Treatments - Steve Norton (#1 of 5)

Steve Norton has been a Certified Lymphedemic Therapist (CLT) for over 20 years and has established a school that teaches lymphedema therapy. He is very well versed in treating and dealing with lymphedema and has gone on to train over 60% of the therapists in the country. In addition to treating lymphedema, Norton has also dealt with patients suffering from lipedema. He has found that classic therapies for lymphedema can also have success with lipedema, although the two are quite different conditions. When approaching therapy for lymphedema and lipedema, it is important to recognize that these are conditions that have existed throughout the course of human history. It is not a result of modern living and unfortunately there are a plethora of stigmas surrounding lymphedema and lipedema. First and foremost, these disorders are not a result of obesity or laziness. Oftentimes, individuals are characterized as being lazy and labeling them as such can have very real consequences for their mental health. Rather than suffering from an eating disorder, being lazy, or being obese, individuals with lipedema simply process food and fats differently. Recognition of this, as well as accurate and specific diagnosis, often results in comfort and reassurance for the patient; lipedema and lymphedema are very real problems that individuals must face and learn to deal with, but those individuals are not at fault for the way their body looks and works. Recognizing and distinguishing lipedema from lymphedema is necessary when assessing an individual’s specific needs. Lipedema often onsets at or around puberty, manifesting primarily in the legs. It begins at the pelvic crest and moves down the legs to the ankles, but never affects the feet. Individuals with lipedema, contrary to lymphedema, have bilateral symmetry between limbs, with skin characterized as soft and lacking elasticity. When touching the skin, adipose nodules can be felt as small bumps in the skin. Individuals with lipedema have a tendency to bruise easily and are hypersensitive to touch and pressure. In some cases, prominent superficial veins may occur. Veins lose support from the skin and this loose environment allows the veins to become easily engorged in blood, causing them to visibly protrude from the skin. While cures do not exist, CLTs can take individuals to a better level of life satisfaction and actively work with patients to improve their symptoms.


Treatments - Steve Norton (#2 of 5)

When comparing pure lipedema to pure lymphedema, there is a lot of contrast. While pure Lymphedema is a fluid congestion, pure lipedema is an adipose congestion. Lymphedema patients are also more easily predisposed to bacterial infections, which can be potentially fatal. This is very rare in pure lipedema patients, however. Individuals with lymphedema almost always have it manifest in their feet as well as their legs, while this is not present in patients with lipedema. While lymphedema can affect the entire body, lipedema only affects the legs. Lymphedema presents asymmetrically, whereas lipedema presents symmetrically. Skin is hard and tight in patients with lymphedema while patients with lipedema have soft and loose skin. The skin also tends to be more sensitive in patients with lipedema, whereas with lymphedema we see a decrease or even loss of sensitivity. This also affects bruising in patients; those with lymphedema do not bruise while patients with lipedema are easily bruised. Overall, there is quite a contrast between the two disorders. That being said, there are effective ways to handle the symptoms present in both. This relies on accurate assessment and diagnosis of a patient’s symptoms. When accurately diagnosing a patient, it is necessary that the CLT distinguishes between the four common variations of lymphatic disorders. The first of these is lipo-lymphedema. Lipo-lymphedema is characterized by all pure lipedema attributes plus those attributes of pure lymphedema. Lipo- lymphedema is a result of unmanaged lipedema. Toes, feet, and calf become edematous, or engorged with fluid, and pitting edemas are present which can later progress. Infections are readily acquired and the skin begins to change. Lipo-lymphedema occurs because lymphatics live in the fatty tissue of the skin. When fat congestion continues, the pathway of a normally functioning lymphatic becomes like a corkscrew. Emptying of fluids thus becomes more laborious and this fluid then begins to move backwards because the valves in the lymphatic begin to fail. Fluid amassing in the limb thus contributes to the swelling of that limb. The second common variation is lipo-phlebo- lymphedema. Lipo-phlebo- lymphedema is characterized by all pure lipedema attributes plus all pure lymphedema attributes plus vein attributes. It is caused by unmanaged lipedema and venous disease and presents as a mixture of chronic venous insufficiency. Water and lymph accumulation occurs in the limbs affected. Because the blood valves aren’t working very well, blood begins to leak out and this results in rusty discoloration of the skin. Like lipo-lymphedema, the valves of the blood veins are not being held together correctly and so they begin to deteriorate. When being assessed, it is important to determine if the patient has more venous attributes or more lymphatic attributes. Therapy is necessary and can address the lack of support that a patient’s legs have. Therapy can also work to reverse the accumulation of liquid and soften the skin. While lipo-phlebo- lymphedema cannot be cured, it can be held at a normalized state. The third common variation is lympho-lipedema, which is characterized by pure lymphedema attributes plus pure lipedema attributes. It is caused by primary or secondary lymphedema with a predisposition for lipedema. It presents as if lymphedema is the sole diagnosis, but the underlying lipedema eventually becomes more apparent with treatment outcome. It is crucial to recognize the underlying lipedema as soon as possible because it helps to shape the course of therapy for the patient. The final forth variation is simply a diagnosis of either pure lymphedema or pure lipedema. The most important aspect of the certified lymphedema therapist is to do no harm. Their job is not to remove tissue for cosmetic purposes. Individuals are often born into the world lacking the nutrients or tissue structure necessary and therefore surgery that removes more tissue only causes more harm. Lymphatics are fragile and finite but are very responsive to care. One can begin to revive lymphatics and free them from the connective tissue that they are trapped in. They live in subcutaneous adipose layers, though, and therefore it is also important to understand the adipose layer in addition to the lymphatic structures.


