What the Health: Lymphedema PT

For this month’s “What the Health” segment, I had the pleasure of interviewing dual-board certified Physical Therapist, Dr. Alex Hill PT, DPT, CLT. On her instagram (@oncopelvicpt) you will see that Dr. Hill addresses all thing pelvic health, oncology, and lymphedema! A little about Dr. Alex Hill’s educational background: “I graduated from the University of Florida Doctor of Physical Therapy program in 2014 and immediately after graduation I started the Women’s Health Residency at Duke University Health System. As part of my residency training, I completed the training to become a Certified Lymphedema Therapist (CLT). In 2016 I became a Board-Certified Clinical Specialist in Women’s Health Physical Therapy (WCS) through the American Board of Physical Therapy Specialties (ABPTS); in 2019 I became a Lymphology Association of North America Certified Lymphedema Therapist (LANA-CLT), which is an advanced designation for therapists who treat lymphedema and related conditions. I became a Board-Certified Clinical Specialist in Oncologic Physical Therapy through the ABPTS in 2020.”

With this post focusing on lymphedema and with such credentials, I had to know why lymphedema, and WHY become board certified in 2 specialties?!

“I first observed the benefits and positive impact of what physical therapy could do for those with lymphedema as a student while shadowing physical therapists who treated both pelvic health and oncology populations, which included people who had lymphedema. These populations are significantly underserved, and I found a passion for working in these specialty areas, so I decided to specialize in both! Because these are more niche practices, they both require more training and knowledge than what I felt like I had as an entry-level new grad, which is why I pursued the Women’s Health Residency and additional training/certification.”

Dr. Hill is a full-time clinician in an outpatient-hospital based clinic and further explains that her caseload solely focuses on these 3 populations: pelvic health, oncology, and lymphedema. “My first patient may be coming to me for side effects from breast cancer treatment and the patient after them may come in for urinary leakage in the post-partum period. It makes for a diverse day of different types of conditions, which I enjoy.“ On top of being a full time PT, Dr. Hill is also the team lead for their Pelvic Health Team which includes some administrative duties and training for new staff. Outside the clinic, she is active with the APTA Pelvic Health and APTA Oncology organizations, as well as mentoring pre-physical therapy and physical therapy students interested in pelvic health and/or oncology physical therapy. AND STILL MANAGES TO HAVE FREE TIME! “I am a big proponent of self-care, having experienced burn-out myself, and I like to recharge by going for hikes and doing Zumba.” I always love hearing other professionals advocating for self-care! 

Therapist and Patient education: Now to get into the specifics of lymphedema so you can better know whether you should go see a lymphedema specialist yourself, or if you are a therapist and need to refer your patient to a lymphedema specialist. “The majority of patients on my lymphedema caseload are cancer survivors, including breast cancer, head and neck cancer, and gynecologic cancer populations.  With my training, however, I also see other swelling conditions that are not oncology-related, like lipedema, chronic venous insufficiency, edema during pregnancy, and post-op edema.”

If you are considering going to a lymphedema specialist or potentially referring a patient to one, here is what to expect on the initial evaluation: “A typical evaluation will include a very thorough review of past medical, surgical, and social history, as these may give clues as to the etiology of the swelling as well as treatment that may need to be implemented and any precautions (especially if they are a cancer survivor). The subjective is also very important and questions include when the swelling started; what makes the swelling better and worse; any injuries, radiation therapy, or surgeries to the area; any history of skin infections (cellulitis) or blood clots; and what treatment has been tried already. The objective portion of the evaluation includes a general orthopedic musculoskeletal exam (range of motion, strength, posture, reflexes, sensation), as well as circumferential measurements of the involved limb or neck, assessment of pitting and skin integrity, and balance if they have swelling in their legs.”

