Section: CME Category: Wound Care

Edema Evolution

Pamela Scarborough, PT, DPT, MS, CWS

Pamela Scarborough, PT, DPT, MS, CWS discusses basic principles of the identifying of fluid overload conditions in the lower extremities and how to adequately adDress the issue to prevent wound development.

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Goals and Objectives
  1. List challenges for recognition and treatment of chronic fluid overload in the lower extremity leading to chronic wounds.
  2. Describe the current state of education for health care disciplines related to the edemas that affect the lower extremity causing chronic wounds.
  3. List suggestions for improving education for health care providers related to the various conditions that contribute to lower extremity edemas and subsequent chronic wounds.
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    Pamela Scarborough Pamela Scarborough has nothing to disclose

  • Lecture Transcript
  • TAPE STARTS – [00:00]

    Scarborough: Will tell you a little bit about Dr. Heather Hettrick. Dr. Heather Hettrick is an Associate Professor in the Physical Therapy Program at Nova Southeastern University in Fort Lauderdale, Florida. As a physical therapist, her expertise resides in integumentary dysfunction with clinical specialties in wounds, burn, and lymphedema management. Dr. Hettrick holds three certifications including a Certified Wound Specialist by the American Board of Wound Management, Certified Lymphedema Therapist by the American [phonetic] of Lymphatic Studies and a Certified Lymphedema and Wound Therapist from the International Lymphedema Wound Training Institute.

    Her work history includes being an Assistant Professor and Director of Clinical Education at the University of New Mexico; Vice President of Academic Affairs and Education for Gordian Medical, Inc., doing business as American Medical Technologies; Clinical Assistant Professor in the Department of Physical Therapy at New York University; Adjunct Professor at Drexel University; Program Coordinator for the Burn Rehabilitation Research at the William Randolph Hearst Burn Center in New York Presbyterian Hospital; and a Master Clinician at the Hospital for Joint Diseases at the Diabetic Foot and Ankle Center.

    Dr. Hettrick is Past President of the American Board of Wound Management, and has served on the Executive Committees of the Board for the Association for the Advancement of Wound Care. She's on the Board of the World Alliance of Wound and Lymphedema Care and is assisting in Haiti regarding education and morbidity management for lymphatic filariasis. Dr. Hettrick is a Key Opinion Leader and is actively involved in numerous professional organizations. She regularly publishes and presents on integumentary-related issues, [Coughs] nationally and internationally.


    [OFF MIC]

    Hettrick: Okay, I'm happy to introduce Dr. Jim McGuire. He is the Director of the Leonard Abrams Center for Advanced Wound Healing and a Clinical Professor in the Department of Podiatric Medicine and Podiatric Biomechanics at Temple University School of Podiatric Medicine, of course, located in Philadelphia. Dr. McGuire earned his DPM degree from Temple in 1981, and he is a fellow and founding member of the American Professional Wound Care Association and the Academy of Physicians in Wound Healing. He also serves as an advisor to the board of the Council for Medical Education and Testing. Dr. McGuire is a licensed physical therapist, a licensed pedorthist, and is certified in wound care by the Council for Medical Education and Testing. He is also board certified by both the American Board of Podiatric Surgery and the American Board of Podiatric Medicine. So, It's my honor to get to present today with both Pamela Scarborough and Dr. Jim McGuire as well. Thank you for being here today.


    [OFF MIC]


    Hettrick: For the handouts, which you'll find, there's two color handouts there that helps with differential diagnosis of edemas. And there's also a handout on some exercises that you can be teaching your patients to do whatever form of edema they have, that you can utilize. And then there's also a handout that we’ll be going over one of the labs later today talking about how to do some basic manual lymph drainage techniques for your patients. Even though some of you may or may not be certified, it's a good idea to just learn how to do some of the basics, to get their systems primed and pumped and ready to go. So, there should be a lot up here and I think they're organizing them right now for you.

    Scarborough: So our disclosures, I have no disclosures that are going to be meaningful. Dr. Heather Hettrick is a Key Opinion Leader for 3M and Faculty for the International Lymphedema and Wound Training Institute. Dr. McGuire, he's on several Speakers’ Bureau, Smith & Nephew, Hollister, Osiris, BSN Medical, and Medline. And he also has research grant with Osiris and NuTech.

    [OFF MIC]

    Our objectives today are to list the challenges for recognizing and treatment of chronic fluid overload in the lower extremity leading to chronic edema.


    We're also going to describe the current state of education. One of the things we want to talk about is how much education you got on lymphedema in your basic healthcare education. I got very, very little, but it was a long time ago. Related to the edema that affects the lower extremity causing chronic wounds, we were going to propose suggestions for improving education for healthcare providers related to various conditions that contribute to lower extremity edemas and subsequent chronic wounds.

    So one of the questions, when we look at root cause analysis and you look at why is something failing, whatever the system you are talking about. In this system, it's understanding, diagnosing, recognizing and putting appropriate lymphedema and phlebolymphedema and chronic venous insufficiency edema treatment; having it done appropriately in our healthcare settings wherever you do your healthcare. So the question is, why is chronic lower extremity edema leading to nonhealing wounds, often misdiagnosed and mismanaged by healthcare professionals? Why do you think?. Does anybody in here think there's a problem with recognizing lymphedema, phlebolymphedema specifically and treating it appropriately? I think we're pretty good with chronic venous insufficiency now. Although we may not fully understand that CVI, chronic venous insufficiency, will ultimately end up with a lymphedema component. Hundred percent of the time, if they've had it chronically, there will be a lymphedema component. So how many of you were educated on this in your clinical programs?

