eNews Online - December 2005 Edition

eNews Online
December 2005 Edition

This Lymphedema eNews is being generated through your request from our website.

In previous studies, we demonstrated that the ReidSleeve resulted in a significant reduction in lymphedema. In these studies, over 80% of the patients responded to treatment using the ReidSleeve and the average improvement after 4 to 6 weeks of treatment was 32 to 88%. Many patients in these studies reported continued improvement for 3 to 6 months after starting treatment with the ReidSleeve and we have done follow up studies to determine the long-term benefit of treatment with the ReidSleeve. We presen ted the results of long-term study of the Reidsleeve in combination with the BioCompresssion pump at the annual meeting of the American Society of Clinical Oncology (ASCO) this year.

Several years ago Dr. Szuba and collegues at Stanford University published a paper describing a young woman with refractory lymphedema of the leg (see abstract below and link to TV discussion of her case). Refractory means that she did not respond to other treatment modalities. Unfortunately, this patient developed severe lymphedema and recurrent infections resulting in numerous hospitalizations to treat the infections. After starting treatment with the ReidSleeve she showed immediate improvement with a 20 to 30% reduction in lymphedema in the first 4 to 6 weeks. The most gratifying improvement was that she never developed another infection. She had no further infections after starting treatment with the ReidSleeve and she had gradual improvement with almost complete resolution of the lmphedema over about 6 months. In a follow up interview for televison done several years after she was treated, she was married, working as a social worker and had no signs of lymphedema.

This case highlights the fact that the tissue damage that occurs as the result of lymphedema lymphedema can take many months to heal. This cases and other similar cases of nearly complete resolution of lymphedema over 3 to 6 months of treatment made it clear that we needed to do a long-term study of patients treated with the ReidSleeve. In addition, recent publications from Dr. Szuba suggested that the use of intermittent pneumatic compression (IPC) could enhance the response to decongestive lymphatic th erapy (DLT). We have been asked by patients and therapists if IPC could enhance the effects of the ReidSleeve. We therefore undertook a long- term study of the combined effects of the ReidSleeve and the BioCompression pump.

We evaluated the efficacy of the ReidSleeve combined with the BioCompression pump among patients with moderate to severe upper and lower extremity edema that had failed other treatments. Patients wore the Reid Sleeve at night. During the daytime, the patients used the BioCompression pump with the Reid Sleeve Optiflow insert for 2 sessions of 60 minutes. Circumferential measurements were made at 3-inch intervals along the length of the arm or leg. The unaffected limb was used as control to determine the per cent change from expected except when both limbs were effected. This study was conducted over more than a year and we have long-term evaluation of the patients treated on this study. This system was extremely effective at reducing lymphedema in both the upper and lower extremities. The first figure demonstrates that patients with moderate to severe upper extremity lymphedema had a reduction of lymphedema of 25% in the first 4 weeks of treatment. The degree of reduction remained stable for a month and was then followed by continued inprovement of 10 to 20% per month during treatment. The graph peaked with patients reaching a 75% reduction in lymphedema. This peak is due to the fact that as patients achieved 90 to 100% improvement they went off the study and into maintence therapy. This graph highlights and important fact that lymphedema is a chronic condition and effective treatment can take time. The more severe lymphedema with accumulation of fibrotic tissue required more time for the changes caused by lymphedema to resolve. However, the finding from this study demonstrate that the majority of patients can achieve significant reductions in lymphedema with treatment.

It is not surprising that treatment of lymphedema can take several months. Lymphedema is the result of the accumulation of excess interstitial fluid. However, the excess accumulation of interstitial fluid results in compensatory responses that results in the accumulation of fibrotic tissue and excess fatty tissue. The fibrotic and fatty tissues cannot be removed quickly by compression. Instead, compression must be applied gently and regularly. With effective mobilization of the interstitial fluid, the fib rotic and fatty tissues can return to normal over time, much like the gradual healing of a cut or abrasion. Our data suggest that this can take several months but the encouraging result is that effective and lasting treatment can be achieved even among patients with moderate to severe lymphedema. However, the compression must be applied so that the already stressed tissues are not further stressed with levels of compression that are too high.

