By Helen Eason
I attended the Lymphoedema Academy training by Professor Jean-Paul Belgrado and Jane Wigg in Melbourne back in May 2017. The whole ethos of this training is to use the developing evidence gained from Jean-Paul’s Indocyanine Green Imaging studies of the lymphatics in real time to teach a new evidence based medical lymphatic drainage technique and treatment concept.
During the course, fibrosis treatment methods, the foams used to break up fibrosis, and manage oedema with increased compression, were discussed.
Jean-Paul has found through ICG that textured foams push fluid in multi-directional ways – up, down, laterally. They move the proteins and fluid around helping dispersal through the initial lymphatic system until the oedema can be eventually massaged or compressed towards a working collector vessel. Of course, we all wanted to know which was Jean-Paul’s preferred foam from his findings and waited with baited breath, pens at the ready to scribble down the answer, which was …..
Thuasne Bande Mousse
We all looked at each other – what was this magic product? No one had heard of it.
You know the yellow foam by Thusane? he said
Blank faces all around. How had this magic product basically bypassed us all. I was straight on the phone to Jenni the next morning. Yes, she had this magic product and she confirmed no one in Australia really purchased it. When she told me a roll was only $18.75 I was blown away – that was much more economical than the foam I was currently using.
The magic package arrived at the practice and we all were eager to see this new amazing product. When we opened the box, there was the magic yellow foam.
“Really, is that it?” we all exclaimed as we passed the roll around. We thought it would be some kind of highly technical memory foam, but ok I thought – lets put this economical soft foam to trial.
I had a couple of clients with really fibrotic breast oedema that were using compression bras with rival foams and self-massage but still refilling quickly after sessions of therapist MLD. They were my initial guinea pigs who both came back with less refill using Bande Mousse. Both found the foam very comfortable and liked how it conformed better to their body so it was less bulky and not so noticeable, improving adherence to use and self confidence when wearing.
I’ve used Bande Mousse or genital oedema, head and neck oedema, hand and feet dorsums, you name it. You can use a whole roll for your padding layer under traditional multilayered bandaging. It works a treat and is durable too. It’s my go to foam now and I still can’t believe how economical it is.
It just goes to show, just like we shouldn’t judge people by their looks, we shouldn’t judge products that don’t look super flashy. I’ve certainly learned that from this simple yellow foam that has earned a place in my oedema toolbox.
Emulsified latex foam bandage (8 mm thickness)
The author Helen Eason is a UK trained physiotherapist with over 20 years experience in the management of chronic oedemas. She is a regular speaker on all things oedema and loves to “question everything”. www.heleneasonphysiotherapy.com
Medical Rehab would like to thank Helen for reviewing this product
]]>by Sarah Gill
As a lymphoedema therapist your mind instantly start to tick over when you get the phone call from the patient who says:
The questions from you come thick and fast: e.g.
From this we can start to get a picture of what condition the patient may be in before we arrive at the appointment. Usually the leaking legs are their prime concern and they have some personal care assistant (PCA) allowance. If the patient has access to community nursing service, I ring the nursing group to inform that I will be visiting the patient for a consultation. ( If the patient does not have nursing assistance we start the process of initiating it through the local Council). I explain how I hope to develop a treatment protocol and ask if they would be willing to assist with some bandaging of the patient. Mobiderm with its ease of use, efficacy and training materials available, make it the ideal product to introduce. I then direct the nursing staff to the Mobiderm website where they can look the products I want to use.
The next step is to ascertain how compliant the patient will be with bandaging, we all know how busy community nursing staff are. At this point I will take in some of the bandages to show the patient and direct them to look at the Mobiderm website. I remind the patient that this will be a short-term plan and that if the nursing care is involved, they need to be compliant to the best of their abilities. The aim being to stem the leaking of the legs and then get them into a Mobiderm autofit thigh high or sock that the PCA will be able to assist with donning.
After I have demonstrated the Mobiderm bandaging protocol to the nurses, preferably to the team who will be working with the patient I direct them to the excellent Mobiderm training videos which they can use as a reference.