Treatments - Steve Norton (#3 of 5)

The main goal of a Certified Lymphedema Therapist is to preserve and maintain the health of the existing structure. Through soft tissue manipulation, fluid discharge can be increased, allowing the mobilization of fluid to help create more structure for the veins and reduce the size of the limbs affected. It is important for the Certified Lymphedema Therapist to pause before inviting more risk. Experts are still unsure of whether or not we can even afford to lose lymphatics. Therefore, removing lymphatics could be extremely harmful. Additionally, it is possible to improve long-term outcomes but this can only be done through therapies with empirical evidence and support. Finally, early identification is crucial to combating lymphedema. It not only allows treatment to begin earlier, but also allows therapists to halt the progression of lymphedema into other variations.
A Certified Lymphedema Therapist will apply Complete Decongestive Therapy (CDT), which is a gold standard for lymphedema and won’t fail the lymphedmic component of a patient’s diagnosis. That being said, it won’t give the patient skinny legs because it cannot alter adipose levels. Complete Decongestive Therapy offers a broad spectrum of treatment forms. Important aspects of this therapy consist of exercise, skin care, and self-care education and routine. The strengths of CDT are that it is best suited to edema reduction, preventing progression into “combined” forms. It also greatly reduces discomfort and improves movement and function, supports weight control and exercise, and provides slow improvement over months and years. Unfortunately, the limitations of CDT are that, for lipedema, the progression is much slower and there are not as many forms of the treatment available. CDT does help create healthier legs, maintain emotional support and help to combat a plethora of other lipedemic symptoms, however, and should be considered when looking for treatment for one’s lipedema. As a certified lymphedema therapist, the first goal is to establish an accurate diagnosis (lipedema (pure), lymphedema (pure), lympho-lipedema, lipo-lymphedema, lipo-phlebo- lymphedema). Then the CLT must adapt CDT to the severity and complexity of that specific diagnosis. It is crucial for the CLT to avoid overtreatment or experimentation on the patient as this is both highly unethical and dangerous for the patient. Moving forward, the CLT then continues treatment and provides accurate guidance. This includes maintaining a current and up to date understanding of recently published literature, mimicking empirically derived treatment options, and addressing anatomical deficits, such as skin compliance. Finally, it is vital for the CLT to recognize the emotional impact of living with lipedema and address this through counseling and emotional support. For pure lipedema, If no edema exists, compression garments might be all that is necessary for treatment. Compression bandaging initiates a controlled working pressure to help arrest growth and help combat pure lipedema. Compression garments come in different forms, but usually have a high resting pressure and are a mainstay of ongoing CDT. Additionally, it is important that the patient adopts a safe and healthy regime of diet and exercise, while also keeping up with self-care.


