sábado, 4 de febrero de 2023

WHAT ARE THE STRATEGIES FOR THE IMPLEMENTATION OF LOW-COST TREATMENT FOR LYMPHEDEMA? - DEVALUING MANUAL LYMPHATIC DRAINAGE (MLD) - Organic Lymphatic Vascular Disease - Pediatric and Primary Lymphedema - Secondary Lymphedema - Lymphatic Vascular Disease - Best Practices Management Guidelines / Treatment Protocols / Patient Care Pathways / Preventive Medicine / Rehabilitation Stratagies


The Lymphatic System is part of the circulatory system and it is indispensable for life. Morphological or functional changes in lymphatic vessels can contribute to disorders such as lymphedema, tumor metastasis, inflammation, and other pathological conditions. Lymphedema (LE) arises when there is a disruption of lymphatic flow (Organic Impairment), leading to the buildup of lymphatic fluid. Nontreatment and undertreatment of lymphedema are associated with an unfavorable prognosis of disease progression and severity, which are barriers to work and causes of social stigmatization, discrimination, and loss of Quality of Life (QoL). 


Lymphedema is a progressive disease of the skin classified as a functional, immune, and lymphatic circulatory system disorder (Organic Lymphatic Vascular Disease). The lymphatics are an active and integrated component of the immune response, and in lymphedema, there is always an increased susceptibility to infection due to the compromised system. Read more about what is an Organic Impairment HERE


It is clear that no patient or their lymphedema is the same and neither is its progress. Some patients with lymphedema have few symptoms, and can easily do different degrees of physical activity, while others feel the strain, experience increased swelling with minimum effort, or even suffer varying degrees of disability and severe complications. Read more about lymphedema and Infectious Cellulitis HERE.


In recent years, some lymphedema guidelines and protocols have been developed to support health policy guidelines, that focus on the implementation of low-budget health management for the treatment of lymphoedema. To achieve this goal, a new treatment concept called “Decongestive Lymphatic Therapy (DLT)” was developed to principally limit or exclude Manual Lymphatic Drainage (MLD) conducted by therapists at the specialist level.



In many countries lymphedema care services are scarce, and various strategies are being used to justify and implement low-cost alternative treatments, including downplaying conservative treatment (CDT) or undermining the importance of Manual Lymphatic Drainage (MLD). The resulting management approach emphasizes the provision of treatment with MLD only for "Very Severe" lymphedema (elephantiasis Stage) and complex cases, thus excluding intervention for patients with mild, moderate, and severe lymphedema. 


Even though the termsComplete Decongestive Physiotherapy" (CDT) and “Decongestive Lymphatic Therapy" (DLT) are used synonymously in some medical literature, they are not equivalent and don't represent the same treatment management focus. Read more about the main differences between “CDT” and “DLTHERE.



Paradoxically, some treatment guidelines while stating that Manual Lymphatic Drainage (MLD) should only be conducted by therapists at the specialist level, simultaneously detract from MLD and recommend as a good and valid alternative, self-management options for the intensive volume reduction phase, even though this has little scientific evidence.

 

Concerning the objective of discrediting Manual Lymphatic Drainage (MLD), there are confusing research studies that focus on demonstrating its unnecessary inclusion as an essential component of treatment, basing the reports only on the treatment results in terms of volumetric reduction measures, but not taking into account the key important functions of MLD. Read more about the principal functions of Manual Lymphatic Drainage HERE.



These studies and trials do not mention the possible serious and irreversible side effects that may arise in the short or long term, if Manual Lymphatic Drainage (MLD) is not included during the application of compression therapy in the process of reducing the volume of the oedematous limb, such as the possibility of lymph displacement to previously unaffected areas. 


Many lymphedema-related healthcare management studies are only cost-saving non-investment strategy toolsIt should be borne in mind that the annual health expenditure for the treatment and maintenance of lymphedema adds far less in comparison to the cost of treatment for many chronic diseases, and even so, many national health systems do not treat or are undertreating lymphedema. 


Early detection and preventive treatment (Preventive Medicine) can reduce overall costs by keeping affected limbs at minimal volumes and other co-morbidities and complications before they become chronic.

