it in the sun or it may help fry you further. Anesthetics. Anesthetics such as the popular skier’s treatment Cool Blue actually kill the pain of most sunburns for a time. This is applied to the skin in the form of a spray or gelatinized rub. It is also frequently mixed with Aloe Vera as sold. Aspirin dissolved in water in small doses may be tried directly applied to affected areas. Other medications. Unguentine is used to treat the ache and itchiness of sunburns. There are other brand name and store brand treatments you may want to ask your pharmacist about. Mycetracin or other multiple healing ointments may help to speed healing though you will want to ask your pharmacist to be sure. A hot shower. A hot shower immediately after mild sunburn can bring about peeling sooner and rid you quickly of discomfort. Vitamins taken internally or applied. Vitamin E, one of the antioxidants, can be taken regularly as part of a daily vitamin and mineral supplement or spread as in an ointment on sunburn. Vitamin C is another antioxidant that will help prevent severe damage from sunburn and shorten its effects. Selenium is a mineral that will help fight sunburn. Preventing further sunburn while you heal. To protect the eyes and the area around the eyes, try placing thin slices of fresh cucumber over closed eyelids when lounging in the sun. The cucumber will absorb all the ultraviolet light and keep the eyes safe and cool. Sunscreens cannot be over recommended in my opinion. Being someone who is sensitive to light and burns readily I know that an SPF 8 or greater sunscreen rating is needed if you plan to only reapply it every two hours or less often, at least for those who need to be as concerned as I do. At any sign of infection, get to a doctor as soon as possible. BUG BITES: Mosquitoes are known to pass blood-born illnesses from one victim to another. They are a major health hazard and are responsible for the transmission of yellow fever, malaria, dengue fever, encephalitis, filariasis, and many other serious diseases. ... Ticks can transmit Lyme Disease so you really want to avoid being bitten as much as possible August officially begins the peak season for bug bites. Dr. Dirk M. Elston, a dermatologist with Pennsylvania's Geisinger Health System, offered the following tips on prevention and treatment of common summer bug bites at ACADEMY ‘03, the American Academy of Dermatology's summer scientific meeting in Chicago, Ill. PREVENTION TIPS: The key to preventing such things as West Nile Virus and Lyme Disease is protection from being bitten. Dr. Elston recommends the following practical tips: Wear long-sleeved shirts and pants when outside Stay indoors at dawn and dusk (when mosquitoes and other insects are most active) Remove standing water in yards and clean out clogged gutters, which are breeding grounds for mosquitoes and other bugs Install or repair window and door screens so that insects cannot get indoors. Before going outdoors, it is important to use insect repellents on the skin and clothing to be completely protected against bug bites. The active ingredient in most commercial agents is either the insecticide permethrin or the chemical repellent DEET. TREATMENT TIPS: If an insect flies through your defenses and leaves a bite, Dr. Elston reports the best treatment method is to apply ice or products containing camphor or menthol to the affected area in order to reduce itch. The average insect bite is harmless and may leave a small red mark or bump that will disappear within a week. Persistent itch can also be treated with prescription-strength cortisone products. "If your bug bite lingers and a rash develops, or if you experience a fever, headache, episodes of joint pain, dizziness or fatigue following an arthropod bite, it is important to consult a dermatologist or other appropriately trained physician immediately in order to rule out a potentially serious condition," said Elston. See also ants, spiders, poison ivy page. This comes from another great article that is no longer available on the internet. The original author was a Dr. Elston, but we do not have any credentials for the doctor. Please check with your doctor to see if the tips provided here are right for you, this is not meant to replace any medical advice from your doctor. We are not medical professionals but are only sharing information on our site in order to help others with lymphedema. This page was edited by Lymphland editorial team 2/07. --------------------------------------------------- BEES