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Why Every Wound Center Should Have a Lymphedema Specialist

Wound healing can be maximized by the management of edema, and offering lymphedema services in the wound clinic can be an ideal solution. This author details the value a certified lymphedema therapist or certified lymphedema and wound therapist can bring to your patients and practice.

In 2019, Sen published an article on “Human Wounds and Its Burden: An Updated Compendium of Estimates in Advances in Wound Care.”1 In this article, the author highlighted the significance of chronic wounds by stating: “A 2018 retrospective analysis of Medicare beneficiaries identified that 8.2 million people had wounds with or without infections. Medicare cost estimates for acute and chronic wound treatments ranged from $28.1 billion to $96.8 billion. Highest expenses were for surgical wounds followed by diabetic foot ulcers, with a higher trend toward costs associated with outpatient wound care compared with inpatient. Increasing costs of health care, an aging population, recognition of difficult-to-treat infection threats such as biofilms, and the continued threat of diabetes and obesity worldwide make chronic wounds a substantial clinical, social, and economic challenge.”1

Further adding to this challenge is the incidence of chronic edema associated with many wound and integumentary-related pathologies. Our understanding of edema and its pathophysiology has been a recent focus in the literature as well as at national and international conferences. New evidence of the microcirculation (specifically the endothelial glycocalyx layer or EGL) redefines all edema as lymphedema and having the potential to result in chronic inflammation and deleterious soft tissue changes. The EGL, a gel-like matrix with hair-like projections extending into the lumen of blood vessels, acts as a molecular sieve regulating fluid and macromolecule movement.

It is now understood that there is only a diminishing net filtration across the capillary bed and no resorption at the venous end.2 All fluid, proteins and other macromolecules are removed from the interstitium by the lymphatics alone. Mortimer and Rockson state, “Arguably, it may be better to consider the presence of chronic edema as synonymous with the presence of lymphedema, inasmuch all edema represents relative lymphatic drainage failure.”3  

What You Should Know About Lymphedema

Clinically, edema is a dynamic insufficiency of the lymphatic system in which there is an abnormal accumulation of serous fluid in the interstitial spaces. The lymphatic system is temporarily overwhelmed but not permanently damaged, leading to a transient lymphedema or lymphatic insufficiency. Lymphedema is a mechanical insufficiency of the lymphatic system where there is an accumulation of protein-rich fluid in the interstitial tissues due to damage or loss of the lymphatic system (vessels or nodes). This is lymphatic impairment leading to the disease of lymphedema. Further, the lymphatic and integumentary systems are interdependent, requiring concurrent lymphedema and wound management strategies when there is impairment in either system.

Optimization of the lymphatic system is the key to edema management, tissue remodeling and wound healing.
Disorders of the lymph system, whether systemic (macro-lymphedema) or localized (micro-lymphedema), produce cutaneous regions susceptible to infection, inflammation and carcinogenesis.4-6 The inter-relationship of the lymphatic and integumentary systems is becoming more readily appreciated as a functional lymphatic system is essential to an organism’s overall health given its role in fluid homeostasis, removal of cellular debris, and mediating immunity and inflammation.7 The chronic inflammation resulting from lymphedema creates a region of cutaneous immune deficiency or a localized skin barrier failure. The associated abnormalities are called lymphostatic dermopathy, which is the failure of the skin as an immune organ.4-6 Because of this, alterations in skin integrity, recurrent infections (commonly cellulitis), venous dermatitis, diminished wound healing, various dermatological conditions, and even skin malignancies become more prevalent, highlighting the inter-connectedness of the lymphatic and integumentary systems.4-6 Impairment or dysfunction in one system leads to associated complications in the other.

In the United States, the most common cause of lymphedema in the upper extremities is breast cancer, and in the lower extremities, chronic venous disease is the most important predictor for the development of lymphedema.8,9 With respect to obesity, lymphatic dysfunction can occur with a body mass index (BMI) greater than 50, and lymphedema may be universal in patients with a BMI greater than 60.10 Various other contributing comorbidities and cofactors may lead to lymphedema, and most clinical presentations of lymphedema result from a combination of approximately seven comorbidities.11 Data from the Canadian LIMPRINT study showed that the most common underlying cause of lymphedema in an outpatient wound clinic was venous disease, 72% of patients had a history of cellulitis, and almost 40% had an open wound.12

The Value CLTs and CLWTs Can Bring

The benefits of working with a lymphedema therapist are obvious but the regulatory space is complicated. From a billing and compliance standpoint, employing a lymphedema therapist can be challenging, particularly in the hospital outpatient department. Expert guidance will likely be necessary.  

