Abstract:
A compression device can treat edema with a plurality of shell structures, each having an inside pad. A ligature network is routed across the shell structures. A plurality of tensioners mounted on at least some of the plurality of shells can separately adjust tension in different portions of the ligature network to affect the balance of compression forces at spaced positions along the plurality of padded shells. At least some of the shell structures have an underpass sized to accommodate passage of a portion of the ligature network. The underpass is integral with a corresponding one of the plurality of shell structures. In one case the shells include an interconnected plurality of volar shells placed on one side of a body part and a dorsal shell on the opposite side.

Description:
CROSS-REFERENCES TO RELATED APPLICATIONS 
       [0001]    This application claims the benefit of U.S. patent application Ser. No. 13/193,225, filed Jul. 28, 2011, the contents of which are hereby incorporated by reference herein. 
     
    
     BACKGROUND OF THE INVENTION 
       [0002]    1. Field of the Invention 
         [0003]    The present invention relates to devices and methods for treating a patient with compression, and in particular, to techniques employing separate shells. 
         [0004]    2. Description of Related Art 
         [0005]    Edema is a medical condition that requires careful treatment. Lymphedema, a type of edema, is a swelling of a body part, often the result of the abnormal accumulation in the affected area of protein-rich edema fluid (primarily lymph fluids). Lymphedema is classified as either primary or secondary. Primary lymphedema is the result of lymphatic dysplasia. It may be present at birth but more often develops later in life without obvious cause. Secondary lymphedema is much more common and is the result of surgery or is a side effect of radiation therapy for cancer. Secondary forms may also occur after injury, scarring, trauma, or infection of the lymphatic system. Lymphedema treatment options offered in the United States include surgery, medication, pneumatic compression pump therapy, Manual Lymph Drainage (MLD), and Complete Decongestive Therapy (CDT). 
         [0006]    Surgery and medication have their place, but their success is not guaranteed and comes with risks. The pneumatic compression pump is a mechanical device that “milks” the lymph fluid out of the swollen extremity. The problems with pneumatic pumps are numerous and any results achieved are usually very temporary. 
         [0007]    Lymphedema physical therapy treatment would not be possible without compression therapy employing bandages and elastic compression garments. Elastic compression garments are easily used and sold under the trade names. Solaris, JoviPak, CircAid, Biacare, and Reid Sleeve. Another compression therapy involves bandaging with short stretch bandages and is a highly skilled procedure designed to take advantage of natural pumping pressures. 
         [0008]    Lymph is propelled through the various lymph vessels by muscular activity, breathing, etc. Bandaging/garments improve the efficiency of the muscle and joint pump and also prevents the re-accumulation of evacuated lymph fluid. These techniques will also break up deposits of accumulated scar and connective tissue. 
         [0009]    The nature of compression varies greatly when a comparison is made between short stretch bandages and elastic compression garments. Both are necessary complements to a program of Complete Decongestive Therapy (CDT) when utilized by competent and well-trained therapists. The distinction lies in the working and resting forces generated by these two forms of compression. Elastic compression garments are designed to provide a pressure gradient favoring proximal fluid flow and are comfortable and convenient. However, they tend to produce constant resting pressure without enhanced working pressure. Short stretch compression bandages supports a limb without constant “squeezing” (i.e. will exhibit low resting pressure), but when a limb is exercised produces relatively high working pressure. 
         [0010]    No effective homecare device exists to maintain/reduce lymphedema/edema consistent with the principles of CDT (Complete Decongestive Therapy). Therefore, patients are saddled with the responsibility of life-long lymphedema control, but the task is arduous, tedious and time consuming. When self-applied compression is performed with less than sufficient skill, it can also be painful, counter-therapeutic or even damage the limbs&#39; health. 
         [0011]    Aftermarket compression products have tried alternative solutions to replace multilayered compression bandages. Treatment at joints is most problematical for these products. Even at the limb segments (between joints) the solutions offered utilize unsatisfactory materials and tensioning techniques to generate pressure. As a result these products lack continuous working pressure (cast-like containment) longitudinally as well as structure to prevent buckling and bulging of tissues. 
         [0012]    See also U.S. Pat. Nos. 4,676,233; 5,152,302; 6,526,592; 6,785,905; 7,135,005; and 6,991,612; as well as US Patent Application Publication Nos. 2005/0066412; 2006/0135902; 2007/0100266; and 2008/0228117. 
       SUMMARY OF THE INVENTION 
       [0013]    In accordance with the illustrative embodiments demonstrating features and advantages of the present invention, there is provided a compression device for treating edema. The device includes a plurality of shell structures. A plurality of inside pads underlie the shell structures. The device also includes a ligature network routed across the plurality of shell structures The network includes a plurality of tensioners mounted on at least some of the plurality of shell structures. The plurality of tensioners are operable to separately adjust tension in different portions of the ligature network. At least some of the plurality of shell structures have at least one underpass sized to accommodate passage of a portion of the ligature network. The at least one underpass is integral with a corresponding one of the plurality of shell structures. 