Bees and wasps inject venom with their stingers. (Only honey bees leave a stinger behind. The poison sacs are still attached to the stinger, and continue to pump venom into the skin after the bee departs.) There will be stinging, swelling, and redness at the sting site. Usually, the symptoms subside after 20 to 30 minutes Allergy to insect stings can be deadly. Symptoms of allergy can include faintness, dizziness, general itching, shortness of breath, or swelling in places away from the sting site. A second type of allergy is much less serious. This is allergic swelling around the sting area. It usually starts the next day, and can persist for up to 5 days. The area is red, raised, hot, itchy and tender. Infection is also possible. Infection is common with honey bee stings (because of the stinger "foreign body"), but is rare with wasps. Beesting infection usually appears as red streaks. Immediate care: If a stinger is present (honey bee sting), remove it. Drag a sharp object gently across the skin, so it catches the stinger and drags it out. Don't press hard -- this turns the blade into a "shaver" so it cuts the stinger off at the skin line, leaving part of it in the skin. If you have splinter forceps, steady hands, and good eyes, you can grab the SHAFT (not the top) of the stinger and pluck it out. Insect Sting Relief pads contain alcohol and benzocaine. Benzocaine is a topical anesthetic. The pads can relieve the pain of a fresh insect sting. Cold packs can limit swelling. Elevate the sting area. Take an antihistamine such as diphenhydramine to reduce swelling and reaction at the sting site. See the doctor if you: become short of breath or wheezy, develop a severe throbbing headache, get hives, general redness, or widespread itching or become faint or lightheaded Ongoing care: Continue antihistamines until all swelling is gone. Local swelling: The day after a beesting, you may see severe local swelling. If it's itchy, hardens gradually to a central "pimple" at the site of the sting, is surrounded by a thin border of whitened skin, is not particularly tender, tends to go DOWN the extremity as much as (or more than) it goes up, and is NOT accompanied by fever or body aches, it's probably a local allergic reaction. This reaction tends to last about 5 days. Watch for: See the doctor if there is increasing tender red swelling around the wound, red streaks, drainage, fever, tender bumps in the groin or armpit upsteam from the sting, or an unexplained increase in pain or tenderness An insect repellant containing DEET will keep mosquitos at bay. For determined the horse flies, you may have to spray your clothing, because they can bite through it. Mosquitos, black flies, horse flies, and deer flies inject saliva containing an anticoagulant before they start sucking your blood. You have an allergic reaction to the saliva. (Although if you get bitten enough, eventually the reaction is less severe -- kind of like allergy shots.) There are two types of reaction: immediate edema (watery swelling) caused by antibodies, and delayed cell-mediated hypersensitivity caused by your immune cells. The immediate reaction usually goes away in about an hour, but some people have itching that persists for a couple of days. The delayed hypersensitivity comes later -- often the next day -- and persists for several days. Concerns: Severe (life-threatening) allergy to insect bites is rare. Symptoms of systemic allergy can include faintness, dizziness, general itching, shortness of breath, or swelling in places away from the site of the bite. The second type of allergy is annoying, but not dangerous. This is allergic swelling around the area of the bite. It usually starts the next day, and can persist for up to 5 days. The area is red, raised, hot, itchy and tender. Immediate care: If you come home itching, take an antihistamine such as diphenhydramine (sample brand Benadryl). An adult can use 50 mg (2 over-the-counter caps) every four hours. If you're prone to prolonged itching, scrub the bite well with soap and water, let it dry, then rub hydrocortisone 1% cream into the bite Put another dab of hydrocortisone right on top of the bump, then cover it with a bandaid. The bandaid drives the medicine into the skin -- and it keeps your fingernails away For the delayed hypersensitivity, antihistamines alone won't cure the underlying problem. Take an anti- inflammatory medicine, such as ibuprofen 600 mg four times daily. Apply warm packs, 20 minutes every two hours. If it's itching, add diphenhydramine 