Tag Archives: lymphedema therapy

A collaborative approach to wound care and lymphedema therapy: Part 2

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By Erin Fazzari, MPT, CLT, CWS, DWC

Have you seen legs like these in your practice?

Before-After

These legs show lymphedema and chronic wounds before treatment (left image) and after treatment (right image) with complex decongestive therapy (CDT)—the gold standard of lymphedema care. The patient benefited from multidisciplinary collaboration between wound care and lymphedema therapists.

Part 1 of this series (published in the May-June edition) began a discussion of the importance of multidisciplinary collaboration when treating lymphedema and chronic wounds, explained how the anatomy and physiology of the venous and lymphatic systems support this concept, and discussed the global impact of venous stasis ulcers and lymphedema. In this article, I revisit the goals common to lymphedema therapists and wound care clinicians, discuss how collaboration in multidisciplinary treatment centers can enhance patient outcomes, and describe CDT as an example of collaborative treatment.

Benefits of a collaborative treatment approach

In 2012, Birkballe et al. published a study describing the establishment, function, and results of a multidisciplinary lymphedema center in Copenhagen, Denmark. The center serves as a university hospital unit connected to the dermatology and wound-healing departments. Based on data analysis, the authors concluded the center improves lymphedema management, knowledge, and awareness. Its staff consists of:

  • two full-time nurses trained as lymphedema therapists
  • two part-time physicians with extensive knowledge of dermatology and lymphedema
  • hospital-based part-time staff, including dermatologists, surgeons specializing in wound care, podiatrists who treat foot and nail problems and customize footwear, orthotists, laboratory technicians, dietitians, physiologists, social workers, occupational therapists, and administration personnel.

During their first visit to the center, all patients were seen by an experienced nurse and physician. Based on the patient’s individual needs and condition, other healthcare practitioners conducted additional assessments. Data analysis found all patients needed at least one additional assessment and 92% needed at least two. Patients with severe lymphedema, complications, or uncertain diagnoses received CDT in the outpatient clinic or inpatient ward. When maximal edema reduction and therapeutic benefit were achieved, patients transitioned to the second CDT phase and entered an individual follow-up program.

Birkballe et al. assert that the multidisciplinary treatment center offers these advantages:

  • multidisciplinary assessment at the first visit
  • easy access to relevant standardized diagnostic procedures carried out by experienced staff
  • collaborative standardized treatment plans for lymphedema and complications
  • better continuity of care
  • improved lymphedema management, knowledge, and awareness
  • greater patient adherence and satisfaction
  • increased possibilities for education and training of all healthcare professionals
  • more opportunities for research and quality assurance
  • increased awareness and improved care of patients.

Role of CDT in addressing common goals

CDT was developed by German physicians Michael and Ethel Foldi in the early 1980s to address the goals common to wound care and lymphedema therapy:

  • reducing and stabilizing edema
  • achieving ulcer healing
  • preventing recurrence
  • preventing infection
  • maximizing tissue healing.

CDT should be performed by a practitioner who has had at least 135 hours of advanced training in lymphedema, according to the National Lymphedema Network. (See NLN: A crucial resource.) CDT consists of two phases. Phase 1, an intensive treatment phase, aims to improve skin integrity and tissue texture, reduce edema, and prevent infection. Phase 2, a maintenance phase, aims to prevent wound and edema recurrence, prevent long-term infection, and improve quality of life.

NLN- A crucial resource

Phase 1

This phase has four components: skin and wound care, exercise, manual lymphatic drainage (MLD), and compression bandaging with multi-layered, short-stretch bandages with foam.

When the patient’s edema reduction plateaus, tissue texture improves, and wounds heal, as assessed by frequent volumetric measurements, tissue texture assessments, and regular wound assessment. Clinicians measure the affected limbs and fit them for appropriate compression garments for both daytime and nighttime compression. Compression garments may include flat-knit compression stockings, bandage alternative devices, or both. This treatment transitions the patient to phase 2.

Phase 2

During this phase, the patient receives education on edema self-management, skin care, and exercise. In some cases, as determined by the practitioner, the patient learns how to perform MLD and uses an intermittent pneumatic compression device (IPC) at home. In about 6 months, patients should visit the clinician for reassessment and new compression garments.

A systematic review of the literature supports bundled CDT components as an effective lymphedema treatment. Multi­layered compression bandaging with foam is a strong component of CDT for edema reduction. A study by Partsch et al. (2008) found a multilayered compression-bandage pressure of 38 mm Hg or higher increased blood perfusion in the normal limb. How this translates to patients with subcutaneous fibrosis with combined venous and lymphatic edema (phlebolymphedema) isn’t clear. However, the authors concluded that in the standing position, higher pressures more effectively narrow leg veins, reduce venous reflux, and enhance the venous pump. Higher pressures suggest materials with greater stiffness should be used, such as short-stretch, multilayered compression bandaging, custom flat-knit compression garments, and bandage alternative devices. Another study by Pawel et al. (2013) concluded that IPC devices, stockings, and multilayered bandaging are useful and effective in treating venous leg ulcers, whereas two-layer, short-stretch bandages and Unna boots are ineffective.