Linear regression analysis of the percent reduction in lymphedema over time demonstrated a strong correlation between response and duration of treatment. Some patients demonstrated excellent responses within a few weeks of treatment. However, other patients demonstrated gradual improvement over time. Several interesting factors are demonstrated by this graph. First, many patients have a 50% improvement in the first 30 days. Second, small group of patients were transiently worse. This is expected as some patient has infections or other problems. Third, some patients had more that a 100% improvement. After analysis of these patients it became evident that there was some muscle atrophy that occurred in the extremity with lymphedema. Consequently, an exercise program is necessary as these patients improve. Fourth, many patients achieved 90 to 100% improvement and these patients then went on to maintenance therapy. Finally, there was clear and gradual improvement across the group with ongoing treatme nt. This is important because the changes that occur in the tissue due to lymphedema are chronic and effective treatment will have to address the chronic nature of the problem. While almost all studies done for the analysis of lymphedema assessed response over a few days or a few weeks, we found that optimal results achieved with several months of treatment.

Tony Reid MD Ph.D

Combined Modality Treatment using the Reid Sleeve and the BioCompression Pneumatic Pump. The OptiflowBC System.

A novel therapy for lymphedema complicated by lymphorrhea.
Szuba A, Cooke JP, Rockson SG. Vasc Med. 1996;1(4):247-50.
Division of Cardiovascular Medicine, Stanford University School of Medicine, CA 94305, USA.

Lymphorrhea is a rarely described complication of chronic lymphedema, in which the disrupted flow through diseased lymphatic channels gives rise to the external drainage of lymph, often heralded by the presence of an enlarging lymphocele. This report documents the applicability of the Reid sleeve, a novel, conservative form of therapy, in an unusually severe and protracted example of lymphorrhea.

Decongestive lymphatic therapy for patients with breast carcinoma-associated lymphedema. A randomized, prospective study of a role for adjunctive intermittent pneumatic compression. Cancer. 2002 Dec 1;95(11):2260-7.
Szuba A, Achalu R, Rockson SG.

Stanford Center for Lymphatic and Venous Disorders, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California 94305, USA.

Disruption of the lymphatic circulation through breast carcinoma-associated axillary lymph node dissection, with or without radiation therapy, reportedly is the most common cause of lymphedema in developed countries. There is no cure for breast carcinoma-associated lymphedema. Although intermittent pneumatic compression (IPC) has been acknowledged as a potential component of the multidisciplinary therapeutic strategy in the treatment of patients with breast carcinoma-associated lymphedema, prospective stud y of its adjunctive safety and efficacy is required.
IPC was assessed as a component of the initial therapeutic regimen for newly treated patients with breast carcinoma-associated lymphedema. Twenty-three patients who had not previously been treated for lymphedema were randomized to receive either decongestive lymphatic therapy (DLT) alone or DLT with daily adjunctive IPC. Patients with stable, treated, breast carcinoma-associated lymphedema also were assessed in the maintenance phase of therapy. Twenty-seven patients were randomized either to DLT alone or t o DLT coupled with daily IPC. In both studies, objective assessment included serial measurement of volume by water displacement, tissue tonometry to assess elasticity of the skin, and goniometry to measure joint mobility.
During initial treatment, the addition of IPC to standard DLT yielded an additional mean volume reduction (45.3% vs. 26%; P < 0.05). During maintenance DLT alone, there was a mean increase in volume (32.7 +/- 115.2 mL); with DLT and IPC, there was a mean volume reduction (89.5 +/- 195.5 mL; P < 0.05). In both studies, IPC was tolerated well without detectable adverse effects on skin elasticity or joint range of motion.
When IPC is used adjunctively with other, established elements of DLT, it provides an enhancement of the therapeutic response. IPC is well tolerated and remarkably free of complications. Copyright 2002 American Cancer Society.DOI 10.1002/cncr.10976

Insurance Coverage

It is that time of year that we like to remind people if they have insurance deductibles that renew on January 1st to talk to your health care provider about treatment or garments before the end of the year. Many people have very high deductibles and it is great to get those claims in while it is still covered on the current year.

We would like to also remind you that Peninsula Medical provides insurance verification, at no obligation nor cost. We will verify your coverage for durable medical equipment (DME). We determine the estimated percent of coverage and any deductibles yet to be met, and what is required to obtain DME to help assist your decision should you be contemplating any DME purchase before January 1st. This service is available on line by clicking here or if you would prefer to speak with one of our billing specialist about this service, please call toll free 1-800-293-3362 or 800-606-7655 (for East Coast inquiries).