Lymphedema: Exercise Guidelines

Exercise is a vital part of a Lymphedema Treatment program.  The lymphatic system and circulatory systems are greatly affected by active muscle contraction, which helps assist transport of lymph and blood supplies to tissues and organs.

  • Exercise only with the limb in a compression garment or wrap.
  • Include Deep Abdominal Breathing before and after every exercise program.
  • Do not wear tight restricting clothing (eg.  Bra straps, tight underwear, etc.
  • Perform exercise in a slow, controlled manner.  If any exercise causes pain, decrease number of repetitions or do not perform that particular exercise.
  • Alternate each contraction of the muscle with equal time of full relaxation.
  • Progress exercises slowly as to avoid soreness.
  • After exercising, rest and elevate the limb for 15 to 20 minutes.
  • You should rest 20-30 minutes between Manual Lymph Drainage Massage and exercising.

Sonja M. Maul PT, CLT-LANA

National Board Certified Lymphedema Therapist

St. Luke’s*Idaho Elks Rehabilitation Services (SLIERS)

Boise, Idaho 






I. Skin Care – Avoid trauma/injury and reduce infection risk

  1. Keep extremity clean and dry.
  2. Apply moisturizer daily to prevent chapping/chaffing of skin.
  3. Attention to nail care; do not cut cuticles.
  4. Protect exposed skin with sunscreen and insect repellent.
  5. Use care with razors to avoid nicks and skin irritation.
  6. If possible, avoid punctures such as injections and blood draws.
  7. Wear gloves while doing activities that may cause skin injury (i.e., gardening, working with tools, using chemicals such as detergent).
  8. If scratches/punctures to skin occur, wash with soap and water, apply antibiotics, and observe for signs of infection (i.e. redness).
  9. If a rash, itching, redness, pain, increased skin temperature, fever or flu-like symptoms occur, contact your physician immediately.

II. Activity / Lifestyle

  1. Gradually build up the duration and intensity of any activity or exercise avoiding soreness.
  2. Take frequent rest periods during activity to allow for limb recovery.
  3. Monitor the extremity during and after activity for any change in size, shape, tissue, texture, soreness, heaviness or firmness.
  4. Maintain optimal weight.

III. Avoid limb constriction

  1. If possible, avoid having blood pressure taken on the at risk arm.
  2. Wear loose fitting jewelry and clothing.

IV. Compression Garments

  1. Should be well-fitting.
  2. Consider supporting the at risk limb with a compression garment for strenuous activity (i.e. weight lifting, prolonged standing, running).
  3. Consider wearing a well-fitting compression garment for air travel.

V. Extremes of Temperature

  1. Avoid exposure to extreme cold, which can be associated with rebound swelling, or chapping of skin.
  2. Avoid prolonged (> 15 minutes) exposure to heat, particularly hot tubs and saunas.
  3. Avoid immersing limb in water temperatures above 102° F.

VI. Additional practices specific to lower extremity lymphedema

  1. Avoid prolonged standing or sitting.
  2. When possible, avoid crossing legs.
  3. Wear proper, well-fitting footwear.


Sonja M. Maul PT, CLT-LANA

National Board Certified Lymphedema Therapist

St. Luke’s*Idaho Elks Rehabilitation Services (SLIERS)

Boise Idaho

Lymphedema: Links of Interest

Here are some links you may find of interest in relation to Lymphedema…
The National Lymphedema Network is an organization that provides education and guidance to lymphedema patients, health care professionals, and the general public.
The American Cancer Society’s   page about breast cancer and lymphedema. is an independent source of objective information about lymphedema.
The Susan G. Komen Breast Cancer Foundation is a global leader in the fight against breast cancer, through its support of research and education.
LymphesDIVA   LympheDIVAs™ LLC is dedicated to creating medically correct fashion: compression apparel for the savvy and stylish breast cancer survivor with lymphedema, which will inspire her to feel beautiful, strong, and confident.
The Young Survival Coalition (YSC) is a nonprofit dedicated to the concerns and issues that are unique to young women and breast cancer.
Living Beyond Breast Cancer is a nonprofit organization dedicated to empowering all women affected by breast cancer to live as long as possible with the best quality of life. is a nonprofit organization dedicated to providing the most reliable, complete, and up-to-date information about breast cancer.
Lymphedema People  is a website created for, and by, people with lymphedema.
Shop Well with You  (SWY) is a nonprofit organization and body-image resource for women surviving cancer, their caregivers and healthcare providers.
eLymphNotes is an online magazine on lymphedema published by the Lymphedema Awareness Foundation, Inc. (LAF).
Slice of Fashion LLC makes accessories for women with lymphedema.
KT Foundation is a group of volunteer advocates for those afflicted with Klippel-Trenaunay Syndrome (KTS.) The Foundation is a working center providing the latest medical news on KTS, an up-to-date list of specialists and accurate information to support individuals with KTS.
The Annie Appleseed Project  is a great resource for information on complementary and alternative therapies for cancer patients.
Pink-Link   is an online breast cancer support group.
Bella Bandanas makes custom designed Swarovski crystal bandanas.
Spirited Sisters™ and it’s Healing Threads™ Collection of Designer Hospital Gowns understand the physical and emotional demands of fighting any illness. These garments are sophisticated, attractive, comforting and dignified. creates fantastic sleepwear and pillowcases which are made of wick-away fabrics so hot flashes do not ruin your sleep! These fabrics draw perspiration away from the body to the fabric where it evaporates quickly- just like LympheDIVAs sleeves!
I hope these are helpful
Sonja M. Maul PT, CLT-LANA
National Board Certified Lymphedema Therapist
St. Luke’s*Idaho Elks Rehabilitation Services (SLIERS)

