Incorporating Specialized Lymphedema Therapy & the Wound Clinic

WATCH: Author Suzie Ehmann, DPT, CWS, CLT-LANA, discusses the article. 

Experienced wound care clinicians know the management of edema is crucial to healing. However, there is a penchant to treat wounds and edema separately among providers in this industry. As a physical therapist (PT) who holds dual certification in lymphedema management and as a wound care specialist, this author believes in the benefits of treating both simultaneously. However, this mindset is not shared by all wound care specialists, many of whom are not hesitant to admit such. Many colleagues have claimed they “don’t treat lymphedema” or that they “heal wounds and then refer patients to a specialist to manage the swelling.”This perceived need for the division of care is further intensified by those lymphedema therapists who refuse to care for patients living with chronic wounds. Both of these dogmas, however, are a result of the tunnel-vision approach to patient care that still persists — one in which too many providers focus on treating the hole in the skin rather than the whole patient. However, with changes in reimbursement, limitation in coverage amounts, and a significantly greater focus on outcomes (ie, pay for performance) in today’s overall healthcare climate, there is a crucial need for a more dedicated multidisciplinary approach to wound care to ensure successful outcomes as well as economical delivery of care for these patients and the medical facilities providing their care. That said, the ideal wound care team should include physicians, nurses, and edema-management specialists (certified lymphedema therapists [CLTs]) who work collaboratively to meet all needs of the patient in one setting.

This article will discuss the impact of lymphedema and the lymphatic system on wounds and healing as well as the roles that those clinicians who specialize in lymphedema care can bring to the wound clinic setting.

Lymphatic System’s Impact on Wounds

Theroot of this perceived need for separation of specialty services is based on a lack of appreciation of the role the lymphatic system plays in all forms of edema. A quick physiology primer reveals that the lymphatic system, a subset of the circulatory system, is intimately connected to both the circulatory and immune systems. Beyond its immune functions, an intact, functioning lymphatic system is necessary to maintain the proper balance of bodily fluids between the circulatory system and the interstitium. Without argument, wound care specialists alike agree that impairment of the lymphatic system leads to lymphedema. However, in the wound care forum this clinical diagnosis is characteristically reserved for only large, grossly misshapen limbs. As such, if a large, misshapen leg also has a chronic wound, the wound is related to the lymphatic impairment. However, these patients, who may present with only a negligible amount of swelling or, perhaps, only periwound edema or trophic changes in the limb, are not typically thought of as having an “impairment” within the lymphatic system. This example demonstrates the need for bringing a better understanding of the lymphatic system and an incorporation of lymphatic treatment principles into the wound care arena in order to treat both the wound and the edema simultaneously. 

An intact, functioning lymphatic system is imperative for fluid homeostasis (no edema) as well as for appropriate healing response. Edema — although a normal part of wound healing initially — if prolonged could interfere with the healing process. The presence of edema can impair blood flow; decrease delivery or removal of key nutrients (ie, O2 and CO2) due to impaired diffusion; cause increased bacterial colonization due to accumulation of interstitial fluid; and trap growth factors as well as other key peptides and matrix proteins, which further delays healing. Infection and the inflammatory response that follow can further impair the lymphatic system by provoking a cyclical process of chronic swelling and stagnant proteins, leading to further tissue fibrosis and further decline of the lymphatic function. Although this theorized effect of prolonged edema/lymphatic impairment/lymphostasis/lymphedema on delayed healing of a wound appears plausible, currently there are no scientific studies to support direct correlations.  An exception to this can be found in the study of wounds and chronic venous insufficiency (CVI), which is associated with venous hypertension (HTN). Venous HTN creates a high-filtration pressure, causing increased fluid to appear in tissues. This additional tissue increases the lymphatic load. Initially this is a low-protein edema (dynamic insufficiency/orthostatic edema/dependent edema/venous edema). However, when this is not addressed, protein permeability increases, lymphatic vessels become dysfunctional due to prolonged lymphatic hypertension, and tissue fibrosis occurs. Continuous increase in protein and its degradation leads to chronic inflammation, which bears an additional negative impact on the lymphatic system and all its functions.