         [0014]    In accordance with another aspect of the invention, there is provided a compression device for treating edema. The device includes a plurality of shell structures, and a plurality of inside pads underlying the shell structures. The device also includes a ligature network routed across the plurality of shell structures. The network includes a plurality of tensioners mounted on at least some of the plurality of shell structures. The plurality of tensioners are operable to separately adjust tension in different portions of the ligature network One of the plurality of shell structures includes a plurality of panels having at least one coupling device connecting together at least a coupled pair of the plurality of panels. 
         [0015]    In accordance with yet another aspect of the invention, there is provided a compression device for treating edema. The device includes a plurality of shell structures. The plurality of shells include a dorsal shell and an adjacent plurality of volar shells. Also included is a plurality of inside pads underlying the plurality of shell structures. The device also includes a ligature network routed across the plurality of shell structures. The ligature network includes a plurality of tensioners mounted on at least some of the plurality of shell structures. 
         [0016]    In accordance with still yet another aspect of the invention, a method is provided for treating edema in a body part with a ligature network and a plurality of padded shells. The plurality of padded shells include a dorsal shell and a plurality of interconnected volar shells. The method includes the step of routing the ligature network across the plurality of shells. The method also includes the step of placing the plurality of volar shells on one side of the body part and the dorsal shell on the opposite side. In another step, with the body part embraced by the padded shells, tension in different portions of the ligature network is separately adjusted to affect the balance of compression forces at spaced positions along the plurality of padded shells. 
         [0017]    By employing devices and methods of the foregoing type an improved technique is achieved for treating edema. For example, lymphedema limb areas need not be immobilized and the present device does not function as a cast or an immobilizer. Areas of joint articulation can sustain movement without abrasion or discomfort. The natural muscle and joint pumps will be allowed to activate a natural fluid pumping effect. Allowing movement within a compression device tends to reverse lymphostatic fibrosis. 
         [0018]    A disclosed embodiment is presented for treating the hand, although treatment of other body parts is described. The embodiment for treating the hand employs a number of padded shells, one placed on the dorsum and three others placed on the palm. The three palmar shells include a transverse shell placed at the knuckles (metacarpophalangeal joints). This transverse shell has, running from right to left, a sinuous curve that tends to flatten these knuckles. This avoids cupping that would tend to apply excessive stress to the region. 
         [0019]    The other two palmar shells are located side by side, below the transverse shell, i.e., closer to the wrist. One of these shells is located medially (closer to the thumb) and the other is located laterally (further from the thumb). The adjacent edges of these two shells (medial and lateral shells) are curved inwardly to accommodate the natural curvature or cupping in the center of the palm. 
         [0020]    In order to achieve an appropriate pressure, a disclosed ligature network is formed from a number of cords that are routed across the padded shells to produce a desired effect. In particular, these cords are routed through guides strategically placed at various locations on the opposing shells A disclosed network has two circuits that are independently tightened by two tensioners. The disclosed tensioners are cord winders placed in strategic locations on one or more of the shells. 
         [0021]    In this disclosed embodiment the ligature network is constrained by a number of guides on the various padded shells. The guides can be integrally molded as part of the plastic of the outer shell. The disclosed guides have a number of open channels alternating with underpasses, which underpasses are closed on top and open on the bottom. In some cases an end of these guides terminate in a concave gutter that leads to the edge of the shell where the cord can jump from one side of the treated hand to the other. In a disclosed embodiment, this gutter is actually formed as three gutters diverging from a common point, allowing the user to select one of the three that is best suited to the hand being treated. 
         [0022]    In this embodiment a pair of manually operable winders on the dorsal shell each have an incoming pair of cord ends that can be drawn inwardly to shorten the length of a loop of cord that is passing over designated shells. In this case one of the winders adjusts the tension in a loop of cord that runs between the dorsal shell and the transverse shell on the palmar side. The other winder adjusts the tension in a loop that runs between the dorsal shell, and the medial and lateral shells. 
         [0023]    The disclosed dorsal shell connects to the volar shells solely by means of the ligature network. On the other hand, the volar shells connect to each other by means of a coupling device. In one case the coupler is a number of flexible splines that connect between respective pairs of the volar shells. In another case the coupler is a complex substrate that is composed of three interconnected regions, one for each of the volar shells. This substrate can be molded as a single element with the three regions connected by flexible bridges. 
         [0024]    These padded shells are fashioned to accommodate the specific body part being treated. For example, an outline of a hand may be applied to plastic panels, which may be appropriately notched to allow articulation of the thumb. 
         [0025]    All of these padded shells include a plastic panel that is relatively stiff, so that the shells can apply transaxial pressure without squeezing the hand laterally. This arrangement cancels out high lateral pressures, and accentuates high dorsal and palmar pressures. 
