By Robyn “Redd” Smith,
M.ED., COTA/L, CLWT, CLT, LASH-FKT
A patient with two swollen legs walks into a vein clinic.
Now, that may sound like the beginning of a joke, but it is actually the opening line to our story. A story showing how making an addition to your options of care in your practice can make all the difference for your patients. And, I am not speaking about a short-term fix, I am talking about a lifelong improvement in your patient’s life.
Care to hear more? Read on.
The addition I am referring to is the inclusion of a certified lymphedema therapist (CLT) in the team executing the Interdisciplinary Team (IDT) Plan of Care.
I know most of you have heard of us – yes, I am a lymphedema therapist – but I have found that there is a lack of details of what it is we really do to help our shared patients. Few people except lymphedema therapists can verbalize how we improve not only the patient’s health but their quality of life.
If I may have a few minutes of your time, I would like to lead you down an educational path, clarifying some of the most misunderstood characteristics of lymphedema treatment.
Whether you determine you need to include a CLT, CLWT (certified lymphedema & wound therapist) or CDP (certified decongestive physiotherapist) in your treatment model will be your choice; but after our journey, you will make that decision based on a more thorough understanding of the amazing, evidence-based treatment offered by lymphedema therapists. So, let us begin.
What does a certified lymphedema therapist do?
In short, a lymphedema therapist assists the body in completing its assigned task of moving fluid from the interstitium into the lymphatic system, on its way back to the vascular circulatory system. Ever since the lymphatic system moved front and center in 2014 as THE body system responsible for 100 percent of the fluid homeostasis in the body (Stanley G. Rockson, 2018), there has been a desire for methods to improve the lymphatic function for patients with chronic lymphatic system failure, aka, lymphedema.
Lymphedema therapists use an evidence-based treatment method called complete decongestive therapy (CDT) or complete decongestive physiotherapy (CDP).
CDT/CDP consists of four components of care: Skin hygiene, unique exercises, manual lymphatic drainage (MLD) treatments and static compression.
Each of the components are of equal importance and all work together for the best outcome; if one is left out of the mix, the others will not work optimally.
One plus one plus one plus one does not equal four in the world of lymphedema treatment – the combined result is more like 1,111. But lose one of the components and we are back to a result of the simple number. Forgive my automotive analogy, but I can have tires, a chassis, a drive train and a driver that can each be interesting to look at, but it is only when all four are put together correctly that things happen. And so it is with the components of lymphedema care.
Two of the components are quite easy to understand. Skin hygiene equals keeping the skin on the edematous limb clean and free of infection. Any opening in the skin on a patient with lymphedema can lead to increased risk of infection in an already-challenged immune system (Stanley G. Rockson, 2018). Gentle washing of the skin, keeping the skin hydrated to guard from cracking of dry skin and prompt care of any traumatic break in the skin is the goal.
The component of exercise is – plain and simple – the use of body movements that actuate the calf muscle pump. Foot pumps, circles with the ankle; that’s all it takes (Peter Glouiczki, 2017). It’s the other two components, MLD and static compression use, that lend a bit of mystery to lymphedema treatment; those will be the topics we meander past on our educational journey.
Manual lymphatic drainage, isn’t that a kind of massage?
MLD is not a massage in the traditional sense of the word but lacking a concise way to explain MLD to patients, that term has been adopted even though it is somewhat misleading and clearly a misnomer.
Whereas traditional massage is a manipulation of the muscles and soft tissue done at a moderately deep-to-deep level, MLD consists of a very specific manipulation of the <ital>skin <end ital>and generally should be done superficially (although we do have a few deep techniques).
Lesson learned? <ital>We are not squeezing the fluid out. <end ital>
A good portion of the intensive training a CLT/CLWT/CDP completes entails the learning and hours of practiced perfection of the movements and rhythm of the manual hand movements that are MLD.
Performed correctly, those hand movements actuate (open) the lymphatic capillary via pulling on anchoring filaments connected to the capillary’s swinging tips and then using the weight of the hand moving across the skin to affect a pressure change and move the interstitial fluid into the lymph system.