Consequences of CVI

The damage to the lymphatic vessels in the presence of CVI has been well documented. Via fluorescence microlymphography, it has been observed that lymphatic capillary networks are partially or almost completely obliterated among those living with severe CVI with trophic changes.¹ Furthermore, examination of active venous ulcers have revealed that lymphatic vessels were absent from the superficial and intermediate layer. Even upon healing, which occurs largely by scarring, the adjacent lymph vessels remain significantly damaged.²

As a result of the aforementioned lymphatic impairments found to be associated with CVI and venous ulcers, it was suggested by the author that components of complete decongestive therapy including manual lymph drainage and compression with reduced stagnation of lymph, venous blood, and interstitial fluid should have predictably beneficial effects. This brings us back to the role of edema management and the need for edema-management specialists to play key roles in the management of chronic, nonhealing wounds, particularly those related to CVI. Although any wound with signs of edema (even periwound swelling - pitting edema periwound) can benefit from appropriate compression to improve the microcirculation in/around the wound.

Role of CLTs

The care and treatment of lymphatic and venous impairments are specific enough that the need for CLTs (ie, those clinicians specializing in chronic edema management and impairments) has become increasingly relevant. In most cases, the role of the CLT is taken by an allied health professional such as a PT or occupational therapist who has completed comprehensive training focused on the anatomy and physiology of the lymphatic system, as well as extensive training on compression modalities including bandaging and garments for long-term edema management.

The treatment for lymphedema, traditionally known as complete decongestive therapy (CDT), involves skin care as well as manual lymph drainage (massage to help stimulate lymphatic system), compression (primarily with use of short-stretch bandages layered over foam, but can also include use of intermittent pneumatic compression pump), and exercise. An average treatment session will run approximately 45-60 minutes and consist of an individualized treatment program featuring the necessary components of CDT as outlined above. An example of an average treatment includes: 1) Cleansing and moisturizing of skin, cleansing of wound, and application of primary wound dressing, as necessary. 2) Administration of manual lymphatic drainage, as necessary. 3) This is followed by fabrication and application of multicomponent lymphedema wrap. This wrap traditionally consists of short-stretch gauze, such as bandage to wrap the toes. Next, a stockinette is applied over the limb followed by an orthopedic-type wool to secure open cell foam shapes at the foot and ankle. The remaining leg is then cushioned by either rolled-open cell foam or thicker foam bivalve shapes cut to cover the limb. The foam has many purposes, including even distribution of pressure of the compression across the limb to provide structure to the bandage and minimizing slippage. This also increases the static stiffness index of the bandage system, thereby maximizing both venous and lymphatic benefit. 4) The final component of CDT is having the patient participate in some form of home-exercise program.

The benefits of the inclusion of a CLT within the wound care team include: 1) All patient needs being met simultaneously, which means more economical and efficient delivery of care for both the patient and the clinicians. 2) Patients are not spending hours in the wound clinic for weeks/months healing the wound only to be referred to the CLT to spend additional time to manage swelling. 3) Patients appreciate that multiple healthcare issues are being addressed (with increased satisfaction with provided services). 4) Wound care clinicians are not spending time applying compression treatments that are not effectively managing the swelling, which frees them up to see/manage other patient care needs. 5) Better edema management leads to optimal wound outcomes. 6) Maximized flow of successful patient care through the wound clinic.

Divide & Conquer

An example of this evolving beneficial relationship exists currently between this author’s local wound clinic and an edema management program housed on a community hospital campus. Patients referred by the wound clinic typically fall into one of four categories: 1) Those who present with edema that is not managed by compression modalities available in the wound clinic. Stereotypically speaking, these patients also tend to present with morbid obesity and somewhat unusually shaped limbs or unusual tissue texture (see Figures 1A and 1B). 

This would also include those patients whose edema is not sufficiently controlled by the standard compression wrap — those whose limbs “swell through” bandage systems typically utilized in the wound care setting. This uncontrolled swelling within the compression bandage can in itself be the source of new wounds unrelated to the original presenting wound. Finally, there are those patients who present with swelling in adjacent/proximal quadrants (ie, patients living with a venous leg ulcer as well as thigh swelling). 2) Those whose underlying diagnosis would benefit from compression, but the patient is unable to tolerate compression modalities offered by the wound clinic. Often, the patient may present with mixed disease that would preclude a traditional compression wrap or the patient cannot tolerate high-compression products typically utilized in the wound care setting. 3) Those who require dressing changes that are of greater frequency than can be accommodated in the wound clinic. A typical patient schedule for the wound clinic is once or twice per week. Daily dressing changes are not the typical plan of care. If daily dressing changes are needed, they are typically deferred to home care. However, if there is an additional need for compression these daily dressings tend to not be a plausible treatment regime, even for home care. 4) Those who are referred because of failure to heal despite conventional treatment who also have some component of swelling or who have very focal swelling (ie, foot wound related to trauma with chronic swelling).