The treatment plan includes all aspects of patient care including skin care, wound care, exercise, occupation therapists to find a solution so the patient can sleep in a bed and new compression garments if required. Treatment commences with 5 days of bandaging for approximately 8 hours a day. The patient needs to have a family member or carer to remove the bandages for night-time. As the lymphoedema therapist you undertake the first day of bandaging on the Monday with the nurses following for the next 4 days. The patient rests on the weekend and then this protocol is repeated the following week. The patient’s wounds must be dressed, and absorption pads placed over areas of leaking. The patient is then transitioned into a Mobiderm autofit thigh high or sock which can be worn either daily or at night-time with compression wraps or garments worn in the daytime.
protocol for community nurses
Bandage time:
8 hours per day if possible. Duration – dependent on case approx. 5 to 10 days. To be removed at night - time.
Equipment:
Cotton bandage
Mobiderm bandage (blocks 15 x 15 mm),
1 to 2 times 10cm Biflexideal short stretch
Method:
Post - treatment management
Tips for the therapist:
Advantages:
Disadvantages
Photo by William White on Unsplash
]]>Mobiderm is comprised of open-cell foam in an adhesive non-woven fabric and can be purchased in two different sizes 15mm x 15mm blocks for the limb and torso and 5mm x 5mm blocks for the hand/foot and areas of scar tissue build up. When two areas of pressure are placed on the Mobiderm (think bandages/compressive material & muscle movement) a shear effect (foam squares move down and across simultaneously) is created. This shear effect mobilises the skin which pulls on the collagen fibers stimulating the opening of the initial lymphatic vessels. It also creates a pressure differential in the interstitial tissues. Click here to see the video on how Mobiderm works.
Most products just compress which reduces the rate of filtration. Mobiderm not only reduces filtration it also stimulates the lymphatic system. The initial lymphatic vessel (figure 1) Is stimulated by the sheer effect of the Mobiderm opening to draw in the odematis fluid (figure 2) this starts the peristaltic reaction in the collector lymph vessels (figure 3) and lymphangion stimulation as the system is loaded (figure 4)
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Figure 1
Figure 2
Figure 3
Figure 4
So how does this help us reduce oedema in the breast and chest wall?
When the 15mm x 15mm blocks are placed over the area of oedema on the breast or chest wall the shear effect of the Mobiderm starts to stimulate the lymphatics when compression is introduced through either:
The 15mm x 15mm squares are most effective due to the amount of subcutaneous tissue in this area. If the patient has a fibrotic scar a small strip of the 5mm x 5mm Mobiderm between the bra and skin has been shown to soften the scar.
The adaptability of Mobiderm allows you to treat your patients successfully, reducing their oedema and support their lymphatic system.
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When I have a patient who has oedema in their legs upper thighs and glutes I always state/ask the following: “This can sometimes be a difficult subject, but with your condition it is common to get swelling in your genitals. Have you noticed any changes in this area?”
Sometimes scrotal oedema is quite evident and at other times the patient may just feel that the area is heavier. Can the patient describe the change in size to that of a grapefruit or melon and do they have difficulty urinating due to a retracted penis? Does the swelling come and go or get worse at any particular time of day? These questions that need to be asked before a treatment protocol can put in place. We have two different methods to choose from depending on the severity of oedema and the overall condition of the patient. Method 1 is suitable for palliative care/aged care and all of our training materials are also available for your patients use.
Method 1:
Ask the patient to wear some compressive shorts as underwear – such as cotton bicycle shorts. It is important that the patient does not wear underwear underneath the shorts. Cut the Mobiderm 15mm-x-15mm roll into either 2 or 3 strips measuring 15cm in length and insert these into Cotton short stretch bandage (which you cut open to form a tube). Place these strips directly in between the compression shorts and the scrotum. These can be worn either at night time or during the day when the patient is home. Also, direct the patient to do 3 x deep abdominal breaths 3 to 4 times a day and self lymphatic drainage were appropriate.
Method 2:
The materials you need for this are: Cotton short stretch bandage,
Mobiderm 15mm x 15mm blocks in a sheet, 8cm Biflexideal light short stretch bandage .
Please note that you and your patient can view this method by going to:
VIDEO - Gential treatmetns and Mobiderm and/or Click here to download the complete procedure for Mobiderm Scrotal Bandaging
As the scrotum reduces in size adjust the size of the scrotum sack. If you are unable to bandage the Mobiderm scrotal sack will still be effective in cotton bicycle shorts or a scrotal sling.