Leg

A model for the future

Literature on collaboration between lymphedema therapists and wound care clinicians is minimal. Lymphedema management has never belonged to any medical specialty, and only recently have U.S. clinicians become more aware of this disorder and its management.

But that’s changing. If you Google “lymphedema and wound care clinics in the U.S.,” you’ll find more of these clinics are being developed throughout the country. Multidisciplinary centers with collaborative teams have a place in the future of health care. Consider how a multidisciplinary setting for lymphedema and wound care could enhance your practice and improve your patients’ quality of life.

Erin Fazzari is a physical therapist at Good Shepherd Penn Partners: Penn Therapy and Fitness, in Philadelphia, Pennsylvania.

Selected references

Birkballe S, Karlsmark T, Noerregaard S, Gottrup F. A new concept of a multidisciplinary lymphoedema center: established in connection to a department of dermatology and the Copenhagen Wound Healing Center. Br J Dermatol. 2012;167(1):116-22.

Farrow W. Phlebolymphedema—a common underdiagnosed and undertreated problem in the wound clinic. J Am Col Certif Wound Spec. 2010;2(1):14-23.

Foldi M, Foldi E. Foldi’s Textbook of Lymphology: For Physicians and Lymphedema Therapists. 3rd ed. Munich, Germany: Urban & Fischer, 2012.

Lasinski BB, McKillip Thrift K, Squire D, et al. A systematic review of the evidence for complete decongestive therapy in the treatment of lymphedema from 2004 to 2011. PM R. 2012;4(8):580-601.

Law K. Addressing the Whole, Not Just the Hole: A Collaborative Approach for Patient Success [Lecture]. Penn Medicine at Radnor, Radnor, PA; 2014.

National Lymphedema Network. Position Statement: The Diagnosis and Treatment of Lymphedema. www.lymphnet.org/pdfDocs/nlntreatment.pdf

National Lymphedema Network. NLN Position Statement: Training of Lymphedema Therapists. www.lymphnet.org/pdfDocs/nlntraining.pdf

Partsch H, Flour M, Smith PC; International Compression Club. Indications for compression therapy in venous and lymphatic disease consensus based on experimental data and scientific evidence. Int Angiol. 2008;27(3):193-219.

Pawel D, Franek A, Kolank M. A comparative clinical study on five types of compression therapy in patients with venous leg ulcers. Int J Med Sci. 2013 Dec;11(1):34-43.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

A collaborative approach to wound care and lymphedema therapy: Part 1

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By Erin Fazzari, MPT, CLT, CWS, DWC

Have you seen legs like those shown in the images below in your practice? These images show lymphedema and venous stasis ulcers, illustrating the importance of collaboration between clinicians in two disciplines: lymphedema and wound care.

My experience

Over the last 12 years as a physical therapist specializing in lymphedema therapy and wound care, I’ve had the opportunity to treat many patients with wounds in multiple settings. I’ve also had the opportunity to collaborate with medical professionals in multidisciplinary treatment centers where lymphedema therapists and wound care clinicians act as a team. Through this experience—and through review of the literature—I’ve learned that such a team has improved patient outcomes.

To help the team reap maximal benefits, I’d like to share information related to lymphedema, its management, and how collaboration in multidisciplinary treatment centers can enhance outcomes.

In Part 1 of this two-part series, I discuss pathophysiology related to wounds and lymphedema and begin the discussion of collaboration.

The basics

To understand the role of lymphedema therapy as it relates to wound care, it’s first necessary to take a step back and define both chronic wound and lymphedema. A chronic wound is a wound that doesn’t heal in an orderly set of stages and in the predictable amount of time that most wounds do. Delayed healing may result from a variety of underlying factors, such as poor systemic immune function, malnourishment, chemotherapeutic agents, high bioburden, repetitive mechanical trauma, and cytotoxic agents.

Lymphedema is a condition of localized fluid retention and tissue swelling characterized by high-protein edema caused by a compromised lymphatic system. All exterior regions of the body (for example, face, neck, torso, extremities, and genitals) can be affected. Common causes of lymphedema and accompanying diseases that can contribute to lymphedema include heredity, filariasis, trauma, surgeries, lymph node dissections, radiation therapy, malignancy, obesity, diabetes, chronic heart failure, dependent mobility and, of course, venous disease—the principal culprit of our wound for discussion, the venous stasis ulcer.

