Hi Dr Khoury,
Thank you for your message and for sharing this case. Others might have more insights, but here are some thoughts - would there be some other way that he can receive complex decongestive therapy (CDT)? According to guidelines, for all cases, regardless of severity grades, conservative management is initially recommended, and CDT is the mainstay of conservative management. An initial trial of conservative therapy is also required for coverage of certain adjunctive interventions (e.g. Intermittent sequential pneumatic compression). Also, regarding the compression therapy currently in use, was it originally initiated by a lymphedema therapist? For effective lymphedema management, ideally the device should be selected by a lymphedema therapist so as to meet the specific needs of the patient. As for non-adherence, it's frequently described among lymphedema patients. Best practices suggest referral to a specialist (mental health services) if no improvement is seen after 3 months of initiation of standard of care. While surgical management is indicated in specific cases, upon talking about indications with Dr Alex Wong, it seems like primary lymphedema and morbid obesity might pose a barrier to the patient's surgical candidacy. I also asked if he knew of any lymphedema therapy services in your area, and he shared this phone number 800-826-4673 for OT/lymphedema therapy at COH.
Below is a summary of main points relevant to this question, from WoundReference's topic Lymphedema - Treatment and Emerging Strategies for Prevention (
https://woundreference.com/app/topic?id=lymphedema-treatment-and-emerging-strategies-for-prevention#conservative-management-by-lymphedema-stage)Conservative lymphedema management consists of:
* Physical therapy: For moderate/severe limb lymphedema, the standard of care for management is complex decongestive therapy (CDT), a two-stage treatment program applied by lymphedema specialists. Intensive CDT is used during the initial treatment phase and is composed of compression therapy, manual lymphatic drainage (MLD), exercise and skin/nail care. Maintenance CDT is initiated after the patient’s response to intensive CDT has plateaued and includes use of low-stretch compression garments, continued exercise, self-skin/nail care and self-MLD, as needed.
> Regarding compression therapy with lymphedema compression bandages: it's important to note that the type of compression device should be selected by a lymphedema specialist and can include inelastic bandages, multicomponent bandage systems garments or adjustable compression wraps.
> For patients unable to commit to the standard intensive phase of complex decongestive therapy (e.g. due to poor mobility), or for patients who cannot receive high levels of compression, or who have skin ulceration, expert committees suggest that the intensive phase of the complex decongestive therapy be modified according to the patient's needs and conditions.
>> Modified intensive therapy with high pressure: for patients who are able to tolerate high levels of compression, but are unable to commit to standard intensive therapy for physical, social, psychological or economic reasons. Consists in less frequent changes of lymphedema compression bandaging (e.g., 3 times a week as opposed to daily), skin/nail care, exercise, lymphatic drainage.
>> Modified intensive therapy with reduced lymphedema compression bandaging pressure: for patients who cannot tolerate or receive high levels of compression (e.g, due to associated moderate peripheral arterial disease [ankle-brachial index between 0.5 and 0.8] or lipedema). Consists in lymphedema compression bandaging changed daily to 3 times a week, skin/nail care, exercise, lymphatic drainage, with or without intermittent sequential pneumatic compression.
>> For patients with limb ulcers, lymphedema compression bandaging may need to be modified. Intermittent sequential pneumatic compression is usually helpful as an adjunct to complex decongestive therapy.
>>> Intermittent sequential pneumatic compression: Of note, Medicare does not cover pneumatic compression devices (i.e. IPCs) as initial therapy for lymphedema in the home setting. A patient must first undergo a 4-week trial of conservative therapy, which includes the use of an appropriate compression garment, exercise and elevation.
* Address Patient's Concerns: Psychosocial issues (e.g, depression, poor adherence to treatment) and pain are common and need to be properly addressed. Poor adherence is common among patients with lymphedema. It is important to understand the reason for poor adherence and attempt to address reasons behind it. Referral to a specialist (mental health services) is warranted if no improvement has happened in 3 months. If needed and feasible, treatment should be modified to accommodate patient's preference. Depression should be ruled out
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