]]>When a patient walks into your clinic room for the first time, encouraging them to see the benefits of treatment for their lymphoedema can be a challenge. Whether patients have had long term lymphoedema or have developed it recently, directing them to an intervention of a bandaging sequence or purchasing Mobiderm Autofit Sleeve can be difficult, especially when they have not experienced the benefits of these products in their treatment. Patients may also not know where the areas of lymphoedema are more present in their limb, what fibrosis feels like or what the physical sensation of reduction of fluid can be. This is where the Mobiderm bandaging System can be utilised as a diagnostic tool for both you and your patient during clinic practice time.
For a patient with arm lymphoedema the materials you require are: Cotton Bandage Short Stretch, Mobiderm roll -15m-x15mm blocks, Biflex bandage16+.
The method described below can be seen on this link:
Mobiderm application_in_treatment_time
When the bandages have been removed you can show and explain to your patient that the areas where the indentations from the Mobiderm squares are deeper are the areas where the lymphoedema is more present in the arm. The areas where the squares are not as deep the lymphoedema is not as present. This information can be used to assist the patient in where to perform self lymphatic drainage or fibrosis techniques as part as their on-going management plan. The patient will also usually feel a lightness in their limb, this information can be used to direct them to what the benefits of a 3 day Mobiderm bandaging sequence would be or how the combination of a Mobiderm autofit sleeve or Veno elegance daytime arm sleeve could improve their lymphoedema.
Photo by Toa Heftiba on Unsplash
]]>As health practitioners we can add to the Quality of Life (QoL) of our patients firstly by asking the right questions, secondly by listening and thirdly, by intervening with the patient’s wishes foremost in our minds.
The World Health Organization defines QoL as “individuals’ perceptions of their position in life in the context of the culture and value system in which they live, and in relation to their goals, expectations, standards and concerns.” QoL embodies overall well-being and happiness, including access to school, work opportunities, absence of military conflict or threats, as well as good physical and emotional health. It’s relative, subjective and has intangible components, such as spiritual beliefs and a sense of belonging.
A number of questionnaires/studies have been developed to measure QoL in patients with lymphoedema. Articles such as the following shed insight into the poor information provided to patients and a general lack of understanding of lymphoedema by health professionals.
Health-related quality of life with lymphoedema: a review of the literature.
Morgan PA1, Franks PJ, Moffatt CJ.
Abstract
This article reviews qualitative and quantitative studies that evaluate health-related quality of life (HRQoL) in lymphoedema. Qualitative studies reveal a number of factors that can affect HRQoL. These include a lack of understanding of lymphoedema by health professionals and poor information provided to patients. Emotional responses include shock, fear, annoyance, frustration and negative body image. Treatment can be costly in terms of time and disruption to lifestyle. Quantitative studies show that patients with lymphoedema experience greater levels of functional impairment, poorer psychological adjustment, anxiety and depression than the general population. Increased limb volume is poorly related to the impact of lymphoedema on the patient. Factors leading to deficits in quality of life include the frequency of acute inflammatory episodes, the presence of pain, skin quality, lymphoedema in the dominant hand and reduced limb mobility. There is some evidence that the adoption of patient-centred guidelines can improve quality of life in patients with breast-cancer-related lymphoedema. HRQoL is an important outcome in the management of patients with lymphoedema. Further studies must examine how lymphoedema impacts on patients other than those with breast-cancer-related lymphoedema and the consequences to patients of different approaches to care.
Click here to go to QOL and lymphoedema articles on Google Scholar
So how do we aim to improve the QoL of our patients? ASK questions such as: “How can I best help you”? LISTEN to the answer which may be as simple as the patient being tired of trying to put on compression socks everyday and instead would prefer to wear an item such as an Mobiderm autofit sock which has Velcro tabs and is easier for the patient to wear. HELP have the patient’s wishes foremost in your mind. Give them the best information you can and then help them with all the tools you have available.
