“Patients must be put in a position to help themselves”

Dermatologist and phlebologist Dr. med. Anya Miller is committed to her patients even outside of her Berlin office. The president of the German Society for Lymphology (DGL) has contributed significantly to the development of numerous AWMF1 guidelines, as well as the S2k guideline2 “Diagnosis and treatment of lymphedema”. Whether in theory or in practice, her focus is on quality of life for patients.

Bauerfeind life: Together with your colleagues, you updated the 2017 guideline this summer. What were the most important changes?

Dr. Miller: Above all , we radically expanded the complex decongestive physical therapy (CPDT) by placing far more focus on the patient. In my view, the instructions for self-management are a central element of overall treatment. Edema always means restricted quality of life. As physicians, physiotherapists and medical supply retailers, it is our job to train patients and share our own knowledge, enabling patients to help themselves far more than they could in
the past.

Manual lymph drainage, compression therapy, movement , skin care and self-management: how important is the interplay between the five pillars of CPDT?

Dr. Miller: Studies have shown that CPDT is only really successful if we apply all the pillars together. That means: if edema patients are only given lymph drainage and then walk out of the office without any compression, then, in nearly all cases, they might as well not have bothered. Compression is the most important basic therapy for the treatment of edemas. And of course, patients also need to learn that they should get moving. Skin care is very important , and last but not least self-management. After all , patients don’t have a physician or therapist with them most of the time. So why shouldn’t they learn to apply breathing techniques or specific techniques to stimulate lymph drainage themselves? With self-management , we are giving patients back their freedom by teaching them to help themselves. This makes them more cooperative on the long term, reducing late complications and ultimately improving their quality of life.

You said that compression is the most crucial basic therapy. What do you see as particularly important in this regard?

Dr. Miller: Compression therapy needs to be adapted on a highly individual basis. During care, good collaboration is required between the physician, the physiotherapist and the medical supply retailer. Physiotherapists, who have more frequent direct contact with the patient , are often able to sense better than physicians how far the edema has spread and how deep it goes. Ideally, the physiotherapist should share this knowledge with the medical supply retailer doing the measurements. In addition, it is important to incorporate the patient’s everyday routine into care. Where are there restrictions or sensitivities? For older women who might need to get to the toilet very quickly, are pantyhose really necessary? And might a lower leg stocking that will actually be worn sometimes prove more helpful than thigh-high stockings that will be left in the closet? The provider and the supplier need to have sensitivity here.

Do you receive feedback about patients from the therapists?

Dr. Miller: I require it! Every patient I send to receive lymph drainage should come back with a report. After all , information such as “Patient can’t manage to put on the stockings” or “Patient does not wear the stockings” is very important to me. Then I can think about whether to send over a care service or whether another explanatory meeting is needed.

Where do you see opportunities for further improving lymph therapy in everyday life?

Dr. Miller: That starts with us as physicians: all physicians should be familiar with the condition of lymphedema, how to prescribe lymph drainage, the current prescription guidelines. I hear the same thing all the time: “I can’t do that , there’s no room in my budget”. But that’s not true – starting from Stage II and for hereditary lymphedema, long-term therapeutic measures can be prescribed without affecting the overall budget for prescriptions, so there is no risk of the costs being reclaimed by the insurance company. When it comes to physiotherapists, intensive treatment should only be provided by therapists who are properly qualified and who undergo further training regularly. And physiotherapists should check whether the stockings fit and whether the patient is wearing them. They spend the most time with the patient. When it comes to the medical supply retailers, I wish that a follow-up appointment were scheduled 14 days after every stocking delivery to check whether the stockings fit. Providing information and asking follow-up questions is really crucial. This applies to all individuals involved in the treatment process. These considerations take a great deal of effort initially, but they pay off in the long run for everyone – above all for the patients. 

1 The Arbeitsgemeinschaft der Wissenschaftlichen Medi­zinischen Fachgesellschaften e.V. is the German umbrella organization for 184 professional medical societies.
2 S2k Guideline: guideline for which a formal consensus was reached.

Images: Thomas Lebie