The venous stasis ulcer is one major debilitating result of advanced venous disease. Venous ulceration is the most common cause of lower-extremity ulcer, accounting for half of these ulcers and affecting 1% to 2% of the U.S. population, with 3% to 5% of patients older than age 65.

Venous stasis ulcers and lymphedema

So how are the venous ulcer and lymphedema related? The venous and lymphatic systems are closely intertwined. When explaining the systems to patients, I often refer to the lymphatics as the sewer system of the venous system.

Most wound care clinicians are familiar with the pathophysiology that results in venous disease and the cascade of events that leads to a venous ulcer. Many clinicians, however, aren’t as familiar with the role of the lymphatics in this process.

Under optimal circumstances, the venous system is responsible for the removal of 90% of interstitial fluid at the capillary level. The remaining 10% is the responsibility of the lymphatic system. However, the lymphatics have a built-in safety net to manage excess interstitial fluid that occurs when the veins function inefficiently or ineffectively. Venous reflux may be present, but edema in the tissue isn’t yet visible when the lymphatics are able to manage the load. Edema in the lower extremities, as well as other areas of the body, is visible only when both the veins and lymphatics are no longer capable of managing the load.

The lymphatics are also responsible for the removal of large macromolecules from the interstitial space, including proteins that are unable to diffuse back into the venous system at the capillary level. A venous stasis ulcer occurs when the increase in protein concentrations in the tissue results in chronic inflammation and infiltration of white blood cells and fibroblasts. This leads to fibrosis of the edematous tissue, dilation and insufficiency of lymphatic tissue, and damage to endothelial cells, further reducing lymphatic flow and enhancing the destructive process.

The body’s physiologic responses illustrate the close anatomic and physiologic connection between the two systems. Consequently, it should be a priority for us, as clinicians, to address both the lymphatic and venous systems when edema is detectable in the tissue.

Worldwide impact

The anatomy and physiology of these systems have a huge impact on our patient population. Each year in North America, 5 to 7 million chronic wounds occur. Lower-extremity venous stasis ulcer is the most common of these, with an incidence of 2.5 million. In the United States alone, chronic leg wounds account for 2 million lost workdays per year.

When it comes to lymphedema, 1 in 30 people worldwide are estimated to be afflicted with this debilitating disease, not including those suffering from venous disease.

World organizations have begun to recognize the importance of addressing lymphedema and wound care collaboratively. (See World action on lymphedema and wound care.) As noted earlier, anatomy and physiology don’t separate the venous and lymphatic systems, so wound care and lymphedema clinicians need to work collaboratively to help patients.

Common goals

A good place to start collaborating is to understand that the disciplines of lymphedema therapy and wound care have many common goals, including:

  • reducing and stabilizing edema
  • achieving ulcer healing
  • preventing recurrence
  • preventing infection
  • maximizing tissue healing.

Multidisciplinary teams are the wave of the future of health care. Consider how a team approach with lymphedema and wound care professionals would enhance your practice, and watch for Part 2 of this series, which will further address common goals, review the gold standard of management (complex decongestive therapy), and illustrate how collaboration in multidisciplinary treatment centers can enhance patient outcomes.

Selected references

Ditzler K. Collaborating lymphedema and wound care [lecture]. Penn Medicine at Radnor, Radnor, PA; 2014.

Foldi M, Foldi E. Foldi’s Textbook of Lymphology: For Physicians and Lymphedema Therapists. 3rd ed. Munich, Germany: Urban & Fischer, 2012.

Law K. Addressing the Whole, Not Just the Hole: A Collaborative Approach for Patient Success [Lecture]. Penn Medicine at Radnor, Radnor, PA; 2014.

MacDonald J, Asiedu K. WAWLC: World alliance for wound and lymphedema care. Wounds. 2010; 22(3):55-9.

MacDonald J, Geyer, MJ, eds. Wound and lymphoedema management. World Health Organization: 2010 http://whqlibdoc.who.int/publications/2010/9789241599139_eng.pdf

Macdonald JM, Sims N, Mayrovitz HN. Lymphedema, lipedema, and the open wound: the role of compression therapy. Surg Clin North Am. 2003;83(3):639-58.

Norton S. CDT theoretical review course for the certified lymphedema therapist. Norton School of Lymphatic Therapy; 2005.

Pawel D, Franek A, Kolank M. A comparative clinical study on five types of compression therapy in patients with venous leg ulcers. Int J Med Sci. 2013 Dec;11(1):34-43.

Sen CK, Gordillo GM, Roy S, et al. Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair Regen. 2009 Nov-Dec;17:763-7.

Erin Fazzari is a physical therapist at Good Shepherd Penn Partners: Penn Therapy and Fitness, in Philadelphia, Pennsylvania.