         [0026]    Lymphedema is a staged condition according to disease severity (stages 1, 2, 3). As such it requires modifications in the approach according to the quantity of swelling and tissue integrity. The above noted shells apply the external force, but inner-padding materials will be tailored to modify the force according to the disease severity, desired gradient of pressure, limb girth and abnormal contours if any. 
         [0027]    With this in mind, the inside of the disclosed panels will be fitted with pads; for example, one or more layers of foam material. In one embodiment the layer next to the plastic panel is relatively dense and readily accommodates transaxial force, while the layer closest to skin tissue is an open cell foam that conforms more closely to the curves of the hand and increases comfort. 
         [0028]    Proper treatment requires that skin integrity be preserved to combat any localized immune deficiency. To address this requirement the shells&#39; pads ought to be hypoallergenic, customized to the patient, and hygienic. 
         [0029]    Lymphedema treatment requires that a gradient of pressure be exerted regardless of the contour of the swollen limb. Pressure applied to hypothetical conical shapes will respond according to the “law of Laplace” (P=Tc/R), however swollen limbs are not always conical. To address this anatomical requirement “zones” of pressure are created and padding modified suitably to direct fluid from distal areas towards proximal areas. Limbs that have received treatment in the clinic (e.g., with CDT) become more normally shaped (from columnar to conical again) and readily responsive to the above compression device. 
         [0030]    Devices of this type may be used as an adjunct to, or a follow-up after, professional therapy. Also, after the initial fitting of the device, a user will be able to readily remove the device and later place it back on the body part under treatment without the need for professional assistance. In addition, since the tension in the ligature network is readily adjusted, a user can easily adjust tension throughout the day as needed. 
         [0031]    Devices according to the foregoing principles can achieve high working pressure, and low resting pressure throughout. Such devices are adaptable to the edema reduction process by allowing movement, and normal activity. In the disclosed embodiment, tension is easily adjusted so a user is able to regularly conduct subtle re-tensioning. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0032]    The above brief description as well as other objects, features and advantages of the present invention will be more fully appreciated by reference to the following detailed description of illustrative embodiments in accordance with the present invention when taken in conjunction with the accompanying drawings, wherein: 
           [0033]      FIG. 1  is an outside view of a dorsal shell that is part of a compression device in accordance with principles of the present invention; 
           [0034]      FIG. 2  is an outside view of a trio of volar shells cooperating with the dorsal shell of the compression device of  FIG. 1 ; 
           [0035]      FIG. 3  is an outside view of the pad of  FIG. 2 ; 
           [0036]      FIG. 4  is a sectional view of one of the padded shells taken along line  4 - 4  of  FIG. 2 ; 
           [0037]      FIG. 5  is a sectional view of a fragment of one of the padded shells taken along line  5 - 5  of  FIG. 1 ; 
           [0038]      FIG. 6  is a sectional view of one of the padded shells taken along line  6 - 6  of  FIG. 5 ; 
           [0039]      FIG. 7  is a sectional view of one of the padded shells taken along line  7 - 7  of  FIG. 5 ; 
           [0040]      FIG. 8  is an exploded view of the compression device of  FIGS. 1 and 2 ; 
           [0041]      FIG. 9  is an outside view of a trio of volar shells that is an alternate to that of  FIG. 2 ; 
           [0042]      FIG. 10  is a sectional view of one of the padded shells taken along line  10 - 10  of  FIG. 9 ; and 
           [0043]      FIG. 11  is an outside view of a trio of volar shells that is an alternate to that of  FIGS. 2 and 9 . 
       
    
    
     DETAILED DESCRIPTION 
       [0044]    Referring to  FIGS. 1-7 , the illustrated compression device has dorsal shell structure  16  ( FIG. 1 ) and volar shell structure  10  ( FIG. 2 ). Dorsal shell structure  16  has shell  18  (also referred to as panel  18 ) lying between surrounding walls  21  of inside pad  20 . This embodiment is designed for the left hand, although designing for a right hand will be apparent. 
         [0045]      FIG. 1  shows the outline of dorsal shell panel  18 , it being understood that the right and left edges are rolled approximately 45°, except at the curved notch  16 A provided for thumb T. Notch  16 A allows articulation at the thumb joint. Overall, dorsal shell structure  16  can be given an appropriate curve to accommodate the natural curves of the human hand. The dorsal shell structure  16  can be provided in a number of standard sizes to accommodate hands of various sizes. 
         [0046]    In  FIG. 2  volar shell structure  10  includes three panels including a transverse volar shell  12 A, a medial volar shell  12 B, and a lateral volar shell  10 C, respectively. The right and left edges of volar shell structure  10  are again rolled approximately 45°, except in the vicinity of curved notch  11 , which is provided for thumb T and allows articulation at the thumb joint. The adjoining portions of shells  12 B and  12 C are curved inwardly (toward the dorsal shell of  FIG. 1 ) to accommodate the natural cupping of the palm. Shells  12 B and  12 C are located between the wrist joint and the transverse proximal edge of shell  12 A. 