Through an intimate understanding of the lymph system, its watershed, and anastomoses, certified lymphedema therapists move fluid from areas of poor lymphatic circulation to areas that can move and process the fluid. And we now have the images to show it happens: https://www.youtube.com/watch?v=YmwC0A3PWhM
I’ve heard that a pump can be used as a replacement for MLD in the treatment of edema. Is that true?
Manual lymphatic drainage done by a CLT/CLWT/CDP is the only method that can move fluid to a new area of the body using anastomoses and based on the known watersheds of the body.
However, a pump can continue that movement up the body that a therapist began and can be a valuable adjunct in lymphedema care. However, the use of a pump as a replacement for MLD is not suggested (Stanley G. Rockson, 2018)
How does static compression fit into lymphedema treatment?
Gravity, in the world of varicosities, hemosiderin staining and edema, is the enemy. Well, maybe not the enemy, but definitely a troublemaker. Static compression adds a lock to the work that the therapist has completed, if you will.
If MLD is done and then no compression is donned, much of the fluid will reflux back down the limb. It is paramount that once that fluid movement is begun, the patient wears inelastic compression 24/7 and because lymphedema is a lifelong diagnosis, they will need to continue compression in some form for the rest of their lives (P.T., 2000).
I have seen patients with lymphedema in compression bandages that look horribly restrictive. I don’t think my patients will go for that.
This has been a common challenge for therapists and patients alike that historically the only option for inelastic compression was short stretch bandages. (FYI-Short stretch bandages have a stretch rating of about 60 percent as opposed to standard “ACE-type” long stretch bandages that stretch 200-300 percent and are not safe to use in lymphedema treatment.)
Fortunately, there are now innovative, updated options to meet the need for static compression with adjustable Velcro wraps (AVW) that are easy to don and doff, have been shown to offer more efficacious compression levels than short stretch bandages (Robert J Damstra & Hugo Partsch, 2013) and are user-friendly for patients allowing them to adjusting the compression throughout the day.
An added bonus is that patients can complete their skin hygiene easily by removing the compression for showering and replacing without the need for a trained clinician to reapply.
While early results using AVW were once only anecdotal, we now have studies to show the improved outcomes when compared to short stretch bandaging. (G. Mosti, 2015) The use of AVWs has shown a striking improvement in patient satisfaction and adherence to wearing of compression according to the Plan of Care. What more could you ask for?
What type of training goes into becoming a CLT, CLWT or CDP? Can anyone hold those credentials?
To become a medically-credentialled CLT, CLWT or CDP, one must already hold another medical credential. Most CLT/CLWT/CDP are occupational therapists, occupational therapy assistants, physical therapists or physical therapist assistants. It is important to note that although a licensed massage therapist (LMT) may take the certification classes and use the credentials CLT, they may neither bill insurance for the service nor offer/promote it as a medical treatment.
Becoming certified as a lymphedema therapist takes no less than 135 hours of training in the anatomy, physiology, pathophysiology and treatment of the lymphatic system in patients both with and without extenuating co-morbidities such as congestive heart failure and diabetes. Students must pass comprehensive written exams daily, demonstrate proper form and understanding of MLD and static compression, complete several case studies and perform a lengthy practical exam to receive the certification.
It should be noted that most classes have two or more students who fail the exams or the practical and are not granted the certification. The take-away is that this is not an easy certification to gain.
To assure that your patients are receiving care from someone fully trained in all of the necessary facets of lymphedema care, watch for the combination of an accepted medical credential <bold,caps>AND <end bold caps>the credential of CLT (certified lymphedema therapist) or CLWT (certified lymphedema and wound therapist) or CDP (certified decongestive physiotherapist).
Be aware that there are also non-medical credentials of MLD or CDT and others that are single day and half-day classes taught by non-medically trained instructors meant to only give a basic overview of the treatments and should not be construed as someone prepared to take over the complete lymphedema treatment of your patient.
Do I need to hire a lymphedema therapist to be on staff at my clinic?
That is certainly an option that is quite successful for some clinics, but most physicians opt to refer patients to a clinician in their area. It is a simple process that works just the same as referring a patient to a respiratory therapist or a physical therapist or home health or any other such referral.
