“Success requires a team effort”

Successful lymphedema treatment requires time, a daily routine, patient adherence – and each expert looking beyond his or her own specialist field. A physician and a therapist talk about their experiences and wishes.      

“Anyone can be affected by lymphedema, and then you’re stuck with it for life,” says Dr. Hans-Walter Fiedler, specialist physician at the center for vascular medicine in the Soest area. Treating lymphedema patients is one of his daily tasks, which keeps this vascular surgeon very busy. After all, the number of those affected increases more quickly than the number of qualified and interested physicians and specialized lymphology therapists, he explains. Furthermore, in his experience, patients do not always take their problems seriously, and many physicians are neither sufficiently skilled in the diagnosis of lymphedema nor in the implementation of the required compression treatment. Dr. Fiedler understands the latter because the various documentation requirements are extensive and highly specific, meaning family physicians who are not familiar with the regulations should refer their patients to a vascular specialist, if in doubt, to prevent potential recourse claims. “Apart from that, incorrectly prescribed compression products can also cause damage,” he explains. 

“Anyone can be affected by lymphedema,
and then you’re stuck with it for life.”

Dr. Hans-Walter Fiedler is a Specialist in Vascular Surgery at the treatment center for vascular medicine in Werl in the Soest area and a lecturer at the Federal Technical College for Orthopedic Technology (BUFA) in Dortmund.

Not least, Dr. Fiedler also bemoans a lack of hospitals for inpatient decongestion measures in North Rhine-Westphalia. This is the region where he and two other physicians work at a center for vascular medicine that is part of Hellweg Catholic Hospital Group in Werl, a historical pilgrimage town, as well as in the district town of Soest.

The correct diagnosis requires time, which is not only a scarce commodity during the everyday clinical routine, but it is also not sufficiently remunerated in lymphology. “In stage 1 lymphedema, the physician cannot be entirely sure yet that the swelling is clinically associated with chronic congestion syndrome because it looks just like many other edemas with different causes,” explains Dr. Fiedler. For a definitive diagnosis of stage 2 lymphedema, the healthcare professional could, for example, palpate the patient for increased connective tissue in the subcutaneous adipose layer and check skin folds for the Stemmer’s sign. “Plus, every physician should look beyond his or her own particular field,” the specialist adds. “An accurate medical history is also part of the process. Could there be cardiac or renal insufficiency? What medication does the patient take?” Once lymphedema has been diagnosed, the decongestion phase is first step. All five elements of complex decongestive therapy (CDT), comprising manual lymphatic drainage, compression, skin care, exercise and self-management, are each incredibly important, and they are mutually dependent. Lymphatic drainage without subsequent compression, for example, only has a temporary effect; insufficient skin care can cause dry skin and even complications, such as erysipelas; moreover, it is essential that patients undergoing compression therapy get active, take care of self-management and possibly also lose excess weight. 

Obesity: increasingly the leading cause of lymphedema

Being reminded of self-management is an important aspect Dr. Fiedler shares with his patients: “Compression and activity need to go hand in hand. Otherwise, it’s pure ‘thrombosis prevention’. No matter what they do – going for a walk, even with the walker, swimming, water aerobics – people have to work on themselves.” In the majority of cases, this also includes weight loss. He reports that, obesity is now the leading cause of lymphedema in his practice. Contrary to hereditary or post-operative edema, for example, this type of lymphedema tends to progress quickly and manifest on both sides. “Weight reduction is the only way to ensure a positive outlook with CDT in cases of lymphedema,” says Dr. Fiedler. Without weight loss, obesity-induced lymphedema will rapidly progress from stage 1 to 2 and 3. “These patients will deteriorate very quickly,” the physician explains, and also refers to the “significant mental health component.” Usually, patients visit his practice for the first time in stage 2 or 3, which is rather late for this condition. Ideally, these and many other chronically congested patients should undergo decongestive treatment quickly in an inpatient setting – which is rarely possible because of the lack of local acute care hospitals. Although lymphedema cannot be cured, an early diagnosis can be highly beneficial to at least maintain the stage or, in the best case scenario, reduce it from stage 2 to 1. The goal of the treatment is, however, to return to Stage 0 (latency stage), i.e. “non-visible” edema with persisting lymphological damage.