50 mg every four hours. Rub hydrocortisone 1% cream over the bite site three times daily. If the reaction is particularly severe, you may need to see the doctor for steroid pills (such as prednisone or Medrol). Watch for: See the doctor if there is increasingly painful red swelling around the wound, red streaks, drainage, fever, tender bumps in the groin or armpit upsteam from the bite, or an unexplained increase in pain or tenderness NASTY SPIDERS Black Widows hang out in the darkness. Description: You'll always feel a black widow bite. It feels like a sharp pinprick. Looking closely at the skin, you may see a couple of tiny red fangmarks about 2 mm apart. Within minutes, the area around the bite becomes vaguely reddened, to a diameter of about an inch or two. The area begins to tingle. In a half-hour or so, painful muscle cramps develop upstream from the bite. (If the bite is on the leg, the thigh then the abdomen will begin to cramp and hurt. If the bite is on the arm, the venom affects the upper arm and shoulder, then the chest.) As the poisoning progresses, there's shortness of breath, chest pain, and generalized muscle pains. Concerns: While a black widow bite is very painful, it rarely kills a grown adult. But children and elderly victims can die. Immediate care: Get to the hospital. You may require IV medication (calcium, muscle relaxers like diazepam, and narcotic pain medication). For life-threatening bites, antivenin may be required. The brown recluse (fiddleback spider) has tiny fangs. The bite is almost never felt. Because this spider is reclusive, it usually isn't seen either. The bite starts as a blister, which then becomes bloody. The blister pops, leaving an ulcerated hole in the skin that gradually enlarges over many days. Immediate care: Relax. First of all, that funny bump on your skin almost certainly ISN'T a brown recluse bite. Second, we don't do much about them. We just bandage the hole up and watch for infection. Most other therapies, such as cutting the bite area out, using steroids, etc, are controversial. If you do develop an enlarging skin sore, go see your doctor garden spiders do the most biting. But the bite isn't dangerous. You may develop some local swelling and pain at the site of the bite. The local reaction can persist for several days, and often looks like an infection. (It rarely IS infection, but if you go to the doctor, he'll probably treat it as infection just to be safe.) ANTS Fire Ants: 1. Remove all ants from the body to prevent further stinging. 2. Elevate the extremity where the person was bit. 3. Apply a topical steroid cream, such as hydrocortisone, with a concentration of at least 0.25 percent. 4. Administer oral antihistamines. 5. Monitor carefully for severe allergic reactions. 6. Monitor carefully for infection. POISON IVY Poison ivy causes misery for thousands of people each year. Its sticky resin causes symptoms such as swelling, a red itchy rash, blisters and oozing which may appear as soon as a few hours after exposure to as long as two weeks later. The more sensitive someone is to poison ivy, the sooner the symptoms will appear. And if they have had a reaction to poison ivy before, they will be even more sensitive to it the next time they are exposed. It is important for these people to avoid the plant carefully. Poison ivy usually appears on the body in the areas where the skin is the thinnest. The arms, the legs (especially the shins), and the face are affected most often. The rash will break out in a straight line of blisters that itch intensely, or in patches of red, bumpy skin. About five days later, the blisters crack open and release a watery discharge. It takes at least a week to two weeks for the irritation to heal. Most people can treat themselves at home, with no need to see a doctor. Here are some things to do if you have been exposed to poison ivy: 1. Wash the exposed area as quickly as you can. If you don't have quick access to a shower, a water hose will do. You want to remove as much of the resin as possible, as soon as possible. Sometimes thorough washing is enough to prevent the rash from developing. 2. Change clothes and wash the clothing as soon as you can. Any sticky resin on the clothing will remain until the items are washed. Simply coming into contact with the resin can cause irritation. Any items that can't be washed should be isolated and stored in a well ventilated area for at least three weeks. This includes shoes and boots. 