Lymphedema therapists work in all settings of healthcare from acute care in ICUs to SNFs to home health to outpatient clinics. Wherever your patient is, a lymphedema therapist can treat them.
How do I find a therapist to work with?
There are many options online that allow you to look up therapists in your area. However, because most of the lists are compiled by the schools certifying the students and there is not one all-inclusive list, it may take a bit of searching.
Sometimes the best method is to ask an occupational or physical therapist you currently work with for normal OT/PT services if they know someone who is certified in lymphedema care in your area. We are a pretty tightknit group and generally will know who of our colleagues are trained in lymphedema therapy that can meet your patient’s needs.
Can a lymphedema therapist cure my patient’s lymphedema?
Unfortunately, at this time we do not have a cure for lymphedema, but the treatment methods offered by lymphedema therapists can offer livable options when faced with a lifelong diagnosis. (Peter Glouiczki, 2017) Much like a diagnosis of diabetes (DMII) that can be controlled by daily care and a concerted effort of the patient’s healthcare team, patients with lymphedema can be given the tools to live a life with substantially improved health and quality of life.
How does our story end?
Research shows us that a CEAP score of C2-3 or above, even in a patient with no visually-apparent edema, already has the beginning of chronic lymphatic system failure (Rassmussen, 2016). We know now that so-called venous edema, varicose veins, CVI and lymphedema are not separate and unrelated diseases but are all diagnoses on the continuum of chronic lymphatic system failure.
<boldital>Now <end bold ital>is the time to examine each of your patients for the beginning of lymphatic disease. Too busy to add one more thing to your plate? I have the solution and it’s as simple as writing a referral.
So how does our initial story end? A patient with swollen (or not visually-swollen) legs walks into a vein clinic and low and behold after evaluating the patient, the physician refers the patient to a lymphedema therapist to treat the patient’s edema and as medical professionals working together they forever change the patient’s health and quality of life. They become heroes.
And that my dear reader, is <boldcaps>NO <endboldcaps> joke. VTN
RESOURCES
- Mosti, A. C. (2015). Adjustable Velcro® Compression Devices are More Effective than Inelastic Bandages in Reducing Venous Edema in the Initial Treatment Phase: A Randomized Controlled Trial. European journal of Endovascular Surgery, 50, 368-74.
P.T., M. J. (2000). Overview of treatment options and review of the current role and use of compression garments, intermittent pumps, and exercise in the management of lymphedema. American Cancer Society Lymphedema Workshop.
Peter Glouiczki, M. F. (2017). Handbook of venous and lymphatic disorders (4th ed.). Boca Raton, FL: Taylor & Francis Group, LLC.
Rassmussen, J. A. (2016). Lymphatic transport in patients with chronic venous insufficiency and venous leg ulcers following sequential pneumatic compression. Journal of Vascular Surgery, 4(1), 9-17.
Robert J Damstra, M. P., & Hugo Partsch, M. P. (2013). Prospective, randomized, controlled trial comparing the effectiveness of adjustable compression Velcro wraps versus inelastic multicomponent compression bandages in the initial treatment of leg lymphedema. Journal of Vascular Surgery – Venous & Lymphatic Disorders, 13-19.
Stanley G. Rockson, B.-B. L. (2018). Lymphedema: A Concise Compendium of Theory and Practice (2nd ed.). (S. G. Byung-Boong Lee, Ed.) Switzerland: Springer International Publishing AG.
Robyn “Redd” Smith, M.Ed., COTA/L, CLWT, CLT, LASH-FKT is an occupational therapy practitioner, a certified lymphedema and wound therapist and the executive director of Life Rehabilitation International Inc. a 501(c)3 non-profit dedicated to bringing lymphedema and wound treatment to resource-poor areas of the world. Redd’s 40 years of experience as a professional educator coupled with her unique teaching style make learning complex medical concepts both easy and fun. Redd consults for several companies in the healthcare arena, is a frequent author in national and international publications, and is the developer of THE Americas MODEL-CDP ™ — a protocol for practical lymphedema management. Redd can be contacted at robyn.smith@fromtheclinic.com