 



Basic and important concepts regarding the treatment of lymphedema:

  • Manual Lymphatic Drainage (MLD) is part of the conservative treatment known as Complex Decongestive Therapy (CDT). The five components of the Initial Phase I are skin care, manual lymphatic drainage (MLD), multilayer compression bandaging, decongestive exercises, and patient education.

  • It must be taken into account that the isolated application of individual components is not recommended and, that treatment without Manual Lymphatic Drainage (MLD) does not represent Complex Decongestive Therapy (CDT).

  • There is a big difference between the terms "Complex Decongestive Physiotherapy" (CDT) and "Decongestive Lymphatic Therapy" (DLT).

  • The term "Compression Therapy is used to describe the compression part of therapy, whether it is bandaging or a custom-fitted garment. Edema volume reduction is principally achieved by compression, and wrapping with a low-stretch bandage is the major component of the intensive volume reduction phase. 

  • The volume reduction produced by compression is mainly due to a reduction in the water content of the tissues, with a proportionally lower elimination of proteins. Isolated application of compression is not recommended because of the risk of draining líquid and not proteins, reducing volume but increasing the concentration of proteins with the consequent risk of generating Fibrosis.


  • Isolated compression therapy of the extremities, particularly in those with lymphedema also affecting the quadrants of the trunk, may increase swelling at the root of the extremity and may even lead to Genital Lymphedema.

  • Manual Lymphatic Drainage (MLD) should always be applied before the compression phase and is not intended to be a stand-alone treatment option. MLD as a stand-alone treatment is used when treating body parts that are not conducive to sustained compression (e.g., face, breast, genitalia, and trunk).

  • The main functions of Manual Lymphatic Drainage (MLD) are aimed at lymph vessel and lymph node drainage; rerouting of lymph into nonobstructed lymphatics; development of accessory lymph collectors; improvement of lymphatic contractility; and prevention of the displacement of lymph fluid to adjunct areas when lymphatic edema is submitted to compression therapy (bandages/compression pumps) for volumetric reduction. It must be kept in mind that the primary role of MLD is "NOT" for volumetric reduction.

  • Preventive Medicine indicates lymphedema treatment in the early stages of the disease, but even in lymphedema stages II and III, adequate treatment with Complete Decongestive Therapy (CDT) is successful in the majority of cases, without having to resort to aggressive surgeries.




IMPORTANT NOTICE 

Lymphedema is a serious chronic and progressive disease due to lymphatic dysfunction (Organic Lymphatic Vascular Disease). The clinical treatment of lymphedema is neither a cosmetic nor an aesthetic treatment. The treatment of lymphedema is to control its progression and alleviate the symptoms related to dysfunction of the lymphatic circulatory system. 

To prevent and avoid serious complications associated with treatment, such as the possible displacement of edema to previously unaffected areas when compression therapy is applied for volume reduction, patients should use highly specialized and experienced therapists. 

Professional qualification and instruction delivered remotely online are not the same as live hands-on practical instruction in the clinical training and certification of lymphedema therapists, similar to all other rehabilitation, medical, and surgical training programs, and especially for developing the necessary manual skills to treat a disease as complex as lymphedema. 

Patients should also take special care when choosing a Multidisciplinary Expert Center of Reference for Lymphedema, as not all countries and centers provide the same treatment options. The best choice is a center of reference that provides Complete Decongestive Therapy (CDT), which is recognized as the “Gold Standard” treatment for lymphedema.

  • Read more about what is the best treatment option for Lymphedema HERE.
  • Read about what are the main differences between the two principal lymphedema treatment protocols HERE. 

REFERENCES

(Click on the texts to read the research articles)

SCIENTIFIC SOCIETIES

PATHOPHYSIOLOGY

CUTANEOUS COMPLICATIONS
INFECTIOUS COMPLICATIONS
CELLULITIS / DERMATOLYMPHANGIOADENITIS
TUMOURS

TREATMENT

COMPRESSION GARMENTS

DISABILITY

DISFIGUREMENT

PSYCHOSOCIAL IMPACT

PEDIATRIC LYMPHEDEMA

LYMPHATIC FILARIASIS / PODOCONIOSIS




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