3. If you do develop a rash, you can help relieve the itching by sponging the affected areas with alcohol, applying a paste of baking soda, using calamine lotion, or soaking in a tub of warm water with a handful of baking soda thrown in. 4. Take an antihistamine like Benadryl. This will help the itching and the swelling. If the itching becomes unbearable, ask your physician to recommend something. Some people are highly allergic to poison ivy and experience extreme reactions. In severe cases, the person's eyes may swell shut, they may develop a fever and intense pain, swollen lymph nodes in the neck, armpits or groin, and have difficulty breathing. If any these symptoms occur, it is important to seek a doctor's help immediately. An infection this severe will have to be treated with an antibiotic. A poison ivy irritation is extremely uncomfortable and far too easy to develop, but you don't have to be a victim. Here are a few things to keep in mind when you're in an area infested with poison ivy: Learn what the plant looks like and avoid it! An old expression goes like this: ‘Leaves of three, let it be!' The plant's appearance varies in different areas of the country. Find out what the species in your area looks like and memorize its appearance. When walking in wooded areas, wear long sleeves and gloves. Tuck pants legs into boots or socks. Don't wear shorts or sleeveless shirts! Don't let your dogs or cats run loose through the area. Poison ivy resin will stick to their fur and you can come into contact with it simply by petting the animals. Bathe your pets as soon as possible if you think they've been near poison ivy. Don't burn the poison ivy plants. This may sound like strange advice, but the oil from the plants can be inhaled through the smoke and cause lung irritation. And don't be fooled into thinking that you are immune to poison ivy. Just because you've never been affected before is no guarantee that the next time you come in contact with it you won't break out into itchy blisters. Take the necessary precautions to protect yourself from this potent plant. --------------------------------------------- ICD 10 Codes I 97.2 Lymphoedema arm, axillary lymph flow area I 89.0 Lymphoedema leg, inguinal lymph flow area (primary or secondary) I 89.9 Other diseases of lymph vessels R 60.0 Oedema without specification R 60.0 Oedema with CVI (chronic venous insufficiency - Ed!) R 60.1 Cyclic Idiopathic Syndrome R 60.9 Lipoedema and E 88.2 ---- http://www.medscape.com/viewarticle/703674?src=mp&spon=17&uac=91492PV From Medscape Business of Medicine Best Ways to Deal With Noncompliant Patients Mark Crane, BA Authors and Disclosures Published: 06/05/2009 Once you've figured out what's ailing your patient, the real challenge is convincing him or her to follow your advice. Only half of all chronically ill patients take medicines as directed, and many don't even bother to get the prescription filled, according to a 2003 World Health Organization study. Beyond that, many patients refuse to make recommended lifestyle changes that can improve their health. Noncompliance is dangerous for the patient and frustrating for the physician. As more insurers and Centers for Medicare & Medicaid Services (CMS) promote pay-for-performance programs, physicians will potentially be scored and reimbursed on the basis of patient outcomes -- meaning that noncompliant patients could drag down doctors' scores. Patient refusal to follow a treatment regimen also affects the nation's healthcare system. "The cost of patient noncompliance is easily in the tens of billions of dollars a year in needless complications and hospitalizations," says David B. Nash, MD, MBA, an Internist and Chairman of the Department of Health Policy at Jefferson Medical College in Philadelphia, Pennsylvania. "If we could improve compliance, we'd be well on our way to fixing the healthcare system regardless of what reforms are ultimately passed." Up to 11% of hospital admissions, 40% of nursing home admissions, and about 125,000 deaths a year are due to noncompliance with prescribed medication regimens, according to the American Pharmacists Association. As former US Surgeon General C. Everett Koop once lamented, "Drugs don't work in patients who don't take them." Economic Woes Increase Noncompliance Today's tough economy has created new reasons why more patients are noncompliant. Patients don't take medications if they can't afford them. Many patients who have lost their jobs and health insurance are forgoing prescription drugs or office visits. "People who have