         [0047]    Shell panels  18 ,  12 A,  12 B, and  12 C of  FIGS. 1 and 2  may be made of a molded thermoplastic (injection molded, blow molded, or vacuum molded). Suitable materials include PET, PETG, Nylon 6, Nylon 66, or ABS, although other embodiments may employ various synthetic materials, sheet metals, composite materials, or other materials that are shaped by stamping, etching, forging, etc. Shell panels  18 ,  12 A,  12 B, and  12 C are designed to be relatively stiff in order to transmit compression forces normal to their surfaces. 
         [0048]    In  FIGS. 2, 3 and 4  volar panels  12 A,  12 B, and  12 C are interconnected by means of inside pad  14 , specifically its bridges  15 A,  15 B, and  15 C acting as coupling devices. In  FIG. 3  inside pad  14  is shown as a collection of three pads, namely inside pads  14 A,  14 B, and  14 C sized to receive shell panels  12 A,  12 B, and  12 C of  FIG. 2 , respectively. In particular, panels  12 A,  12 B, and  12 C are positioned between walls  17 A and  17 B before being glued in place. (Pads  14 A,  14 B, and  14 C are also referred to as three strata of a substrate.) 
         [0049]    Flexible bridges  15 A and  15 C of  FIG. 3  allow pad region  14 A and thus shell  12 A to articulate relative to the other two pad regions  14 B and  14 C (and their respective shells  12 B and  12 C). Flexible bridge  15 B allows articulation between pad regions  14 B and  14 C, and therefore articulation between shells  12 B and  12 C. Bridges  15 A,  15 B, and  15 C are coplanar with pad regions  14 A,  14 B, and  14 C, and allow them to act as three coupled pairs of articulating strata. (Inside pads  14 A,  14 B, and  14 C are also referred to as a predetermined set of inside pads.) 
         [0050]      FIG. 4  shows the sinuous shape of volar shell  12 A whose inside surface lies against pad region  14 A of inside pad  14 . In this view, inside pad  14 A is shown bordered by walls  17 A. The inside surface of shell  12 A has a central region with a convex central interval  12 A- 1 , and is bordered on the right and left by a transversely spaced pair of concave intervals  12 A- 2  and  12 A- 3 . 
         [0051]    In  FIG. 4  the surface of pad region  14 A facing the skin is fitted with a sheet of hook and loop material  19 . In fact, sheet  19  is coterminous with the three sectors of inside pad  14  ( FIG. 3 ) and thus underlies elements  14 A,  14 B,  140 ,  15 A,  15 B,  15 C,  17 A and  17 B. 
         [0052]    Referring again to  FIG. 1 , inside pad  20  has a structure similar to pad  14  of  FIG. 3 , except pad  20  is designed to accommodate a single shell panel  18 . For this reason, pad  20  has a single surrounding wall  21  with an inside perimeter matching the outline of shell panel  18 . The underside of pad  20  is covered with hook and loop material (not shown), in a fashion similar to the other inside pad (pad  14  of  FIGS. 2-4 ). 
         [0053]    Referring to  FIGS. 1 and 2 , padded shell arrangements  16 / 20  and  10 / 14  are pressed together with a ligature network employing nylon cords arranged in a pair of circuits  24  and  26  Circuit  24  terminates at network tensioner  28 , while circuit  26  terminates at network tensioner  30 . 
         [0054]    Tensioner  28  is a manually operable winder that can be rotated clockwise (counterclockwise) to wind (unwind) cord segment  24 A relative to a reel (not shown) inside the tensioner. Cord segment  24 E will not be wound although winding may be implemented in other embodiments. Tensioner  30  is a manually operable winder that can be rotated clockwise (counterclockwise) to wind (unwind) cord segments  26 E relative to a reel (not shown) inside the tensioner. 
         [0055]    In this embodiment tensioners  28  and  30  are identical, but need not be so. Winders of this type can be obtained from Boa Technology, Inc. of Steamboat Springs, Colo. 
         [0056]    In  FIG. 1  circuit  24  has cord segment  24 A running from winder  28  atop shell  18  through channel  38 A, underpass  40 A, channel  38 B, underpass  40 B and channel  38 C. The structure of these channels and underpasses will be described in further detail presently. Cord segment  24 A traverses the edge of shell  18  and crosses over to run atop shell  12 C, that departed segment being shown in phantom as cord segment  24 B. 
         [0057]    In  FIG. 2  cord segment  24 B is threaded through gutter  142 A, channel  138 D, underpass  140 C, channel  138 E, underpass  140 D, channel  138 F, underpass  140 E, channel  138 G, underpass  140 F, channel  138 H, and gutter  142 B. Cord segment  24 B traverses the edge of shell  12 C and crosses over to run atop shell  18 , that departed segment being shown in phantom as cord segment  24 C. 
