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Clinical Perspective
Therapy for lipedema
Incorporating new clinical guidelines
By Guenter Klose
ipedema, which mainly affects women, approach for the treatment and management therefore essential that the treating therapist
L
is much more complex than its defining of lipedema, e.g. the Dutch Guidelines 2016 conduct a comprehensive evaluation to
characteristics suggest. According to the and the United Kingdom Guidelines 2017. Such establish the patient’s past medical history
and to assess their current complaints.
European Lipedema Consensus Group, an approach calls for treatment not only of the
the two main criteria for the diagnosis physical symptoms but also the psychological But can a thorough physical evaluation
e: disproportionate fat determine the real source of the patient’s
of lipedema ar issues that are often associated with the
accumulation in the legs (and sometimes condition. However, given how the predominant suffering?
the arms) and subjective complaints such as medical model in North America focuses solely Lipedema is often associated with
ness in the area 1,4
pain, heaviness, and tender on physical manifestations, implementation emotional and psychological distress.
1 However, lipedema Patients often believe this distress is caused
of the affected tissue. of such a multifaceted approach can be
is often complicated by a wide range of challenging. Development of a treatment by the physical pain and the embarrassment
other physical conditions and emotional and plan often falls to a lymphedema therapist. hey feel because of the disproportionate
t
The following considerations are based on appearance of their legs. However, data
psychological suffering. These complexities
can lead to misdiagnosis or treatments that new understandings about lipedema published
collected by the Foeldi Clinic has revealed
fail to address underlying issues. over the last three years in a series of articles that in many cases, mental health issues
oot definition of the word Lipedema – Myths and Facts, Parts
en the r were present before the onset of symptoms
Ev entitled
1-5, by T. Bertsch and G. Erbacher, experts at h lipedema and
lipedema has led to misunderstandings of the y associated wit
typicall
2,3
condition. The term “lipedema” was first the Foeldi Clinic in Germany that specializes that these issues have an influence on
coined by E.V. Allen and E. A. Hines in 1940. 1,3-6 7 Since
in treating lymphological disorders. the patient’s perception of pain.
“Lipo” means “relating to fat” and “edema/ Therapists are encouraged to incorporate mental health issues often precede the
oedema” means “swelling due to the these new findings into their clinical practice; sical issues, simply
manifestation of phy
wever, pure heir self-care.
accumulation of fluid.” Ho patients can use them to guide t treating the physical symptoms, as is typical
3
lipedema does not consist of fluid edema. of traditional lipedema therapy, may not
Nevertheless, lipedema may be combined with Assessment get at the root cause of the patient’s suffering.
efer
other causes of swelling such as orthostatic Though the number of lymphedema therapists A r ral to a mental health professional will
edema (fluid accumulation in the lower is growing, there are still few physicians in likely prove beneficial.
extremities from being in an upright position) North America who specialize in lymphedema An additional challenge in diagnosing
or lymphedema (the accumulation of fluid and/or lipedema. This can make it difficult and treating lipedema is that patients often
due to lymphatic failure).3 for patients to receive an accurate diagnosis. have comorbidities such as obesity and
Recognizing the complex nature of ed lymphedema.
uent obesity-associat
Non-expert physicians may assign the diagnosis subseq
lipedema, many articles and guidelines have without collecting information critical to Because there is significant overlap between
been published that promote a multimodal successful treatment of the condition. It is these conditions, clear differentiation may
be impossible, even for very experienced
Guenter Klose, MLD/CDT Certified Instructor was educated at the renowned professionals. In cases of severe obesity,
Földi Clinic in Germany and was involved in establishing the first lymphedema a consult with a bariatric specialist may
1,5
treatment centers and certification courses in the United States. His company, prove helpful.
Klose Training, provides the highest-quality lymphedema therapy education to The following specific guidelines pertain
many hundreds of therapists in the U.S. and internationally. His most recent only to the treatment of PURE lipedema, which
airly rare. More often than not, lipedema
innovation is t is f
he development of advanced, online courses. www.klosetraining.com
is associated with various comorbidities.