lost jobs are putting off preventive care and canceling routine visits," says Rick Kellerman, Chair of the Department of Family and Community Medicine at Kansas University School of Medicine in Wichita, Kansas, and past president of the American Academy of Family Physicians (AAFP). "That creates long-term potential for conditions to develop into more serious illnesses." On the basis of widespread money problems, physicians should take the time to ask about a patient's financial circumstances that can affect compliance. "Patients are often reluctant to tell physicians that they've lost a job and can't afford medicine," says Kellerman. "Perhaps it should be part of a standard history to inquire about whether they might have trouble filling prescriptions or returning for follow-up care." It's especially important to counsel patients about dosage when money is tight because some patients split pills to make them last longer. Physicians can also provide free samples, substitute generics whenever appropriate, and refer patients to pharmaceutical company or government assistance programs. Section 1 of 6 Best Ways to Boost Patient Compliance Physicians face 2 chief noncompliance challenges: patients who can't comply due to financial reasons, and those who don't want to make the effort to lose weight, test their blood sugar, or say no to harmful lifestyle choices. For doctors, it's vitally important to take time to tell patients why the treatment is necessary. "As many as 1 in 5 patients don't fill the original prescription because the doctor didn't convince them that they really needed it," says Kellerman. "It takes time to sit down with the patient and make sure they have all the information they need, but currently, the reimbursement system and shortage of primary care doctors doesn't make that easy." "There are multiple reasons for noncompliance," adds Donald J. Palmisano, MD, JD, a vascular surgeon/attorney in Metairie, Louisiana, and former president of the American Medical Association (AMA). "Patients may not understand what you told them. I typically ask the patient to repeat back to me what it is he's supposed to do. It's important to explain that if the patient doesn't take the medicine, he's at increased risk for stroke or some other illness. "If I suspect the patient is unclear, we give written instructions and may follow up with phone calls. It's important to know if the patient is able to read. I've been amazed over my career at how many patients cannot," says Dr. Palmisano. Patients need to know what the drug is and how it works in terms that are understandable to them. How and when should they take the drug? For how long? What side effects can be expected? What are the consequences of stopping the medication? If doctors can answer these questions, it's far more likely that your patients will follow your advice. Depending on your practice workflow, it may be useful for a medical assistant or nurse to discuss the prescription with the patient. He or she can stress the importance of the prescription and make sure the patient understands what is expected. Section 2 of 6 Technology Can Help Promote Patient Compliance Type the words "patient compliance" into Google and you'll get 3.7 million hits, mostly from vendors eager to sell you programs to encourage patient compliance. Some of them can be helpful. The solutions take the form of patient education, reminders, and ongoing monitoring, including call centers, email reminder programs, computer programs, high-tech packaging, and other tools to remind patients of dosages and refills. As electronic health records and e-prescribing grow, these technologies help physicians and health plans determine whether patients are taking their medications. Horizon Blue Cross Blue Shield of New Jersey, for example, is working with Merck & Co., Inc. to send text messages to physicians, informing them of patients not filling their prescriptions. Another program, supported by Pfizer Inc., provides automatic voice mail reminders to patients, replacing mailed notices. Electronic alerts have proven helpful and effective in encouraging patients to get screening and treatment for dyslipidemia. A report published in the January 2008 issue of Circulation described a randomized controlled trial in which investigators from The Netherlands found that 65% of patients who received electronic alerts were screened vs 35% of patients who had inquired by themselves.