Lymphedema: Medicare Coverage and the Lack There Of

Medicare covers the treatment of Lymphedema under Physical Therapy Services, but the compression bandages, garments and devices required are not covered.  Here is a portion of an article written by Robert “Bob” Weiss, M.S. NLN LE Legislative Advocate, which can be found on the National Lymphedema Network website,

Medicare Coverage of Compression Garments:    Current Medicare policy does not cover the cost of the compression bandages, garments and devices required in the daily Phase 2 treatment of lymphedema. In mid-2000 Robert Weiss and the NLN made formal requests for a National Coverage Determination (NCD) on the treatment of lymphedema. Responses from the HCFA (now CMS) Coverage and Analysis Group centered around the claim that “the supplies, namely the compression garments used for the treatment of lymphedema, do not fall within a separate benefit category set forth in the Social Security Act.” (Dr. Sean Tunis, Director, in a letter dated March 1, 2001 ).

This unsubstantiated statement from HCFA/CMS, the basis for continuing denials of compression bandages and garments, has been disputed by Medicare Administrative Law Judges (ALJs) around the country. Most recently, four different California ALJs ruled in four different cases that compression bandages, sleeves and stockings used in the treatment of lymphedema meet the statutory definition of “prosthetic devices” in §1861(s)(8) of the SSA as expanded by CMS Pub. 100-2, Medicare Benefit Policy Manual , Ch. 15, §120 Prosthetic Devices.

On January 2, 2007 a request was made to CMS to add over 100 new and revised codes to the HCPCS Code Book for lymphedema treatment supplies. The CMS HCPCS Workgroup rejected this proposal on November 2, 2007 without referring to legal and medical arguments presented, only stating that “no insurer (i.e. Medicare, Medicaid, Private Insurance Sector) identified a national program operating need to establish unique codes to distinguish all the products listed in this application. Existing codes adequately describe the array of products available.    

In a recent discussion with SADMERC, the Medicare contractor responsible for developing and maintaining HCPCS codes, I was asked whether I was working with the manufacturers, since I have no standing to submit specific requests for product coding. In August 2006, while preparing the formal request for HCPCS code changes, I contacted major manufacturers of compression bandages and garments (i.e. Bellisse, BSN Jobst, CircAid, Derma Sciences, Hartmann-CONCO, Innovative Medical, Juzo, KT Medical, Lohmann Raucher, Medi, Lohmann, Peninsula Medical, Sigvaris-Ganzoni, Solaris, Telesto) asking them to submit requests to list their products as prosthetic devices with an L-code to demonstrate that there is a need for change. To my knowledge, no formal requests were submitted.

Robert “Bob” Weiss, M.S.
NLN LE Legislative Advocate

Check out more Legislative Updates at



Sonja M. Maul PT, CLT-LANA

National Board Certified Lymphedema Therapist

St. Luke’s*Idaho Elks Rehabilitation Services (SLIERS)


Lymphedema: Protein-Rich Lymph Fluid and the Roll of Dietary Protein

Since the fluid associated with lymphedema is protein-rich a question that often arises is, “Should I stop eating protein so there won’t be protein in this fluid?” The answer to this question is, No! Do not stop eating protein. It won’t solve your problem because proteins are essential nutrients.”

Dietary proteins are present in the foods we eat and are important to good health because:

·  Proteins are the building blocks of the body.

·  Proteins are the only nutrients that can repair worn-out tissue and build new ones.

·  Proteins are used by the body in manufacturing hormones.

·  Proteins have a role in building antibodies to fight infections.