    [OFF MIC]

    Okay, that's what we're seeing all over the country. That's what we're seeing all over the world actually. So there's a lack of education in our different healthcare's curriculums and there are insufficient number of trained lymphology clinicians. I only know about a handful. Now Heather's going to know many more because she's really in that world. But I'm not working with anyone that is a lymphology specialist.


    Would you agree the lack of understanding by healthcare providers regarding recognition and early interventions for venous insufficiency and lymphedema? Would you say that, that is an issue in healthcare for your patients who have wounds? When these patients with lymphedema and chronic venous insufficiency come to you with wounds, what happens from the time they had their initial swelling until they got their wound in the medical management process? With the clinicians who were supposed to be recognizing -- I've got the swelling; six months later, they say, well, now I have this wound. What happened in that interim that the healthcare providers didn't recognize what was happening? So, we have a lack of understanding by our healthcare providers regarding recognition and early intervention.

    Are there reimbursement challenges and barriers? Are there? You bet, you bet. For instance, some of the products that we need, we can't get CMS to pay for unless there's a wound. So what happens, we have to wait until this person's skin opens to give them the appropriate treatment intervention and get it reimbursed. So that's one of the problems also. And then there is the ongoing challenge for patients regarding long-term complications for treating these chronic lifelong conditions. You don't heal lymphedema, you can heal the skin, you don't heal chronic venous insufficiency. So this is a lifelong condition that never goes away.

    So, is the formal healthcare education system adequately addressing the lymphatic system as a critical system? What do you think?

    [OFF MIC]

    No, I'm seeing most of you’re saying no. Would ask how many of you had formal training, and I didn't see one hand, unless somebody is being shy. You don't need to be shy here.


    What are you seeing in your clinical practice? I do want some answers on this, please. What are you seeing in your clinical practice related to venous insufficiency, lymphedema and phlebolymphedema? How many of you are seeing this in your clinical practice?

    [OFF MIC]

    Okay, wonderful.

    How many of you have seen patients looking for physicians who know how to do this? Have you seen a patient that's been to someone else and now they're coming to you looking for help? Has anyone had that situation?

    [OFF MIC]

    Several of you have, good. So how are you addressing the care of these people with lymphedema, and phlebolymphedema and chronic venous insufficiency? Like I said, I think we're doing better with chronic venous insufficiency, but some people don't recognize that does lead to a lymphedema component ultimately, called phlebolymphedema, which we’re to discuss in a few minutes. So anyone who wants tell us what you're doing? What do you think would help you serve your patients? What do you think would help you serve your patients?

    [OFF MIC]

    Education, reimbursement. Anything else you can think of that you would tell to serve your patients?

    [OFF MIC]

    Scarborough: Access to care, absolutely, yes. Holistic care; looking at the whole person and not just the hole in the person. Anything else? Yes, ma'am.

    Unknown Speaker: Therapy that I can initiate the day I see them.

    Scarborough: A therapy she can initiate the day she sees that patient. I'm hoping we can give you some things today. Yes, ma'am? Someone over here had their hand up.

    Unknown Speaker: This is pretty much the same thing, I guess, some more people out there that can manage.

    Scarborough: More people out there that can manage it. We don't have enough lymphedema specialists actually.


    This came from a very long article looking at education and training in England, specifically, but I think it's going to be the same for the United States. And I'm going to read this to you, because I thought it was very well stated.

    Students and clinicians should be able to establish a diagnosis of lymphedema along with differential diagnosis, which is part of what we're going to be doing today, and be aware of the effective therapeutic interventions. ; however, it is commonly misdiagnosed.

    How many of you have had a patient that was misdiagnosed and given a diuretic?

    [OFF MIC]

    Yeah, that's one of the favorites out there. This paper summarizes published knowledge on lymphedema and lymphatic system teaching in medical courses. The lack of results suggests that despite an exponential increase in understanding and research in the lymphatics, we have a lot of knowledge now about the lymphatics. This is not yet translated into the realms of medical education. Until this undergraduate educational gap is addressed, there will continue to be a lack of awareness and resulting poor management of patients with these afflictions. Would you agree with this physician statement? I think we're still there.

    So we have a paucity of clinicians adequately trained to recognize and treat lymphatic dysfunction. We have few medical allied health professional schools that teach them the lymphatic system and the consequences and the sequela of its dysfunction and damage, resulting in a paucity of clinicians, specialists, and scientists across the world who recognize and adequately treat lymphatic dysfunction conditions. Fewer of these clinicians and professionals are in teaching roles.

    This is a statement from a lymphedema patient, and it really went to my heart, and so I wanted to share it with you.


    Mary says, “None of us chose to have lymphedema. But the lack of support, medical, financial, therapeutic suggest we are to be penalized and that we just don't matter.” And that's how Mary felt. Didn’t that bring tears to your eyes? It brought tears to my eyes.

    TAPE ENDS [0:14:22]