         [0058]    In  FIG. 1  cord segment  24 C is threaded through gutter  242 C, channel  2381 , underpass  240 G, channel  238 J, underpass  240 H, channel  238 K, underpass  2401 , channel  238 L, and gutter  242 D. Cord segment  24 C traverses the edge of shell  18  and crosses over to run atop shell  12 B, that departed segment being shown in phantom as cord segment  24 D. 
         [0059]    In  FIG. 2  cord segment  24 D is threaded through gutter  342 E, channel  338 M, underpass  340 J, channel  338 N, underpass  340 K, channel  338 P, underpass  340 L, channel  338 Q, underpass  340 M, channel  338 R, and gutter  342 F. Cord segment  24 D traverses the edge of shell  12 B and crosses over to run atop shell  18 , that departed segment being shown in phantom as cord segment  24 E. 
         [0060]    In  FIG. 1  cord segment  24 E is threaded through channel  438 R, underpass  440 N, channel  438 S, underpass  440 P, and channel  438 T, before returning to winder  28 . 
         [0061]    Referring now to circuit  26 , in  FIG. 1  cord segment  26 A runs from winder  30  atop shell  18  through channel  432 A, underpass  434 A, channel  432 B, underpass  434 B and channel  432 C. Cord segment  26 A traverses the edge of shell  18  and crosses over to run atop shell  12 A, that departed segment being shown in phantom as cord segment  26 B. 
         [0062]    In  FIG. 2  cord segment  26 B is threaded through gutter  336 A, channel  332 D, underpass  334 C, channel  332 E, underpass  334 D, channel  332 F to a diverging trio of gutters  337 . Cord  26  is shown traveling through the center one of the trio of gutters  337 , but one of the other paths can be chosen if it provides a more comfortable route between fingers I and M. Cord segment  24 B traverses the edge of shell  12 A and crosses over to run atop shell  18 , that departed segment being shown in phantom as cord segment  24 C. 
         [0063]    In  FIG. 1  cord segment  26 C travels through the center one of a diverging trio of gutters  237 , but one of the other paths can be chosen if it provides a more comfortable route between fingers I and M. From there, cord segment  26 C travels through channel  232 G, underpass  234 E, channel  232 H, underpass  234 F, channel  2321 , and underpass  232 G to the center one of a diverging trio of gutters  137 . The chosen one of the trio will be chosen to optimize the comfort when passing between fingers A and S. Cord  26  traverses the edge of shell  18  and crosses over to run atop shell  12 A, that departed segment being shown in phantom as cord segment  24 D. 
         [0064]    In  FIG. 2  cord segment  26 D travels through the center one of a diverging trio of gutters  37  (one of them chosen for best comfort). From there cord segment  26 D is threaded through underpass  134 H, channel  132 K, underpass  1341 , and channel  132 L to gutter  136 D. Cord segment  24 D traverses the edge of shell  12 A and crosses over to run atop shell  18 , that departed segment being shown in phantom as cord segment  24 E. 
         [0065]    In  FIG. 1  cord segment  26 E is threaded through channel  32 M, underpass  34 J, channel  32 N, underpass  34 K, and channel  32 P, before returning to winder  30 . 
         [0066]    Referring to  FIGS. 5-7 , the general scheme for guiding cords is illustrated for a specific cord interval over a specific shell, but this scheme is typical of how cords are to be guided for all the shells. In this illustrated case, dorsal shell  18  has a channel  238 J that is open on top (i e., an open topside) and is bordered on opposite sides by a parallel pair of walls  238 J- 1  Channel  238 J communicates on its right with underpass  240 H, which is closed on top and open on the bottom (i.e., an open underside). Channel  238 J and underpass  240 H are integral with and made of the same material as shell  18 . The opposite end of channel  238 J communicates with underpass  240 G, which is structured similarly to underpass  240 H. Underpass  240 G in turn communicates with relatively short channel  2381 . The distal end of channel  2381  communicates with gutter  242 C, which runs to the edge of dorsal shell  18 . 
         [0067]    Cord segment  24 C is shown in phantom routed under underpass  240 H, and between walls  238 J- 1  of channel  238 J. From there cord  24 C travels under underpass  240 G, and through channel  2381  and gutter  242 C. Cord  24 C is shown exiting from gutter  242 C and passing over wall  21  of pad  20 . 
         [0068]    The inner surface of pad  20  is fitted with a sheet of hook and loop fastening material  23  that is glued in place. 
         [0069]    Referring to  FIG. 8 , winder  28  ( 30 ) is shown with a knob  28 A ( 30 A) rotatably mounted on body  28 B ( 30 B). Body  28 B will be held in cantilevered clips  18 A, while body  30 B will be held in cantilevered clips  18 B. Clips  18 A and  18 B are molded into shell panel  18 . 