Photo by Zoltan Tasi on Unsplash
]]>As a lymphoedema therapist I am often asked by patients “What about diet?” “Should I change my diet?” The first response I have is “Well, let’s talk about your nutrition then”. Immediately, I take the focus away from the word diet, which often has a negative connotation and replace it with the word nutrition. Trying to get the patient to look at it from the perspective of what we add in to help treat our lymphoedema rather than what we leave out. Nutrition is one of the pillars of lymphoedema treatment along with bandaging, manual lymphatic drainage, compression garments, skin care and exercise. For optimal nutrition, eating a balanced and healthy diet is the best, not for just those of who have lymphoedema but for all of us.
Try and boost your nutrition and health by:
Sprinkling herbs and spices instead of salt: Common salt contains sodium, which binds water in the body. In other words: if you consume too much salt, your body will retain unnecessary body fluid and therefore enhance oedema formation. A high salt diet also increases blood pressure, no matter whether you use table salt, herb salt, sea salt or Himalayan salt. Convenience foods, ready made sauces, etc., contain a lot of salt, so try and avoid them and instead focus on adding natural foods that you prepare yourself. So, sprinkle some herbs or spices instead of salt.
Drinking more water: It is important to ensure that you drink an adequate amount of fluid each day. Reducing your fluid intake will not help reduce lymphoedema and may actually worsen it. Try to drink eight glasses of fluid each day to meet your requirements. Good hydration (water) is also essential for basic cell function and especially important before and after lymphoedema treatment to assist the body in eliminating waste products.
Eat Protein: There is a common misconception that lymphoedema may be positively affected by limiting protein intake. This is not the case – although lymphoedema is defined as an accumulation of water and protein in the tissues, it is essential to understand that lymphoedema cannot be reduced by the limitation of protein ingestion. Also, if you have lymphoedema it is important to ensure you eat and adequate amount of protein each day as this helps to prevent your body’s muscle being broken down which can make fluid build-up worse.
Focusing on nutrition may help your patient maintain their ideal body weight or lose weight if needed. Research studies indicate that obesity does have an influence on lymph fluid level and that even small amounts of weight loss can be helpful in reducing oedema.
Photo by Edgar Castrejon on Unsplash
]]>We know from research that exercise helps lymph move through the lymphatic system. Exercise makes the muscles contract and pushes lymph through the lymph vessels. A specific exercise program, designed to assist the lymph drainage from your swollen limb is an important part of your overall management for lymphoedema and something that you can do to help yourself.
Exercises have other benefits too.
They can help you to keep a full range of movement and make you feel better.
What you’re able to do will depend on:
Talk to your doctor or lymphoedema specialist before you start any exercise as they can advise you about what you should and shouldn’t do.
Start exercising gently and build up slowly. Walking can be a good way to start if you haven’t done any exercise for a while. You can gradually increase the distance and the pace. Other examples include yoga, Tai chi, pilates, cycling, swimming or water aerobics.
Try to do some exercise every day. Think about how you can build it into your daily routine. You’re much more likely to carry on doing exercise if it becomes a regular part of your day.
Exercising with bandages on such as the Mobiderm Bandaging System further enhances the pumping action of the lymphatic vessels. Even wearing a daytime compression garment such as the Veno Elegance daytime compression sleeve or Venoflex micro compression sock whilst exercising can help create a greater pressure differential in the interstitial tissue, increasing lymph flow.
Deep breathing exercises help the flow of the lymph fluid through the body. It allows lymph to flow into the lymph system in the chest away from the area with lymphoedema.
Photo by Brian Mann on Unsplash
]]>Sympathy, empathy, and compassion are words that have not only remained largely uncontested in health care, but are often treated interchangeably within palliative care research, policy, education, and practice – but are they? And according to whom?
In a Straussian grounded theory study by Shane Sinclair PhD, Associate Professor, Cancer Care Research Professorship, University of Calgary, Canada, of 53 palliative care patients, it was discovered that patients could not only delineate between the aforementioned care constructs, but were also clear on their preference for compassion. Sympathy was understood by patients as a pity-based response to a distressing situation that is characterized by a lack of relational understanding and the self-preservation of the observer. While it shared the attribute of acknowledging a distressing situation, with empathy and compassion, patients were clear that it was unhelpful, unwelcome, and often compounded their distress. While patients identified a number of distinguishing features between empathy and compassion, their relationship to one another was more like ‘close cousins’ in comparison to the ‘distant/estranged’ relationship status that each of these shared with sympathy.