Treatments - Steve Norton (#4 of 5)

The lipedema component of a patient’s diagnosis is harder. Wearing elastic garments is very helpful for patients to continue to wear throughout the day, but it is important for the patient to sleep free of any compression clothing at night. The patient’s skin should be allowed time to rest and relax and this is best done at night when they are lying down and have less gravitational pull on the fluids in their legs. Additionally, the usual schedule for compression garments is to be checked every 6 months, unless an individual is hard on their garments (pulling at them, sticking their fingers into them, etc.). If compression garments are not what the patient wants, compression bandages act as another possible form of treatment, although it tends to be found more in cases where lymphedema coexists. The benefits of compression bandages are that they are much easier to get into and are worn nightly and whilst exercising. They often take around 3 or 4 minutes to tighten, whereas compression garments take much longer, around 45 minutes or so of wrapping and tightening. In addition to both of these garments, it is important that the patient practices proper skincare, avoiding infections at all costs. Alternative therapies do exist and can prove beneficial to the patient. These therapies consist of special diets and supplements, special exercise routines (although these should always be done with support, such as compression garments), pneumatic compression pumps (although these are not always advised), acupuncture, surgery, spa treatments, and many others. The primary risk with alternative therapies occurs when individuals seek cosmetic enhancement and volume reduction. These surgeries often introduce new problems that did not exist before and are considered dangerous when compared to more empirical forms of treatment, such as CDT.


Treatments - Steve Norton (#5 of 5)

To be a Certified Lymphodic Therapist, you need to have taken 135 hours from a school approved by the Lymphology Association of North America, located in Atlanta. This education system standardizes therapy and education so that all therapists are aware of empirical studies and the therapies that are most effective for patients’ well being. When measuring garments it is integral to measure them in a specific way, and should be measured by a CLT. This ensures that the garments are tight where they need to be and looser in other places. Specific measuring drastically reduces the chances of hurting the patient, which could result from the garments cutting at the patients skin or constricting their skin too tightly. Pool exercise can prove to be very beneficial for patients with lipedema and Lymphedema, as it creates an environment with less gravity and thus less pressure. While this helps to alleviate a lot of pain and discomfort, it also allows individuals’ limbs to swell freely. Therefore, it is important for the water to not be too warm. Warm water increases blood circulation which can cause lymphatics to swell if they are not kept tight with garments. Therefore, cooler water and elastic garments make pool exercise a safer and better suited form of exercise for patients with lipedema and Lymphedema.


Manual Lymph Drainage

Manual lymph drainage is a manual, hands on technique that is employed by therapists and patients to move lymph fluid. Molly Nettles, from GRU Cancer Center, explains that it is similar looking to a massage, but the touch is much lighter than what one would expect for a traditional massage. Manual lymph drainage utilizes an extremely gentle touch, very light to the skin and tissue; therefore, is not painful. Nettles expresses that a stage one patient utilizing manual lymph drainage is a positive form of treatment that can be used now and into the future. If a patient did begin to develop a fluid component with swelling, more aggressive compression techniques would be necessary. In this video, Molly Nettles demonstrates the technique of MLD. To apply the technique, begin by applying pressure forming a lateral stretch, followed by a longitudinal stretch, forming a “C.” The stretching of the skin helps to open lymphatic vessels and allow fluid to rush into them. Without stretching the skin, less fluid will be moved. Manual lymph drainage is a tool that can be used for stage one Lymphedema to help move fluid through the lymphatic system, reduce pain and increase immunity.


Dry Brushing – Upper Body

Dry Brushing is a method that can be used to improve lymphatic flow and circulation with the added benefit of exfoliation. Dry brushing helps in easing the discomfort lipedema may bring. In order to receive the best benefit it is best to look for a brush with a long handle and natural bristles. Artificial bristles tend to scratch the skin of the surface so it is recommended not to use them. It is also recommended not to dry brush if the skin is already irritated. "The goal of dry brushing is to stimulate not to irritate." The best way to use the brush would be using it on dry skin while the brush itself is also dry. There are a few steps used when dry brushing the upper body. Each step has its own method and its own way of dry brushing. The first step for dry brushing on the upper body is to start at the top and work your way down. Start around the jaw bone and brush down towards the collar bone with as much contact with the brush as possible. Repeat this method on each side of the neck for about seven strokes. Next, start behind the head at the hairline, then pull the brush around to the front of your neck. This method would also be repeated seven times on each side of the neck. Move then to the breast area. With this method start below the breast bone, and work your way around and up towards the armpit in a circular motion. Moving right from the breast to the armpit, with this step you would just brush your armpit in a circular motion. Once again seven times on each side. From the armpit the next step starts from around the top of your thigh and would go up towards your armpits. Next is the abdominal region where you would make a circular motion around the abdomen clock wise, then counter clockwise. With this step you would like to feel the skin stretch while brushing. Move from there to the upper back, with this step you start at the top and brush down and out towards the front of your body. This should also be done seven times on each side. The last place is the lower back. Start at the center lower portion of your back and brush your way towards the front on each side.
Remember each of these steps are recommended to do on both side (if possible) and at least seven times. Dry Brushing is meant to be a relaxing process so "be sure to treat yourself, take care of you!"