         [0070]    As previously mentioned, dorsal shell  18  will be glued in place on pad  20  between walls  21 . Likewise, volar shells  12 A,  12 B,  12 C will be glued in place on inside pad  74  between walls  17 A and  17 B. Satisfactory results will be achieved with urethane based adhesives, both spray and liquid form, although other adhesives are contemplated as well. 
         [0071]    Compression glove  70  is shown with five receptacles for the thumb and the four other fingers. Glove  70  fitted on both sides with a number of hook and loop fasteners  72 , six being visible on the dorsal side of the glove in this view. A similar number of fasteners are fitted on the volar side of glove  70 . 
         [0072]    Fasteners  72  will attach to a sheet of hook and loop fastening material glued to the underside of inside pad  20  (hook and loop sheet not visible in this view),. The inwardly facing side of previously mentioned inside pad  14  is fitted with a sheet  74  of hook and loop fastening material, which allows attachment to complementary fasteners  72  on the volar side of glove  70   
         [0073]    Glove  70  has pockets on the dorsal and volar sides, dorsal pocket  76  being visible in this view. Pocket  76  has an opening  76 A through which one can insert an inside foam pad  73 . Foam pad  73  is closer to the skin than pad  20  and will be made out of a softer material to increase comfort. The same can be said for the pad on the volar side of glove  70 . 
         [0074]    It is desirable that the stored pair of inside pads in the glove pockets be more compliant than pads  14  and  20  to add to the wearer&#39;s comfort. Also, a softer material will tend to feather the compression forces near the edges of the device, thereby avoiding the tendency to apply undesired lateral compression. Open cell foam material has been found satisfactory for this purpose, although other types of resilient materials can be used as well. An acceptable open cell foam material is available from Canal Rubber Supply Co. of New York (light to medium density). In this embodiment the pocketed foam is ½ inch thick (1.3 cm), but the thickness may be varied, and will typically remain within a range of ¼ to ¾ inch (0.6 to 1.9 cm), with the thickness chosen to accommodate the needs of the patient. 
         [0075]    Inside pads  14  and  20  (also referred to as an intervening pair of inside pads) will be a relatively stiffer material designed to transmit forces normal to their surfaces. Satisfactory results will be achieved when pads  14  and  20  are made from molded foam (PE, PU, EVA, etc.) or cast urethane, although other materials are contemplated as well. 
         [0076]    Referring to  FIGS. 9 and 10 , an alternate volar shell arrangement has a shell structure  510  including transverse shell  512 A, medial shell  512 B, and lateral shell  512 C Components corresponding to those previously illustrated in connection with  FIG. 2  have the same reference numerals but increased by  500 . In particular, cord segments  524 B,  524 D,  526 B, and  526 D are threaded through overpasses and channels that are essentially the same as those previously illustrated in  FIG. 2 . Volar shell structure  510  will cooperate with the dorsal shell arrangement shown in  FIG. 1 . 
         [0077]    This embodiment differs in that the previously mentioned inside pad of  FIG. 3 , has been replaced with three discrete inside pads  525 A,  525 B, and  525 C arranged to hold shells  512 A,  512 B, and  512 C, respectively. Pads  525 A,  525 B, and  525 C each have peripheral walls whose inside perimeters match the outlines of shells  512 A,  512 B, and  512 C, respectively. Shells  510 A,  510 B, and  510 C are interconnected by flexibles splines  615 A,  615 B, and  615 C which act as coupling devices. 
         [0078]    First spline  615 A connects between semicylindrical hood (concavity)  52  on shell  512 A and semicylindrical concavity  54  on shell  512 B. Second spline  615 B connects between semicylindrical hood (concavity)  56  on shell  512 A and semicylindrical concavity  58  on shell  512 C. Third spline  615 C connects between semicylindrical hood (concavity)  60  on shell  512 B and semicylindrical concavity  62  on shell  512 C. Splines  615 A,  615 B, and  615 C may be riveted on either end to concavities  52 - 62 . 
         [0079]    As before, flexible splines  615 A,  615 B, and  6150  allow articulation between shells  512 A,  512 B, and  512 C. Splines  615 A,  615 B, and  615 C may be made of material similar to that of pads  525 A,  525 B, and  525 C. 
         [0080]    In  FIG. 10  previously mentioned concavities  52  and  56  are shown containing splines  615 A and  615 C. Pad  525 A has wall  517 A bordering transverse shell  512 A. The inner face of pad  525 A is fitted with a sheet of hook and loop fastener material  519 , which is glued in place. The layered arrangement of pad  525 A is typical of that found in pads  525 B and  525 C. 
