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Q: I am a Certified lymphedema therapist but encounter head & neck lymphedema infrequently. As such I’m not as confident treating as I am with extremity lymphedema. What are the most critical adjustments in the CDT approach that I should make to provide skilled therapy to this specialized patient?
A: Perhaps the most glaring challenges inherent to managing the head and neck patient are:
It is important to realize, placing oneself in the position of the patient that compression of the face and neck will be difficult to tolerate emotionally, socially and experientially. As compared to extremity (arm/leg) patients, where sleeves and trousers can cover compression solutions, a face-mask or other compressive complex is impossible to hide. Unfortunately lymphedema is only responsive to consistent compression since it becomes entrenched in the tissues chronically. Without an “intensive” approach, swelling reductions are short-lived and quickly return when compression is removed making the process even more emotionally taxing. My advice is to expect unrest, resistance, emotional catharsis and a need for your deepest empathy when discussing and employing a compression treatment strategy since it will be a frightening, undignified proposal to the patient.
On a positive note the intensive investment of compression accompanied by manual lymph drainage (MLD) will provide remarkable results and in time require less intensity of effort and duration in home care phase. Offer this upbeat perspective and ask for your patients’ tolerance during this difficult chapter. Regarding MLD, the overriding objective is to recruit or train functioning collateral vessels to compensate for the disturbance in normal lymph flow within or around the damaged tissues. Since the compression regime is less intensive, and supple, pliable skin of the face and neck is more easily engorged with fluid, MLD must also occupy more treatment time and be self administered repeatedly.
Stimulation of functioning lymph vessels coupled with gravity (administered in an upright/seated position) produces noticeable improvement. Take time to map a sequence of strokes according to sound MLD decongestive theory and train your patient to apply the strokes precisely. Since most people will not grasp the importance of correct MLD application (“massaging” as if rubbing oils into the skin) it is of utmost importance to spend the required time instructing and assessing correct technique to avoid erythema, inflammation or skin injury. Avoid use of the word “massage” entirely when describing MLD. Several (4-5) 15 minutes self-MLD sessions at intervals while at home will continue to stimulate vessels, improve collateral flow and influence skin texture, which in turn promotes better range of motion, comfort and function. This requirement will also lessen in time if the intensive investment is made initially.
Unlike other skin regions, the face and neck are far less tolerant to radiation and develop fibrosis spontaneously in many patients. Incision sites adhere and surrounding tissue swells creating deep creases or fissures in the radiation skin. Until the skin’s desquamation has ceased, direct site contact with MLD is contraindicated, however surrounding tissues can and should be treated to assist in drainage locally. Since the fibrosis is usually a recent skin change it is important to reverse the hardening process with immediate manual therapy. The traction of MLD and circular motions of the fingertips on these tissues will greatly improve the texture, relaxing taut skin, improving flow across incisions and improving neck function. Direct compression with foam materials and textured surfaces can also create lasting, pronounced improvement on new onset radiation fibrosis.
Q: It seems as though compression of the neck could easily do more harm than good. What safe options are available for therapeutic compression of neck and face lymphedema?
A: It is true that compression of the neck by encircling should be viewed with great suspicion and should only be administered with absolute care and precision. Furthermore the supervising physician must be apprised of the method and effects of techniques used in the CDT system and approve of the use of specialized compression for his/her patient. When there is a need for neck, chin and cheek compression, a safe system may include a “Jobst Facioplasty Mask” since it anchors neatly to the top of the head and has a controlled tension around the neck. Its lightweight fabric creates a scaffold for padding pieces to be formed against the skin directly. It does not provide coverage for the front of the face, (upper cheeks, nose, eye, forehead) so is best applied to swelling of the neck, chin, lower jaw, and lower cheek regions. Also a chin-strap that anchors atop the head can be fashioned out of 10 or 12cm short stretch bandage material (Comprilan/ Rosidal K) by doubling into layers and attaching a Velcro closure to the top. Padding can then be positioned under the chin to compress the same area. A solution such as this may not stay in place while sleeping unless monitored closely, however it remains a safe application since short stretch materials will not constrict and tighten when they shift.
When a full-face coverage is required, consider a “cut and sew” custom-measured fabric such as made by Barton Carey, Inc. or the Jobst “custom seamed”. These fabrics are quite inexpensive, quick to produce and can be altered with a scissor at the clinic to further customize the fit. Again these act as a scaffold for anchoring padding into position.
Please address questions to: Editor c/o NLN, 116 New Montgomery Street, Suite 235, San Francisco, CA 94105 or e-mail: nln@lymphnet.org. Deadlines for submissions (for the following issue) are: Feb 1, May 1, Aug 1, Nov 1.
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