[1] Numerous new high-tech devices can help patients remember when to take their pills. Some offer subscribers a reminder service via a pager or other wireless device. MedivoxRx Technologies Inc., in Pittsford, New York, has a talking pill vial that reminds blind, visually impaired, and illiterate patients to take their medicines. The Med-eMonitor System, developed by Rockville, Maryland-based InforMedix, Inc., combines compliance and disease management on the basis of the patient's care plan. The system includes a portable drug storage device that uses chimes to prompt the patient to take the medicine. It also asks patients whether they have taken the meds, monitors their health status by asking other questions, and records the time and date of all interactions. The system automatically uploads the patients' information to a central database. If there is cause for concern, it triggers an outbound email, page, or cell phone text message sent to the patient's physician. Section 3 of 6 Companies Help With Nurse Coaches and Teaching Aids Some manufacturers are using nurse coaches to promote compliance, especially with high-cost specialty drugs. For example, McKesson Specialty, a provider of reimbursement, distribution, and clinical services for specialty drugs, runs nurse-coach programs through partnerships with manufacturers and health plans. For drugs that require self-injection, McKesson's nurses teach patients how to inject the drug, conduct monthly phone-ins, and coordinate care. Some pharmaceutical companies are providing physicians with practicing counseling tools to help patients. For example, a portable teaching aid from teriparatide (Forteo®), an osteoporosis drug, demonstrates to patients how bone strength and density can improve from treatment. The teaching aid is a 3-dimensional model that replicates before-and-after treatment bone biopsies from the hip of a clinical-trial patient of the drug. A program for tazarotene (Tazorac®) is designed to encourage teens to regularly apply the acne medicine. Messages are delivered through text messages received on teens' cell phones from a mobile "buddy" who they've selected. The program offers patients a series of incentives and rewards, such as wallpapers and ringtones, the magazine reports. David Nash comments, "All of the new methods are helpful, but there's no magic bullet and nothing substitutes for the basics: taking the time to explain to the patient why you're prescribing the medication." Section 4 of 6 Should You Dismiss Noncompliant Patients? At times, you'll encounter patients who complain endlessly about their conditions but stubbornly refuse to follow the recommended treatment. "We doctors tend to blame, but perhaps I could have done a better job of communicating," says Kellerman. "If I have trouble communicating with a patient, I try to look at myself first. It's rare to discharge a patient unless he's disruptive or abusive to the staff." Patients who repeatedly break appointments or don't show up for scheduled procedures may be discharged from a practice, however. "I had a patient scheduled to have his colostomy closed," says Dr. Palmisano. "He never showed up. We had a hard time locating him. We finally did and reschedule, but he didn't show up again. He came to the ER [emergency room] a few nights later, drunk and creating a disturbance, cussing out the staff. "I told him I couldn't continue to treat him and that it was in his best interest to find another doctor. I gave him a referral to a clinic and told him I'd be available in case of an emergency. It's rare to discharge patients, but sometimes you have to. It gives them a reality check that they cannot keep acting the same way." Some pay-for-performance programs could lead to unintended consequences, including pressuring physicians to discharge noncompliant patients who might undermine their performance scores. "I worry about 'cherry picking' and 'lemon dropping' in poorly designed pay-for performance programs," says Kellerman. "If I'm paid based on patient outcomes over which I don't have ultimate control if the patient is noncompliant, I could be penalized financially. That could be an incentive to drop patients who need my help the most." "Every doctor has an obligation to do the best he can for patients," says Dr. Palmisano. "So doctors may get an extra percent or two of reimbursement if they follow certain guidelines under these programs. We have to remember that patients are individuals, and we can't let managed care or government policies dictate the ethical practice of medicine." "All physicians can do is make