Winter 2020 Lymphedemapathways.ca 13
am that builds strength, flexibility,
activity progr
FIGURE 1 balance, and general endurance is highly
1,2,12
recommended. Physiotherapists play a key
role in tailoring an exercise program to each in-
dividual’s needs. As with anyone, patients with
e more likely to maintain a program
lipedema ar
they find interesting and fun. Patients will likely
lose motivation if they are mandated an exercise
routine with a set number of repetitions. Aquatic
therapy or simply movement in water is very
beneficial for patients with lipedema.
Main pillars of the new interdisciplinary therapeutic concept. European Lipedema Forum Compression therapy
Compression therapy should become part of
Therapy goals expectations and treatment goals and bring 1
the daily routine for patients with lipedema. Al-
The main goals of treatment should be to 1
these into alignment with what is possible. though there are no scientific studies to date on
reduce soft-tissue pain and address the Any comorbidities must also be addressed, ects of compression on pure lipedema,
the eff
psychological vulnerability of the patient as appropriate. studies examining the efficacy of compression
1 Physiotherapists often fail to
with lipedema. therapy for other conditions have shown that
address the latter because they are trained to Therapy compression reduces inflammation of the
focus on the tangible physical and subjective oach is critical to the
A multimodal appr tissues, improves microcirculation, and has a
complaints (discomfort and pain) of their successful treatment of lipedema. The following positive effect on the hypoxia factor. Hypoxia
patients. Digging deeper to investigate what information touches on some key points of is insufficient oxygenation of the tissues; it can
the patient with lipedema is really suffering the new therapeutic concept recommended 1
contribute to the pain in lipedema.
from would seem to be out of the scope of by the European Lipedema Forum, as Finding a suitable pair of compression
practice for therapists entrusted to treat the 1
ated in Figure 1.
illustr tights, comfortable leggings, or a suitable
lipedema. But if a key component of the combination of garments to ease with donning
patient’s suffering is due to severe mental Physio and movement therapy and doffing is possible in nearly every case.
stress, depression, and/or poor body image Manual Lymph Drainage (MLD) Depending on the clinical picture, custom-made
and self-acceptance, limiting treatment of 1-3
Since lipedema is not a fluid edema, MLD flat-knit garments are preferred, especially in
lipedema to physical manifestations is unlikely will not reduce the limb volume but can those patients with a combination of lipedema,
to be effective in the long term. Although there help to reduce the subjective complaints of 1,12 However, not
lymphedema, and obesity.
is no validated lipedema-specific questionnaire he patient. In my o
t wn work with patients all patients with lipedema require custom
available to date, there are a number of other with lipedema, I have found that the pressure garments. Many women with lipedema prefer
8-11 that can
validated tools available to therapists sensitivity of the affected tissues is, quite a textured material, which can provide a micro-
help them assess whether their patients with often, markedly reduced after a relatively massage on the skin and relieve discomfort
lipedema need psychotherapy or psychosocial small number of treatments, i.e. 6-8 sessions. (see photo on page 15).
services. If a need is identified, the therapist Although the amount of pressure exerted
should then make the appropriate referral. during MLD must be adjusted to the patient’s Psychosocial therapy
Therapists who are treating lipedema
tolerance, a firmer stroke than is often used As mentioned before, many patients with lip-
are typically trained more specifically in by practitioners may offer better results. 1,4
edema experience severe mental stress which
lymphedema therapy. While certain techniques MLD improves tissue health overall but the is particularly relevant because mental health
used for treating lymphedema are beneficial for thing, human t 7
soo ouch provided by MLD issues can exacerbate pain perception. Many
treating the physical symptoms of lipedema, may have additional benefits for a patient patients with lipedema have difficulty accepting
it is imperative that therapists review the with deeply rooted psychological issues as is their own body, especially the shape of their legs,
latest literature pertaining to lipedema so they common with patients with lipedema. largely because of the prevailing beauty ideal that
understand what lipedema is, and, perhaps 13 It is
is constantly promoted in today’s media.