Once a patient has been evaluated, they can expect what every patient loves… EXERCISES! “Remedial exercises are the number one exercise I start people with since it is a component of the gold standard of lymphedema treatment, Complete Decongestive Therapist (CDT). Remedial exercises are active, repetitive, non-resistive motions of the involved body part. They’re used mainly with compression bandaging to help reduce the size of the limb. A typical treatment session includes remedial exercises to promote lymphatic circulation, exercises like stretching or strengthening to address any impairments noted on exam, aerobic activities like stationary bike or UBE, manual lymphatic drainage, and if indicated, compression bandaging which will reduce the size of the limb. I also make recommendations for compression garments and either measure them in the clinic or refer them to a local garment vendor to get measured and fitted.”

What are some things Dr. Hill wishes other physical therapists knew about the lymphedema specialty? “I’m currently working in a primarily orthopedic/sports clinic and I’ve enjoyed talking with my colleagues more about what lymphedema is, signs and symptoms of lymphedema and other types of swelling, and indications for referring to a lymphedema specialist. Initially recognizing persistent swelling is an excellent first step, but more clinicians should be educated on risk reduction practices and precautions for lymphedema, signs and symptoms of lymphedema, and when to refer to a specialist.”

Precautions (these are just a couple!): avoid putting heat or extreme cold on the involved area, as this can cause increased swelling. If you can, avoid taking blood pressure on the involved arm as there is a small risk of exacerbating the lymphedema. If a patient has lymphedema, they should be wearing their compression while exercising.

S/S: heaviness, tightness, achy in the involved area; swelling; skin changes including skin thickening in the involved area; jewelry or clothing feels/looks tight. 

When to refer: if a patient has a history of cancer with a new sudden onset of swelling this could be a sign of cancer recurrence and the patient should be seen by their oncologist for work up. If they have a history of lymphedema and the swelling has progressively gotten worse then that would be an indication referred to a lymphedema therapist. Also, if they are post-op with persistent swelling, or pregnant with swollen legs and/or genitals, they can be seen by a lymphedema therapist. 

Now the question I always love to ask therapists: how do you get your patients? Unfortunately there is still so much inconsistency with MD referrals as well as interdisciplinary advocacy. Luckily, Dr. Hill does not encounter this issue in her clinic often. “Most of my patients are referred from providers in the area who have been marketed to, but I also get referrals by word-of-mouth. Additionally, it’s important with pelvic health and oncology populations to foster relationships with a variety of providers including primary care providers, oncologists, radiation oncologists, surgical oncologists, urologists, OB/GYNs, urogynecologists, vascular specialists, midwives, acupuncturists, and nutritionists/dieticians. Having a multidisciplinary team not only helps your patients, but it helps with referrals too!” Hopefully, our profession as a whole can cultivate such a positive relationship with other healthcare professionals to better help our patients and referrals!

Though she has a great multidisciplinary team, Dr. Hill still believes this is an underserved community and we can do more to advocate for the lymphedema specialty! “Significantly more education and awareness can be done for lymphedema and people who are living with lymphedema. Some insurances do not cover compression garments, which is critical in managing lymphedema long-term. This puts a financial strain and creates reduced access to compression garments for many people. Getting devices like an intermittent compression device, which helps reduce swelling, can take jumping through hoops to obtain as well. The Lymphedema Treatment Act (https://lymphedematreatmentact.org/) was first introduced into Congress in 2010 (currently awaiting reintroduction) with an aim of improving insurance coverage for lymphedema treatment. People can get involved with supporting the Lymphedema Treatment Act by contacting Senators and Representatives as well as sharing information about this cause.”

Interested in following more lymphedema PT’s on insta to get a better glimpse in the field? Dr. Alex Hill recommends these 4 accounts: @lymphedemapodcast @cancerrehabpt @lymphlifeot @the_lymph_therapist. She also lists a few other great resources: “The National Lymphedema Network and Lymphatic Education and Research Network are fantastic organizations for updates on patient education and resources for clinicians. The Lymphology Association of North America (LANA) has resources to find lymphedema specialists, links to support groups and other lymphedema-related organizations, and information on how to become a LANA Certified Lymphedema Therapist.”

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