Dry Brushing – Lower Body

Dry Brushing is a method that can be used to improve lymphatic flow and circulation with the added benefit of exfoliation. Dry brushing helps in easing the discomfort lipedema may bring. In order to receive the best benefit it is best to look for a brush with a long handle and natural bristles. Artificial bristles tend to scratch the skin so it is recommended not to use them. It is also recommended not to dry brush if the skin is already irritated. The goal of dry brushing is to stimulate not to irritate. The best way to use the brush would be using it on dry skin while the brush itself is also dry. After completing the steps of dry brushing on your upper body the next place to go towards is your lower body. The lower body is an important place to dry brush because it tends to be place most over looked when it comes to taking of one's body. The following steps have a mixture of both the upper and lower region of our body.
The first place to start when dry brushing on the lower body would be the gluteal region. With this step you start underneath your bottom and brush up and out towards the side. This step should be done seven times on each side. The next place would be the groin area. Start at the top of the thigh and brush out and up on each side, seven times. The next area is the top of the foot. In this step brush in a half circular motion on the top of your foot. Next, start on the ankle and go up towards the knee around the whole ankle. With this step make sure to use long strokes. Following that, start from your knee and brush up to the hip. Same as the last step with the use of long strokes. Do not forget to keep brushing until your covered your entire thigh. The next place is the palm. With this step you start towards the fingers and brush up towards the end of your palm. Then move to the wrist to the elbows. Brush in an upwards motion and do not forget to get the entire arm. From there move to the upper arm from your elbow to your shoulders and move all around the arm. Dry Brushing is just another method to aide in keeping the skin healthy and you are encourages to "keep living, and have fun" regardless of the circumstance.


Compression - Yvonne (#1 of 2)

Yvonne Russell begins by introducing compression as a treatment for lipedema. Russell explains short stretch, which is a one-way lateral stretch no more than 40%. Selecting a garment to maintain limb circumference is especially important. Because it can be difficult to tolerate the pressure of massage and wrapping, it is important for the physician to find a suitable garment while walking. This results in a more comfortable garment that reacts to the need of the limb, providing more compression when you need it, and less when you don’t. The short stretch in the garment will help massage the lymphatics and venous, generating more blood flow. The Farrow wrap, the only short stretch garment to date, has a comfortable spine in the back with thin cotton elastic material.
Next, circular garments, typically made of a nylon material, have a four-way stretch. Over the counter compression stockings are typically circular know. These garments are thin, but still contain the skin being smaller than the limb. Because of the thinness of this product, patients often experience bunching or slipping behind the knee.
Flat knit garments, often preferred for the bigger or abnormally shaped limb, have a two-way stretch made of nylon. The disadvantage to a flat knit garment is its cost and fixed size—if you gain or lose weight in the limb, it will not fit; however, this is a more painful option for many. An expert fitter is necessary due to the thickness of the garment. Russell concludes by introducing the Infinity wrap, offering extra support under clothes. The product is available as a shaper tanker and compression shirt.

 
Compression - Yvonne (#2 of 2)

Yvonne Russell explains some her past experiences with patients. She offers advice, explaining that a limb can always be wrapped, regardless of its shape or size; however, thinking out of the box is necessary for some patients. Following, Russell begins explaining post-surgical garments, typically made of a nylon and spandex combination. Advantages of a post-surgical garment instead of a compression garment are the vast variety of size options and comfortability when putting the garment on. Moreover, Russell shows the micro-massaging garments. This type of garment stimulates the superficial lymphatics by stretching the top layer of skin with the massaging. Layering of the garment often works best. Russell explains at the conference the importance to be creative when looking for a garment that works for each individual patient. She offers a suggestion for ladies, who have struggled with finding a garment, a method of cutting and stitching a leg garment to use as an arm garment. Furthermore, Russell introduces chip foam to subsidize edema. With movement, the garment massages the area—the rigid protein and tissue is broken up. Following, Russell lightens the mood with inexpensive solutions for lipedemic patients such as boot expanders and arm sleeves. She explains the importance of identifying a patient’s goals, while taking into account time and economic commitment. Exploration, as well as trial and error, are also key components in finding suitable garments.