1 Armed with
more importantly, what it isn’t. Movement therapy also notable that an analysis of psychological
this new knowledge, therapists will be able to -
The benefits of exercise are universally recog assessments at the Foeldi Clinic found that
correct any misperceptions their patients have. nized but patients with lipedema may find it a significantly higher number of patients with
As the therapist explores the patient’s own ficult t
dif o engage in a regular exercise routine lipedema reported physical or sexual abuse com-
subjective beliefs about lipedema, it is critical because of their size and general decondition- 1 Details about
pared to the general population.
that the therapist identify the patient’s precise ing caused by perpetual inactivity. A graded an effective therapeutic approach that includes
14 Lymphedemapathways.ca Winter 2020
s emotional and psy
empathy, education, psychotherapy, and the patient’ chological burdens.
use of self-help groups is outlined in Part 5 Although liposuction can reduce the size of Although liposuction can
1
of Lipedema – Myths and Facts. a limb, there are grave risks to the procedure reduce the size of a limb,
and deep-seated psychological issues cannot there are grave risks to the
Weight management be sucked out with the fat. According to the procedure and deep-seated
A high percentage of people in modern societ- European Lipedema Forum, liposuction should
ies, including people with lipedema, are over- -
only be considered for patients with consider psychological issues cannot be
weight or obese. Nutrition education and weight able functional disabilities whose symptoms sucked out with the fat.
portant so it is unfortunate sist despite 12 months of comprehensive,
ement are im per
manag
that most publications that deal with lipedema conservative therapy, whose weight has been
state that diet and exercise have no effect on stable for at least 12 months, and for whom as inflexibility can sabotage the desired goal.
lipedema. This clearly sends out the wrong a preoperative psychological assessment has The more we sho
w empathy and support,
-
message to patients and healthcare profession been completed. Liposuction is generally not and the less we (knowingly or unconsciously)
als. It is quite likely that patients with lipedema recommended for patients with a BMI >35 who comment on behaviors that produce guilt or
e overweight will always have dispropor- 1,6 Patients contemplating 1
who ar have central obesity. shame, the more the patient will engage.
tionate fat distribution, even after an apprecia- liposuction are encouraged to scrutinize the
ble amount of weight loss. However, there are qualifications and track record of any surgeon Final comments
ecognizable health benefits to be gained by they are considering for the procedure.
r The recent initiatives of the European
improving fitness and reducing weight Lipedema Forum, spearheaded by T. Bertsch
(e.g. pain may be reduced). Self-management her, provide an invaluable con-
and G. Erbac
m diets must be avoided as they
Short-ter The Chronic Care Model (CCM) advises that tribution to the understanding of the clinical
almost always fail in the long term and often patients should be given a leading role in esentation and treatment of lipedema. Part
pr
14-17 It is important to 2,19 Together, the patient and
result in a yo-yo effect. their treatment. Lipedema – Myths and Facts is
5 of the series
educate patients with lipedema, especially therapist need to formulate a plan of care that a must-read for every healthcare professional
those with additional visceral obesity, about includes reasonable and attainable goals. The involved in assessing and treating lipedema.
the inflammatory and anti-inflammatory effects therapist should clearly explain the condition, It would also be beneficial to create a new
of various foods because dietary choices can its treatment, and impactful behaviors to the term that better describes the condition currently
help prevent hyper-insulinemia and insulin patient. The importance and power of self- known as lipedema because the condition has
resistance. However, it is beyond the scope management must be emphasized. Motivating very little to do with “edema.” Rather, the con-
of this article to give specific dietary advice. the patient to take an active role in their care dition is a painful, disproportional distribution of
program will foster compliance and positive ate term for a medical
fat tissue. Having an accur
Liposuction long-term results. As therapists, we need to problem that has long been misunderstood and
ception that liposuc-
There is a common misper guard against mandating certain actions, -
misdiagnosed and is frequently treated incor
tion can eliminate lipedema and along with it, a rather than collaborating with the patient, rectly could precipitate a paradigm shift in the
ecognition and treatment of this condition. LP
r
The International Lipedema
Consensus Document
has now been published
as a supplement of
the Journal of Wound
. You can find this
Care
document as well as the
full set of references
at www.lymphedemapathways.ca
Editor’s Note:
Readers are encouraged to refer back
o: G. Klose
t Pathways for
to the Fall 2020 issue of
Pho an interesting interview with Dr. Bertsch
Female patient with lipedema in remission. Pain and pressure sensitivity of the tissues about the paradigm shift in thinking
are managed by weight control, healthy nutrition, regular physical activity and textured about lipedema.
compression leggings.
Winter 2020 Lymphedemapathways.ca 15
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