BOOK REVIEW

The Lymphedema Wellness Manual

by Gay Lee Gulbrandson, CLT-LANA

By: Kathleen Francis, MD

Livingston, NJ

This practical and well-researched manual provides both lymphedema patients and their therapists a detailed guide to understanding and treating lymphedema, with emphasis on working together to apply best practices. It is designed to promote interaction, discussion, and cooperation between patients and their therapists to optimize effective treatment and ultimately enhance independent self-care for the condition.

Throughout the manual, a series of color-coded legends are used to identify subject matter divided into: Author's Position Statements, Indications, Contraindications or Risks, Expert Knowledge, Patient Information and Guidance, Major Consensus Report or Meta-analysis, Sources, and Tips for Patients and Therapists. Another set of color codes is used to define effectiveness ratings for treatments and modalities referred to in the book, with 6 levels ranging from "Recommended" to "Not Recommended, " and an additional color-code for "Expert Opinion."  This reviewer found the color coding somewhat distracting and not particularly helpful, but others may appreciate this organization of material.

The information in this comprehensive manual is encyclopedic and well-researched, but the format, which is in an expanded outline form, may prove challenging for those who prefer a standard approach in which information is synthesized and interpreted by the author and presented in typical prose style. For readers who choose to dip in and out and extract information as needed, this format works well. The "Notes" pages at the end of sections are a nice touch to allow readers to write down information that is particularly relevant or important to them.

The nature of the manual makes it necessary to frequently cross-reference between sections to access the full range of information on a specific topic. This allows the reader to get different types of related information from various sections, increasing the comprehensiveness of the material. For some, the addition of  "For more information see Section ..." after many topics may be burdensome . However, the index at the back of the manual allows a search of the material by subject. In addition, each section begins with tips for both patient and therapist to maximize effective use of the information presented.

An incredibly useful feature of this manual is the series of excellent printable, reproducible, and downloadable forms and handouts for assessment, informational, and educational purposes, which are invaluable for both patients and therapists. These range from HIPAA Notice of Privacy Practices to multiple assessment and monitoring instruments and educational handouts.

Section 2 is especially practical and useful for every type of lymphedema practice. This section provides multiple forms that can be duplicated by therapists for use in their assessments, and for patients to prepare for their clinic visit. The section contains both blank forms and samples that have been filled out as guidance for completing the forms. For therapists, there is important information on Medicare G-codes, status modifiers, and clinical measurements for ongoing progress.  There is an excellent form for physicians to fill out when referring a patient to a lymphedema treatment center, along with a brief "Physician's Guide: Complete Decongestive Therapy, Manual Lymph Drainage" - a one page concise explanation of the treatment techniques for physicians who may be unfamiliar with CDT/MLD. Similarly, the "Patient Information Handout" is a 2-page summary for patients that explains lymphedema and its treatment. The Individual Treatment Protocol (long form) in Section 3 seems excessively wordy and complex for practical use in a busy clinic, but therapists and patients may be able to simplify by extracting sections that are most relevant.

Blank versions of all of these forms, surveys, documentation tools, and educational handouts are provided at the end of the book for printing and duplicating. This is an invaluable resource for both experienced therapists wishing to streamline or improve their practice and for recently trained therapists beginning their lymphedema practice.

In this reviewer's opinion, Section 4 on risk factors contains many recommendations that may be overly restrictive based on current understanding of lymphedema and the dearth of supporting evidence in the literature. For example, the instruction to "never allow blood pressure cuff on affected limbs" is not absolute and may need to be modified in some cases, especially in persons for whom both arms are "at risk," since hypertension is a potentially fatal condition if undetected and untreated, and this severe risk must be rationally balanced against the risk of triggering lymphedema, a distressing not life-threatening condition. Similarly, a somewhat outdated prohibition on lifting more than 12 pounds does not fully take into account individual differences in fitness and strength or the import of recent literature on exercise in persons with lymphedema. The adverse effect that many other recommended restrictions in this section could have on quality of life may not be warranted, given the paucity of supporting evidence in the literature.

Section 5 covers CDT and also includes information on therapist training and certification. Section 6 details "Other

Treatments" for lymphedema, covering diverse topics ranging from hyperbaric oxygen treatment to microsurgery for lymphedema, providing information based on expert opinion and the limited research studies available, and correctly points out that effectiveness for most of these modalities remains unknown. Section 7 on exercises includes an excellent section by the lead author of the "Physical Activity and Lymphedema" study on weight-lifting and lymphedema, Dr. Kathryn Schmitz, which addresses common misconceptions regarding the study results.

Both Section 8 on quality of life and Section 9 on resources provide readers with a wealth of information addressing common patient concerns and providing many useful resources for information on lymphedema organizations, websites, educational opportunities, and products. Section 10 has a series of detailed illustrated "Topic Cards" covering the pathways, structure, and function of the lymphatic system, connective tissue, fluid movement, effects of MLD, and applications of MLD. Finally, the extensive appendices include all the blank forms referred to in the text, a glossary and references, sources and supporting data, and the index.

In conclusion, The Lymphedema Wellness Manual presents a wealth of useful information for both therapists and patients with lymphedema. This wide-ranging compendium is designed to improve care for individuals with lymphedema by not only optimizing understanding of the condition and its treatment, but also facilitating a cooperative approach between patient and therapist. Extremely useful features such as printable and downloadable forms make this an incredible resource for busy therapists and for patients who seek to maximize their therapy experience. The format is unique and may not work for every reader, but there is certainly something for everyone in this all-inclusive and practical compilation.

26 NATIONAL LYMPHEDEMA NETWORK - July I September 2014 

Originally published in LymphLink 2014 Vol. 26 No. 3 © 2014 National Lymphedema Network, www.lymphnet.org. Reprinted by permission.