         [0081]    The inside face of shell  512 A has a convex underside in medial region  512 A- 1 , and a concave underside in outer regions  512 A- 2  and  512 A- 3 . The curvature of medial region  512 A- 1  tends to cup the hand around metacarpo-phalangeal joints of four fingers, excluding the thumb. 
         [0082]    Referring to  FIG. 11 , an alternate volar shell arrangement has a shell structure  610  including transverse shell  612 A, medial shell  612 B, and lateral shell  612 C. Components corresponding to those previously illustrated in connection with  FIG. 2  have the same reference numerals but increased by  600 . Volar shell structure  610  will cooperate with the dorsal shell arrangement shown in  FIG. 1 . 
         [0083]    Volar panels  612 A,  612 B, and  612 C are interconnected by means of inside pad  614 , specifically by its bridges  615 D and  615 E, acting as coupling devices. (Previously described wall  17 B of  FIG. 2  is supplanted by bridges  615 D and  615 E.) Inside pad  614  is shown as a collection of three pad regions, sized to receive shell panels  612 A,  612 B, and  612 C. 
         [0084]    Transverse shell  612 A is bordered on its proximal side by transverse bridge  615 D and on the remaining sides by wall  617 C. Shell  612 B is bordered medially by bridge  615 E, on the distal side by bridge  615 D, and on the outer and proximal sides by wall  617 E. Shell  612 C is bordered medially by bridge  615 E, on the distal side by bridge  615 D, and on the lateral and proximal sides by wall  617 D. 
         [0085]    Flexible bridges  615 D and  615 E allow shells  612 A,  612 B, and  612 C to articulate relative to each other. Specifically, flexible bridge  615 D allows shell  612 A to articulate relative to shells  612 B and  612 C. Also, flexible bridge  615 E allows relative articulation between shells  612 B and  612 C. 
         [0086]    Cord segments  624 B,  624 D,  626 B, and  626 D are threaded through overpasses and channels that are essentially the same as those previously illustrated in  FIG. 2 , except channels  138 F and  338 P have been eliminated and replaced with underpasses  740 G and  940 N, respectively. Underpass  740 G runs directly between channels  738 E and  738 G, while underpass  940 N runs directly between channels  938 P and  938 M. 
         [0087]    Referring now to panel  612 B, the medial portion of that panel slopes down into the palm to achieve an intimate fit. The distal and proximal sections of panel  612 B also slope down (concave underside) to wrap partially around the metacarpal bone of the forefinger and thumb, respectively. 
         [0088]    Transverse panel  612 A has shape similar to panel  512 A of  FIG. 10 . Specifically, the inside face of shell  612 A has a convex underside in its medial region, and a concave underside in its outer regions. 
         [0089]    The arrangement of  FIG. 11  offers several advantages. First, panels  612 A,  612 B, and  612 C cover a greater percentage of the volar region. In particular, the medial/distal corner of panel  612 C intrudes further into this region. Also, panel  612 C is curved about a longitudinal axis to accommodate the lateral edge of the hand and to bring the medial edge and the medial/distal corner of the panel deep into the palm. The radius of curvature of panel  612 C is tailored to accommodate a typical anatomy. In order to achieve a good fit, the medial edge of panel  612 C is made with a somewhat reduced radius of curvature. 
         [0090]    Also, the medial edge of panel  612 C is obliquely skewed from the longitudinal axis. This skewing can be in the range of 5° to 20° (in this Figure the skewing is approximately 12° counterclockwise),. This skewing accommodates the normal anatomical flexing of the thumb&#39;s metacarpal bone. 
         [0091]    While the devices of  FIGS. 1-11  are mentioned for treating a hand, they can adapted to treat to different body parts such as the foot, forearm, upper arm, calf, or thigh. 
         [0092]    To facilitate an understanding of the principles associated with the foregoing apparatus, its operation will be briefly described in connection with the embodiment of  FIGS. 1-8 . In this embodiment two compression zones are achieved by using two tensioners  28  and  30  and two independent circuits  24  and  26 . In the disclosed embodiment, circuit  24  is arranged with four crossovers: two between shells  18  and  12 B, and two between shells  18  and  12 C. 
         [0093]    For circuit  26 , the compression affects primarily the knuckles at the base of the fingers (metacarpophalangeal joints). Specifically, the crossover between courses  26 A and  26 B applies pressure on the medial side of the knuckle for forefinger I. The crossover between courses  26 B and  26 C applies pressure at the gap between fingers I and M. The crossover between courses  26 C and  26 D applies pressure at the gap between fingers A and S. The crossover between courses  26 D and  26 E applies pressure on the lateral side of the knuckle for finger S. 
         [0094]    As noted previously one can select one of the trio of paths for each of the triple gutters  37 ,  137 ,  237  and  337  to produce the most comfortable fit. 