“Working with people is my passion.”

Anne-Christin Mönch

Once the extremities have been decongested with CDT, daily medical compression and outpatient MLD with an appropriate frequency will be a part of the patient’s life for ever more to maintain or optimize the decongested state. To achieve this, the medical treatment center in the Soest area works closely with trusted family physicians, physical therapists and medical supply retailers. “The distances are short, and we ensure open communication,” Dr. Fiedler is pleased to report. He would actually prefer medical retail specialists, who all have to visit recertification courses every two years, to have more freedom when making decisions. They already get back in touch when they suspect that adjustments to the prescription of compression stockings could be beneficial, they give feedback and helpful recommendations, and they refer patients to quickly get a qualified second opinion from Dr. Fiedler to ensure the vascular specialist can approve the indication and fit. “Of course, the physician has to note the diagnosis as well as the length and compression class of the compression stockings on the prescription, but medical supply retailers are often more familiar with other details, ranging from taking measurements to the type of stocking fabric,” he explains. Checking the fit, however, is the physician’s responsibility. Dr. Fiedler’s tip to all those involved: “get a definitive diagnosis, note down details, take pictures and measure the progression as well as any changes, and record everything in an IT system.” The only reason the vascular expert knows many prescription details himself is because he has been teaching phlebology and lymphology at the Federal Technical College for Orthopedic Technology (BUFA) in Dortmund for more than 25 years.

Passionate about lymph therapy 

A qualified and patient-oriented team is also waiting for visitors to Erfurt Lymph Center, a practice specializing in physiotherapy and lymphology. It is very busy in the bright, inviting reception area, while targeted therapy is the focus in the treatment rooms. “When we set up our business in 2020, the idea of a practice specializing in lymphology was unique in Thuringia,” proudly reports Anne-Christin Mönch, Managing Director. The trained physical therapist as well as lymphology and edema therapist really had to put in all her persuasive efforts to get it approved. “After all, it’s so important for practices to specialize to ensure expert and efficient services can be offered!”

Anne-Christin Mönch’s passion for her work is very noticeable. “Working with people is fulfilling, it’s my passion,” she gushes. Listening and talking, holding someone’s hand to encourage them, laughing together – yes, but: “If people don’t wear their compression products regularly, there’s no point in whining when they visit me. I have to be quite strict sometimes,” Anne-Christin Mönch explains. “Edema therapy is like a relationship. Success requires a team effort.” If patients are unhappy, the therapist recommends talking to the physician whether the compression classes could be combined – for example, a panty area in Ccl 1 and with Ccl 2 up to the thigh. 

As a managing director, she is busy developing the lymph center, and although this leaves her less time by the therapy table during everyday business, she still likes to treat patients herself as much as she can and even offers lymphological yoga in her gym. If patients cannot participate personally in the class, they have the option to do the exercises by themselves using the movement challenges in the curaflow app, which Anne-Christin Mönch helped develop. During exercise, too, the therapist recommends wearing compression stockings, being the best example herself: “I even swim in compression products. Combined with the water pressure, it’s ideal!” Because there is such a demand for lymphological therapy, she is constantly looking for additional qualified staff who share her passion and views on edema treatment. For employees to keep up-to-date, further education at Erfurt Lymphology Center is very important. Apart from that, she appreciates precision and hands-on experience: “Applying the techniques correctly is indispensable for the quality of lymphatic drainage. Palpating tissue is something you have to practice.” But before therapists can perform stationary circles, thumb circles, the scoop technique, pump technique and rotary technique on a patient, they have to ensure that there are no contraindications, such as recent radiotherapy, surgery or even renal failure. Just like Dr. Fiedler from the medical treatment center in Werl, Anne-Christin Mönch attaches great importance to a comprehensive conversation with patients where everything has to come to light, with nothing off-limits – and to trusting, transparent cooperation with physicians, including dermatologists, and medical supply retailers. Everyone is working together to ensure the best possible treatment. Among the cooperation partners, there is also a nutritionist who provides edema patients with tips on how to maintain a healthy diet.

