By Manu Aggarwal, MD

It has been almost three years since we added lymphedema therapy treatments to our vein practice at Vein Care Center Laser Specialists. In this time, we have had trained (via Norton School of Lymphedema) two certified lymphedema therapists (CLTs), both part-time and both originally occupational therapists.

Why, you may wonder?


To not recognize lymphedema in patients with chronic venous insufficiency (CVI) is a disservice to patients and to the field of phlebology. Many studies have shown lymphedema is seen in more than 40 percent of patients with CVI.

Often these patients are riddled with open sores, “water blisters,” recurrent cellulitis, rubor and progressive skin changes. Addressing lymphedema with complete decongestive therapy (CDT) and manual lymphatic drainage (MLD), along with skin and nail care, is essential to the comprehensive venous practice.

What we have yet to find is an actual study to show whether treating lymphedema prior to CVI makes a difference; however, we would like to anecdotally say that treating lymphedema first often corrects minimal CVI.

We have found that many patients in our practice present with ultrasound findings demonstrating truncal insufficiency and mild to no varices and significant swelling that affects their activities of daily living. We first treat these patients with MLD and CDT at our facility or other facilities with certified lymphedema therapists. Then we have them return for repeat ultrasound in six to eight weeks.

Many times, these patients resolve their truncal insufficiency and reduce the size of their varices. In addition, they have improved mobility, skin and nail health and do not require an intervention (or minimal intervention).

We also assure that these patients have good educational information, and at-home regimens including a gradient compression pump and short stretch bandages. Many of these patients do better with Velcro wraps because they are easier to put on and adjust as the edema waxes and wanes, depending on their mobility, salt intake and general activity.



Educating the community has also been a challenge, but it is essential.

Having quarterly meetings with all the local CLTs in our community and the surrounding communities has increased awareness to therapy and the need to address skin changes and edema early on.

Many of the area wound centers are now using lymphedema therapy to assist in wound healing and working collaboratively to get patients the treatment that they need and deserve.

Many primary care physicians are now recognizing secondary lymphedema (heart failure, kidney disease, postoperative joint replacement, etc.) and patients are receiving therapy and decreasing the use of diuretics and other “water pills” to temporarily “Band Aid” the symptom of swelling.

We have also met with local nursing homes to educate their medical and rehab staffs on therapy and how to incorporate it into their facilities. Although adoption of the techniques has been slower in these facilities, increasingly, home health agencies are now adding these therapies to help those homebound.

CLTs in our area are using a slower approach with these patients because they don’t want to overload their patient’s failing organs.



While you might not be able to incorporate lymphedema therapy all at once in your practice, it’s important to get started. Your checklist should include these processes:

  • Find a dedicated CLT and be willing to send that individual for training/CME.
  • Start with two days a week for patient treatments.
  • Incorporate a pump in your office for patients to try and to use on days when your therapist is getting backed up in the schedule
  • Incorporate skincare and nailcare into your practice, including providing education handouts and discussion.
  • Have educational handouts for patients to take with them, including short stretch wrapping, self-massaging and skincare
  • Rally other CLTs in the community and become the local expert when they have questions that need to be answered (and be available to them).
  • Keep samples of stockings/Velcro wraps and other treatment supplies to show patients.
  • Add Kinesiology Therapeutic (KT) taping as the CLT perfects the “usual” modalities.
  • Keep advocating for Medicare/insurance coverage of therapy supplies and for passage of the Lymphedema Treatment Act (see update on page 27).
  • Stay informed on new advances in therapy and adjuncts (medication, surgery, skincare); and work with colleagues to help patients in other disciplines, including wound care, dermatology, cardiology, nephrology, and the rest. VTN



Manu Aggarwal, MHSA, MD, is a board-certified family physician and ABVLM-certified physician at the Vein Care Center Laser Specialists (VCC). Since 2007, the VCC has been an IAC-accredited vascular laboratory. In 2015, the VCC was one of the first 50 practices in the country to also be Vein Center accredited. The VCC has been dedicated to venous disease and laser treatments since 2004, and is located in Lima, Ohio, with satellite offices in Celina and Findlay, Ohio. Dr. Aggarwal  may be contacted at




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TREATING LYMPHEDEMA: Working with a lymphedema therapist can improve patient outcomes

Camden Lawless

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