         [0095]    For circuit  24 , compression affects the portion of the hand spaced proximally from circuit  26 . Specifically, the crossover between courses  24 A and  24 B applies pressure on the lateral side of the hand about midway between the fingers and wrist. The crossover between courses  24 B and  24 C applies pressure on the lateral (pinky) side of the hand at a position that is fairly close to the wrist. The crossover between courses  24 C and  24 D applies pressure on the medial (thumb) side of the hand between the thumb T and wrist. The crossover between courses  24 D and  24 E applies pressure on the medial (thumb) side of the palm about midway between thumb T and forefinger I. 
         [0096]    Winders  28  and  30  can be independently adjusted to establish the compression forces at their respective regions. By tightening (loosening) circuit  26  compression forces can be increased (reduced) around the knuckles at the base of the fingers. The sinuous shape of transverse shell  12 A will tend to flatten the adjacent knuckles to reduce cupping and avoid unnecessary stress at this region. 
         [0097]    By tightening (loosening) circuit  24  compression forces can be increased (reduced) around the portion of the hand between the wrist and the knuckles at the base of the fingers. At this point the adjacent edges of shells  12 B and  12 C curve into the palm to accommodate the natural curvature and cupping there. 
         [0098]    Since panels  18 ,  12 A,  12 B, and  12 C are relatively stiff, the forces applied by these panels are substantially perpendicular to the volar and dorsal surfaces of the hand, so that the hand is not squeezed laterally. Pads inside the pockets of glove  70  will usually be a softer material to increase comfort and to provide feathering of compression forces near the edges of shells  12 A,  12 B,  12 C, and  18 . 
         [0099]    The compression forces produced by circuits  24  and  26  will be initially set by a professional the first time the device is placed on the hand. However, the wearer will be instructed on how to independently don the device without professional assistance. Thereafter, the patient can wear the device during the time periods recommended by the therapist. 
         [0100]    To don the device, the patient will put glove  70  on the affected hand in the usual fashion. Then, winders  28  and  30  will be operated to fully slacken circuits  24  and  26 . A patient can then slip the gloved fingers between shell structure  16  on the dorsal side, and shell structures  10  on the volar side. When the hand is positioned as shown in  FIGS. 1 and 2 , winders  28  and  30  can be adjusted to produce the tension in circuits  24  and  26  as demonstrated and recommended by a therapist. 
         [0101]    During the course of a day, a patient may find it necessary to increase or decrease the compression forces. Since winders  28  and  30  are easily adjusted, these compression forces can be easily changed by the patient. 
         [0102]    The device is easily removed by using winders  28  and  30  to remove all tension on circuits  24  and  26 . Thereafter, the gloved hand is withdrawn in a direction opposite to the direction used to don the device, before removing glove  70  Accordingly, the patient can temporarily remove the device for routine activities such as bathing. 
         [0103]    When the device is worn, the compression forces will tend to reduce the patient&#39;s edema. The compression forces will tend to urge edematous fluids in a proximal direction. At the same time, the patient&#39;s fingers, thumb, and wrist will remain highly mobile. Thus, the patient can perform most daily activities. Accordingly, the fingers, thumb, and wrist will be routinely exercising, which will produce a natural pumping effect that tends to reduce edema. In addition, the device is relatively open so that air can reach the hand, which will enhance comfort and avoid elevated temperatures. 
         [0104]    The patient will still need to periodically visit a therapist to check the progress and to perform different types of CDT. At these visits the therapist can inspect the condition of the body part, and recommend any changes in regime deemed necessary. 
         [0105]    The advantages of this device are: time savings and ease of application, comfort, safety, and therapeutic efficacy. Using appropriate materials and an effective tensioning system, this device offers a high working, low resting pressure environment similar to that which his offered to lymphedema patients during CDT using short stretch (non-elastic) bandaging materials. Furthermore compression is achieved while avoiding trauma to the lymphatic, hemodynamic and neurological system, by using customizable thermoplastics and padding to areas like the hand, forearm, upper arm, calf, thigh and other body parts. 
         [0106]    It will be appreciated that various modifications may be implemented with respect to the above described embodiments. In some cases a variety of shells may be manufactured in sizes and shapes designed to accommodate any one of a variety of affected body parts. Also, different sizes can be offered to accommodate patients of different weights, statures, ages, etc. In some embodiments shells may be provided with a large number of alternate channels, overpasses, eyes or lacing hooks, so that the therapist can effectively route a tensioning cord through almost any desired route by selecting different guide elements. In some cases the ligature network will be formed of a single cord but will be segregated into different independent sections by tying some intermediate point on the cord to an anchor, so that tension is not transferred from one section to the other In some embodiments a pad may be a single layer or may employ more than two layers. Also, instead of installing the softer pads in glove pockets, these pads may be attached to the stiffer pads underlying the plastic shells. In such cases the glove may be eliminated. 
         [0107]    Obviously, many modifications and variations of the present invention are possible in light of the above teachings. It is therefore to be understood that within the scope of the appended claims, the invention may be practiced otherwise than as specifically described.