Empathy was understood by study participants as an effective response that acknowledges and attempts to understand an individual’s suffering through emotional resonance. It involves the ability to put oneself in another person’s shoes, to not only acknowledge suffering but to feel with the person and attempt to understand them in the process.
Compassion, from the perspective of patients, included many of the attributes of empathy but added additional, distinguishing components of virtues and actions. To be clear, virtues of love, kindness, acceptance, and genuineness were not equated with morality or piety but were simply understood as the good and noble qualities of healthcare providers. In essence, it involves not just the ‘what’ of healthcare providers but the ‘who’ – the personal qualities that they bring to the bedside. As a result, compassion was perceived as extending feeling with to feeling for, while also adding the quintessential feature of action – doing for. Compassionate action ranged from routine care, motivated by virtues versus remuneration or a mere sense of duty, to acts that went beyond the call of duty by going the extra mile or beyond the ‘job description’.
While an individual’s capacity for compassion is as unique as the experiences of patients receiving it, the call to compassion, while being a high bar, is not an endpoint. Rather, compassion is a dynamic care construct that can be cultivated through practice and when it is expressed, according to patients, is the most potent form of care that healthcare providers can express.
As Therapists it can be difficult to find products that work and are easy for a palliative patient and/or carers to utilise. Oedema and leaking in limbs of patients can often cause them great distress. Mobiderm autoift garments are a range of products that have Velcro tabs and have Class 1 compression. When the garment is worn a shear effect is created on the Mobiderm (foam squares move down and across simultaneously). This shear effect mobilises the skin which pulls on the collagen fibres stimulating the opening of the initial lymphatic vessels. It also creates a pressure differential in the interstitial tissues. Mobiderm not only reduces the rate of filtration it also stimulates the lymphatic system. The Mobiderm autofit sock can be used as a replacement for standard daytime compression socks. It can be easily donned and doffed by carers and can also been worn with Soft cotton short stretch bandage cut into a tube to protect extra sensitive skin. To order products or for more information on the use of Mobiderm in the palliative setting including case studies go to the Mobiderm website.
Photo by Priscilla Du Preez on Unsplash
]]>When most people think of a compression sock, a thick, dowdy, difficult to wear garment often comes to mind. Encouraging patients to wear compression can at times be one of the more difficult tasks of the practitioner’s day.
Often I have patients say to me “Compression socks, I think my Grandma wears those, I don’t want to wear them”. Or “Compression socks, I’ve tried them; I’ve got three pairs in my draw at home that I can’t get on”.
Though compression wear is essential for those who have venous or lymphatic disorders, we can all benefit from wearing compression during our day. Today with the use of modern technology in weaving and fabrics we now have more attractive and pleasant to wear socks available, like the Venoflex Micro. A plus for me is that the yarns in these socks are also Ecotek certified, which confirms the human-ecological safety of the product.
For graduated compression to have its true enhancing effects, a specific decreasing amount of compression must be applied from the ankle to the knee and above. Special medical knitting machines are required to do this along with special testing to confirm the compression is just right. These garments are held to different standards than fashion & sport variations. In fact, wearing an extremely tight compression pant or legging that doesn’t have graduated compression can actually have the opposite effect on the leg’s circulation.
Compression socks come in a variety of support levels for different purposes. Some versions offer light support and are actually designed for preventative and general lifestyle applications – think travel, pregnancy, varicose veins, spider veins & more. Venoflex Micro socks offer Class 2 compression (23mmHg-32mmHg) and as a microfiber stocking it adapts itself perfectly to the leg and is particularly pleasant wearing and comfortable with donning and doffing made easy due to the silky soft material. These socks though designed specifically for therapeutic uses, are fashionable and easy to wear giving the needed support for every compression purpose.
Colours and costs are often an issue for patients but I find that an option of black or caramel covers what most people need. Also when you can purchase at a cost of only $49.50 in 6 different sizes (plus 2 different lengths) you can easily select an item for your patient. You can choose closed or open-toe.
It sounds simple – but an easy to wear, fashionable compression sock offers a remedy for and gives results for those with tired legs, heaviness, fatigue, venous and lymphatic disorders. So let’s wear compression, get our patients to wear compression and look good doing it see the full Mobiderm and Compression sock range.
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