Edema logbook for increased transparency 

A flying visit to treatment room 3, where Mathias S. is lying down. Since fall 2021, he has been receiving lymphatic drainage twice a week after his legs continued to swell. Today, his lymphatic drainage is being performed by Martin Neugebauer, lymphology and edema therapist. He also knows his colleague. It is part of the practice’s philosophy that therapists take turns so that everyone can get to know the different types of edema, allowing them to share their experiences and develop improvement options in the team meeting. Mathias S. has severely abnormal tissue, which is why Anne-Christin Mönch recommends occasional effleurage: “Moving from bottom up to guide the interstitial fluid with its molecular constituents in the proper drainage direction.”

“Edema therapy is like a relationship.
Success requires a team effort.”

Anne-Christin Mönch

Starting at the neck via the stomach and inguinal lymph nodes to the legs and slowly down to the feet – during treatment, interstitial fluid can already start to move, which Matthias S. is feeling as a tingling sensation. “We can then feel that the tissue is getting softer,” the therapist explains. And the patient? “It really is very noticeable after the lymphatic drainage,” Mathias S. confirms. 

Following the lymphatic drainage session, a compression bandage is generally applied, which is another one of Mönch’s favorite subjects. She thinks: “Wrapping must be perfect!” That is why the team likes to use the time in between sessions or in case of cancellations to practice the perfect wrapping technique. Employees from medical supply retail stores frequently come to measure patients for “needs-based, useful stockings”, as Anne-Christin Mönch says: “I can really rely on their work.” Right at the beginning, patients visiting the lymphology center receive an edema logbook the center developed to document treatment progress as well as all data and protocols related to diagnosis and prescription, compression, physiotherapy, nutritional counseling and everything else that is important. The handy leaflet offers a transparent and reliable source of reference, it can save both time and duplicate treatment, and it can be compared with the maternity record pregnant women receive in Germany, as the Managing Director explains, who herself has two children. With the help of the oedema logbook, all those involved in the treatment process receive important information about the respective therapy. Patients of the lymphology center also benefit from a network of physicians that enables short distances and close cooperation. In particular when something has to happen quickly. For example, when a patient had wounds across her entire forefoot and lower leg. Anne-Christin Mönch immediately got in touch with one of her contacts and referred her to a wound care expert. Lymphology treatment started four days later, and within two weeks, the wound was covered with fresh fibrin and the healing process was well under way. 

One thing is certain: “Without lymphological treatment, chronic wounds won’t heal in the long term,” Dr. Hans-Walter Fiedler summarizes as well. Nevertheless, there is not much research in this area. Everyday work with patients shows that manual lymphatic drainage works. “But in addition to the positive effects on depression, there isn’t enough scientific, evidence-based data about the effectiveness of decongestion. This could really be improved. For the benefit of patients, too.”

What needs to be included on the prescription 

In order to prevent questions and unnecessary effort during checks, the prescription for medical compression therapy products must include the following information in Germany:

• Marking Item 7 for medical aid
• The exact diagnosis as well as possible secondary diagnoses, such as obesity
• Medical aid number/product name
• Compression class (Ccl), length and/or style of the stocking
• Number of stockings (unit/pair)
• Specifications for a custom-made solution (flat knit product)
• dditional prescription sheet (supplement) with all medically required additional features (slanted edgings,
• fastenings, silicone top band sections, pads, etc.), including a brief specification of the medical reasons
• For a repeat prescription or a prescription of multiple products: brief justification stating the circumstances

Images: Steffi Behrmann, shutterstock.com/tnkorn yangaun, Frank Steinhorst