In the outpatient wound setting environment, these complex patients have the potential for improved outcomes with the addition of a lymphedema specialist to the medical management team. Lymphedema specialists—typically certified lymphedema therapists (CLT) or certified lymphedema and wound therapists (CLWT)—have extensive education and training on disorders of the lymphatic system and its typical clinical manifestation, lymphedema. Given that many CLTs/CLWTs are rehab specialists, the functional impairments commonly seen in this patient population can also be addressed, creating a time- and resource-efficient model of care.

The standard of care for lymphedema management is typically provided in a two-phase therapeutic approach called complete decongestive therapy (CDT). Phase 1, or the intensive phase, is clinician-guided until a plateau in edema reduction is achieved. Phase 2, or the maintenance phase, is the lifelong management phase driven by the patient. In both phases, emphasis is placed on skin and nail care, manual lymphatic drainage, compression and exercise. Skin and nail care are paramount and many of these patients have skin impairment directly related to the lymphedema and/or other wounds secondary to comorbidities (diabetes and neuropathic ulcers, peripheral vascular disease, and phlebolymphedema to name a few). Additionally, cellulitis is leading cause of hospitalization for this patient population. Infection prevention and skin integrity are an integral part of CDT, further supporting the role of lymphedema specialists.

Lymphedema specialists can address the edema, skin dysfunction (including wounds and chronic inflammatory skin changes/fibrosis) and functional impairments common in the outpatient wound clinic patient population. This can assist with the coordination of care and save the patient time with respect to travel, appointments and a disruption to their treatment plan. Rather than seeing one provider for wound care, another for lymphedema and possibly even another for rehab, the plan of care can be addressed and coordinated at the wound clinic with physician oversight. This patient-centered approach can improve outcomes, reduce health care expenditures and facilitate communication between all stakeholders tasked with managing the patient.

Finding a Lymphedema Specialist

A common question is “Where do I find a CLT or CLWT?” Certified lymphedema therapists and certified lymphedema and wound therapists can be found online at https://www.clt-lana.org/search/therapists/ and at www.ilwti.com. You can search by zip code or state. Employment models can vary between full-time, part-time, consulting, or whatever fits your wound clinic best. Just having access to a lymphedema specialist will enhance your practice model by addressing the medical needs of the patients collectively. Reducing the edema is just one facet of care; facilitating integumentary integrity, remodeling fibrotic tissue, educating the patient on lifelong self-management, compression, exercise and functional mobility is truly the new model of lymphatic and integumentary rehabilitation. Where better situated to offer this medical service line than outpatient wound management clinics?

Heather Hettrick, PT, PhD, CWS, AWCC, CLT-LANA, CLWT, CORE, is a Professor in the Department of Physical Therapy at Nova Southeastern University.


 

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References

1. Sen C. Human wounds and its burden: an updated compendium of estimates. Adv Wound Care. 2019;8(2):39–48.
2. Levick JR, Michel CC. Microvascular fluid exchange and the revised Starling principle. Cardiovasc Res. 2010 Mar 3;87(2):198–210.
3. Mortimer PS, Rockson SG. New developments in clinical aspects of lymphatic disease. J Clin Investigation. 2014 Mar 3;124(3):915–21.
4. Carlson A. Lymphedema and subclinical lymphostasis (microlymphedema) facilitate cutaneous infection, inflammatory dermatoses, and neoplasia: A locus minoris resistentiae. Clin Dermatol. 2014;32: 599–615.
5. Ruocco E, Puca RV, Brunetti G, et al. Lymphedematous areas: Privileged sites for tumors, infections, and immune disorders. Int J Dermatol. 2007;46:662.
6. Ruocco V, Schwartz RA, Ruocco E. Lymphedema: An immunologically vulnerable site for development of neoplasms. J Am Acad Dermatol. 2002;47:124–127.
7. Ridner SH. Pathophysiology of lymphedema. Semin Oncol Nurs. 2013;29:4–11.
8. Rockson S. Diseases of the Lymphatic Circulation in Vascular Medicine: A Companion to Braunwald’s Heart Disease, 2nd Edition. Elsevier;2013:697–708.
9. Mortimer P, Rockson S. New developments in clinical aspects of lymphatic disease. J Clin Invest. 2014 Mar;124(3):915–21.
10. Greene A. Diagnosis and management of obesity-inducted lymphedema. Plast Recon Surgery. 2016 July;138(1):111e–118e.
11. Wang W, Keast DH. Prevalence and characteristics of lymphoedema at a wound-care clinic. J Wound Care. 2016 Apr 1;25(Sup4):S11–5.
12. Keast DH, Moffatt C, Janmohammad J. Lymphedema IMpact and PRevalence INTernational (LIMPRINT) study: the Canadian data. Lymphatic Res Biol. 2019 Mar 10.

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