Beyond the ability to address the needs of these patients, the inclusion of a CLT among the wound care staff affords other opportunities for care management. Therapy visits are structured and billed through the patient’s rehabilitative service coverage. The format of these treatment sessions is dictated by patients’ needs. As the therapist is the sole provider of care, the patient can be in/out of the office in under an hour’s time. In this therapeutic model, all treatment procedures provided lead to billable Current Procedural Terminology (CPT®) codes as outlined in Table 1.  The therapist also has access to other treatment tools such as parallel bars to work on balance and gait and assistive devices to practice safe functional mobility (transfers and gait) in the clinic. Each of these modalities affords the therapist an opportunity to work on multiple goals to maximize wound and edema management as well as functional mobility and safety. Getting the patient to be safely mobile in the community is a great asset to the patient emotionally as well as for enhancing long-term quality of life. The lymphedema therapist has not only knowledge/skill with a variety of compression products, but also has access to other compression products that may not be formulary for the wound clinic. In particular, lymphedema therapists have been trained in application of multicomponent bandages utilizing different density foams in their compression bandage. The purpose of this foam is to help distribute the force of the bandage around the limb and address the trophic changes (fibrosis, lipodermatosclerosis). 

Additionally, the padding affords better containment for those patients experiencing brawny edema or those with unusually shaped limbs. Finally, the layered bandages utilized by lymphedema therapists are short-stretch compression products. The layering allows for the increased working pressure, however, with the lower resting pressure that is tolerated by those with lower ankle-brachial index scores.

Finally, the lymphatic professional has extensive knowledge of compression products to manage the edema long-term, including both over-the-counter circular knit stockings, custom flat-knit or seamed stockings, Velcro straps on compression devices, compression products for nightly use, and pneumatic compression pumps. With the abundant compression products available on the market it can be a challenge, even for the seasoned wound care clinician, to choose the correct product.

The lymphedema therapist has had extensive training in product selection, use/care, and don/doff of the item. The structure of the lymphedema therapy session allows the opportunity for the therapist to spend time with patients to ensure they get the prescribed compression garment on/off. Availability of adaptive equipment to help facilitate this would seem to enhance compliance outside the clinic. Circulation, arterial, venous, and lymphatic concerns are essential to edema management and wound healing. Involvement of lymphatic therapists is essential to provide the full spectrum of care and to optimize outcomes. Collaboration of each specialist simultaneously will optimize these results.

Coverage Policy Info

Therapy is covered by Medicare and compression products are covered if an open wound is present. If no open wound exists or if the wound has healed, Medicare will not cover compression wraps or compression garments. Currently, commercial insurers as well as government-funded insurance plans have coverage for rehabilitative services, thus they cover lymphedema services when they are billed as such. Furthermore, by working with a knowledgeable durable medical equipment provider, obtaining coverage for the compression products utilized (short-stretch bandages and foam that make up the multicomponent lymphedema bandage) when used as a retentive dressing in the setting of a wound is a covered item. If anything, this is another reason that patients living with edema and chronic wounds should be treated simultaneously, since once the wound heals the coverage for the compression product(s) is lost. With regards to compression garments that are necessary to maintain the results of treatment, it is this author’s experience that most commercial insurances and Medicaid offer some coverage for compression garments (this varies region to region). An exception to this is Medicare and “open wounds.” Currently, Medicare does cover compression garments (stocking or Velcro wraps) when there is an open wound, if the device has been approved for the use of Healthcare Common Procedure Coding System code A6545. This code is part of the local coverage determination for surgical dressing. It is covered by Medicare Part B when used for the treatment of an open venous ulcer. However, once the wound heals, Medicare does not cover the medically necessary, physician-prescribed compression supplies used daily in lymphedema treatment. As of the writing of this article, there is a bill being reviewed in the US House of Representatives (Lymphedema Treatment Act) that, if passed, could improve coverage for the treatment of lymphedema from any cause by amending Medicare statutes to allow for coverage of compression supplies.

Suzie Ehmann is coordinator of the edema management program at Stanly Regional Medical Center, Carolinas HealthCare System, Albemarle, NC.

References

1. Eliska O, Eliskova M. Morphology of lymphatics in human crural ulcers with lipodermatosclerosis. Lymphology. 2001;34:111-123.

2. Bollinger A, Isenring G, et al. Lymphatic microangiopathy: A complication of severe chronic venous incompetence (CVI). Lymphphology.1982;15:60-65.