·  Proteins aid the blood in transporting oxygen and nutrients.

·  Proteins are essential to the clotting of blood.

When There is a Shortage of Dietary Proteins

The goal for each individual should be to eat the appropriate amount of dietary protein to meet nutritional needs. This protein should come from a variety of sources, not only meat, and include only a minimum amount of fat.

When there are not enough dietary proteins available to meet the daily needs of the body, proteins are taken from the tissues and muscles to maintain the proper protein level of the blood. A severe shortage of dietary proteins will weaken connective tissues and causes them to swell. This is known as hunger edema and it can be seen in the swollen bellies of starving children.

Seriously restricting the intake of dietary protein in an effort to control the swelling of lymphedema does not help. It has just the opposite effect: It increases the amount of swelling that is present. It also weakens the muscles and other tissues.


Sonja M. Maul PT, CLT-LANA

National Board Certified Lymphedema Therapist

Lymphedema: Nutrition and Lymphedema

There is no special diet that will prevent or control lymphedema; however, good nutrition promotes good health and this helps the body manage with the stresses related to lymphedema.  The main recommendations are eat a low sodium diet and keep hydrated.

Eating a Balanced Diet

Eating a well-balanced diet that includes a variety of fruits and vegetables is recommended for maintaining good general health. It also aids the body in coping with the added stress caused by lymphedema.

High salt foods, which encourage the body to retain fluids, are not part of a recommended healthy diet.  High sodium foods cause the body to retain fluid in general, and will make the lymphedema swelling worse.

Staying Hydrated

The term hydrated describes the state of having adequate fluids in the body. Maintaining this state helps the body remove impurities from the blood and this is important to good health.

Drinking plenty of fluids, particularly water, is essential to maintaining this balance within the body. Cutting back on fluid intake in an effort to reduce the swelling of lymphedema doesn’t work! Instead of the desired effect, the protein-rich lymph of lymphedema attracts more fluid from the other parts of the body. This can cause increased swelling in the affected area.

Drinking eight 8-ounce glasses of water a day is recommended to maintain good health; however this need increases in hot weather, or in very dry conditions, when the body looses fluids more rapidly.

Being well hydrated, by drinking plenty of water, is particularly important after an MLD or pump treatment because it is necessary to flush out the impurities that were moved during treatment.

Caffeine, which is a mild diuretic, reduces the level of body fluids by encouraging the kidneys to excrete more urine. For this reason caffeine containing substances (coffee, tea, chocolate and many soft drinks) should be consumed only in moderation.

Alcohol also has a diuretic effect that stimulates the kidneys to excrete more water and thereby increasing dehydration.


Sonja M. Maul PT, CLT-LANA

National Board Certified Lymphedema Therapist

Lymphedema: Healthy Skin

Maintaining healthy skin is essential for those with lymphedema because intact skin, with no scrapes or cuts, prevents bacteria from entering and causing infection.


The swelling of lymphedema stretches the skin and disrupts the skin’s basic protective mechanisms. Also, as lymphedema increases in severity the skin loses its elasticity, becomes thicker and scaly, and is increasingly at risk.


Protective Structures of the Skin
The secretions from oil and sweat glands in the skin flow through the pores and onto the surface of the skin to form a thin protective layer known as the acid mantle. The acid mantle is normally mildly acidic with a pH that ranges from about 4 to 5.5. (A pH of 7 is neutral. A pH higher than 7 is described as being alkaline. A pH lower than 7 is described as being acidic.)  The acid mantle inhibits the growth of harmful bacteria and fungi on the skin. With the loss of this protection, and the increasing fragility of the skin, those with lymphedema are at increased risk of infection due to bacteria invading through the skin.


Skin Care Steps

Examine the affected skin thoroughly each day. Look for changes in the tissues, any possible cracks, or signs of a developing infection.

Use only mild soap.

Wash gently, and thoroughly, with warm (not hot) water.

Dry gently by patting and taking particular care to dry within the skin folds. A hair dryer on a very low setting can be used to dry awkward areas or between folds. Never use the hair dryer on high heat!

Moisturize the skin thoroughly using a low pH moisturizing lotion. This helps to restore some of the normal protective acid mantel. Moisturizing also helps the skin retain the elasticity that helps to avoid cracks/breaks. I like Eucerin or Cetaphil, but there are many good products out there.

Protect against sunburn. Lymphedema affected skin is particularly sensitive to the sun and a compression garment does not protect it from the UV rays.

Do not perform exfoliation. It can damage lymphedema affected skin.


Sonja M. Maul PT, CLT-LANA

National Board Certified Lymphedema Therapist