sure patients have the information they need to make a rational decision," says Kellerman. "It's ultimately the patient's choice whether to accept our advice." Section 5 of 6 How to Dismiss a Noncompliant Patient Discharging a patient should be a last resort only after repeated attempts to find out why the patient is disruptive or won't comply with your advice. Physicians should personally speak with the patient to ask about any specific complaints, say malpractice risk managers. You may learn that the patient is unhappy with your treatment or office staff. These situations could potentially be corrected. It's important to end the doctor-patient relationship carefully to avoid getting sued for abandonment or discrimination. Most liability insurers have protocols and sample letters that doctors can use to reduce their risk for a lawsuit when they discharge a patient. It's wise to warn patients first that they'll be discharged unless their behavior changes. Document any noncompliance in the patient's chart. You should also document that you informed the patient of the specific potential consequences of failing to follow medical advice, says Dr. Palmisano, who also heads Intrepid Resources, a risk management firm in Metairie. Send a termination letter by certified mail, return receipt requested, and keep the receipt in the patient's file. Give the patient sufficient notice that you will stop treating him or her. A month is usually adequate, but check with your insurer or state medical society for guidance. Inform the patient that you'll continue to treat him or her until the termination date and for any emergencies that occur up to then. Refer the patient to the local medical society or hospital to obtain a list of physicians. Offer to transfer the patient's records promptly once you receive a written authorization. Section 6 of 6 ------------------------- Frequently-Asked Questions What is Lymph Drainage Therapy? For the past thirty years the benefits of Lymph Drainage Therapy have been scientifically documented and medically prescribed throughout Europe. Now it is rapidly gaining recognition in the U.S. by health care providers. Trained in Dr. Chikly's unique technique, therapists use precise, gentle, wave-like hand movements to feel the rhythm, depth and direction of the flow of the body's lymph fluid, to detect obstructions, and to map that flow. This enables the therapist to redirect the lymph to the pathway that is most effective for drainage - with far-reaching benefits. As noted by Dr. Bruno Chikly: The lymphatic system belongs to the circulatory apparatus which provides one way for the blood to leave the heart, the arterial system, and two ways for it to return: the venous and lymphatic pathways. The lymphatic system is therefore another pathway back to the heart, parallel to the venous system. The main functions of the lymph system are: stimulation of the immune system stimulation of the parasympathetic nervous system stimulation of body fluid circulation recovery of crucial substances that have escaped from the blood The lymphatic system drains the interstitial fluid. Stress, disease, injuries, environmental toxins cause the lymphatic system to stagnate or be obstructed, leading to the accumulation of excess fluid, metabolic waste, cells and toxins, foreign bodies and pathogens, and proteins in the interstitial environment, compromising optimum cellular function. This leads to disease and premature aging. Once the interstitial fluid enters the lymph vessels, it is called lymph. Lymph is then transported to the lymph nodes, purification centers, where it is filtered and processed for elimination through the kidneys. What are some of its benefits? Stimulates the functions of the immune system (promotes healing and general well being) Stimulates the parasympathetic nervous system while depressing the sympathetic nervous system (aids insomnia, depression, stress, digestion) Relieves muscle pain and hyper tonus Reduces edema (swelling) Alleviates heavy metal, pesticide and metabolic waste TOXICITY Reduces pain (fibromyalgia, chronic fatigue syndrome) Helps tissue regeneration (pre- and post-surgical, burns, injuries, reduces scar formation) Diminishes the effects of aging Reduces inflammation Improves circulation What are some of its applications? Surgical: pre- and post-surgical tissue regeneration and reduction of edema Sport injuries: sprains, strains, fractures, inflammation, chronic pain, whiplash, sciatica Pediatrics Ear, Nose and Throat: sinus, asthma, allergies, ear and throat infections, vertigo, tinnitus Neurological: migraines, headaches, stroke, facial paralysis, MS, Parkinson's disease, myopathy Gastroenterological: celiac disease, irritable bowel disease, chronic constipation, weight problems Dermatological: scars, burns, wrinkles Gynecological: infertility, menstruation, PMS, swollen legs, varicose veins Metabolic: stress, Chronic Fatigue Syndrome, chronic pain, cellulite, insomnia, toxicity Dentistry: inflammation, periodontitis, tooth extractions, TMJ pain Geriatrics: promotes tissue regeneration and oxygenation, improves circulation, relieves muscles soreness Ophthalmology: chronic edema of eyelids, cataracts, macular degeneration, reduced visual acuity Orthopedics: trauma, sublaxations, sprains, fractures Osteopathic: whiplash, back pain, sciatica Rheumatology: scleroderma, lupus, fibromyalgia, gout, rheumatoid arthritis, nocturnal paresthetic brachialgia Veterinary: Lymph Drainage Therapy can be applied to animals What are the contraindications? Acute infection/inflammation/fever Serious circulatory problems Major cardiac problems Hemorrhage Acute anuresis (absence of urination) Active cancer not under medical control, undiagnosed lump What are the known effects of Lymph Drainage Therapy? Manual Lymphatic Drainage is effective for a wide range of conditions and can be safely applied to everyone from children to the elderly, if the basic precautions and contraindications are respected. Here are a few of the known effects of Lymphatic Drainage therapy. CIRCULATION of lymph, blood capillaries, veins interstitial liquids and cerebrospinal and synovial fluids (indirectly) is ACTIVATED. This action helps to reroute stagnant fluid in the body (i.e., edema, primary and secondary lymphedema) mucosa, muscles, viscera, joints, cranial sutures, periosteum, chambers of the eyes and cochlea. TOXINS and METABOLIC WASTE PRODUCTS are removed, making lymphatic drainage especially effective in TISSUE REGENERATION. Scars, stretch marks, wrinkles, bruising and fracture or surgical incision sites are improved. LDT is used as part of DETOXIFICATION and ANTI-AGING regimens. MACROMOLECULES (PROTEINS) are drained which helps to ELIMINATE PROTEIN-RICH FLUIDS from the extracellular tissues and aid in the REABSORPTION OF EDEMA. FATS are EVACUATED through the lymphatic vessels. These VESSELS ARE located in virtually every area of the body WHERE FATS MAY ACCUMULATE. FUNCTION OF THE IMMUNE SYSTEM is STIMULATED through increased lymph flow. The additional flow carries more antigens to the lymph nodes, thereby INCREASING ANTIBODY/ANTIGEN contact. This has been found to HELP with chronic or subacute INFLAMMATORY PROCESSES - chronic fatigue syndrome, autoimmune diseases, bronchitis, sinusitis, amygdalitis, tonsilitis, laryngitis, arthritis, acne and eczema. FUNCTIONING OF THE PARASYMPATHETIC system is BOLSTERED, and SYMPATHETIC is DIMINISHED with stimulation of the lymphatics. This can be very helpful in dealing with STRESS, DEPRESSION, SLEEPING and DIGESTIVE DISORDERS. EFFECTS OF PARASYMPATHETIC STIMULATION Conserves and restores ENERGY Helps regenerate injured tissue Generally most active during sleep, deep relaxation states Stimulates immune functions Decreases heart rate Decreases respiratory rate Decreases blood pressure Increases blood flow to skin Increases blood sugar level Increases gastrointestinal motility and kidney function Increases secretion of lachrymal glands Increases secretion of salivary glands Increases secretion of digestive glands Increases secretion of bronchial glands Constricts bronchioles Relaxes sphincters and spasms Contracts pupils (miosis) Contracts ciliary muscles (accommodations) Contracts urinary bladder Stimulates erection CHRONIC PAIN is REDUCED as the drainage alleviates tissue-fluid stagnation and possibly inhibits nociceptors (pain receptors). TRIGGER POINTS and FASCIA PULLS can be RELEASED. VOLUNTARY and INVOLUNTARY MUSCLE SPASMS are REDUCED, proving helpful in cases of CONSTIPATION and other muscle-related maladies. DRAINAGE of the lobes of the LIVER is invaluable for releasing most of the post-treatment effects. As with any technique, there are conditions under which lymphatic drainage should NOT be used. These include ACUTE INFLAMMATION OR INFECTION (especially any condition with FEVER), MAJOR CIRCULATORY and CARDIAC problems, ACUTE BLEEDING and MALIGNANCY NOT UNDER MEDICAL CONTROL, ACUTE ANURESIS (ABSENCE OF URINATION). http://home.earthlink.net/~lymph-drainage-therapy/faq.html |