What are the clinical practice guidelines and why should we use them?
How International Lymphoedema Framework guidelines can change your practice
By Pamela Hodgson
Whatcriteria should I be using in my assessment of new patients? How do I know when it is most appropriate to suggest a patient transition from intensive therapy to long term self management? Are my decisions and actions in line with what is considered best practice in the management of lymphedema? If lymphedema therapists have a question, where can they turn for reliable advice amongst the many sources and sites available through the internet? The Education Working Group of the Canadian Lymphedema Framework suggests consulting the series of freely available documents published by the International Lymphoedema Framework (ILF) to help answer these questions and many others. The position documents on clinical practice guidelines (CPGs) for the management of lymphedema, 1st and 2nd editions are highlighted here.
the second, which focused on compression therapy, in 2012. The CPGs are designed to assist patients and health care practitioners in decision-making and provide direction to clinical care. CPGs are an invaluable tool for both experienced and inexperienced therapists to add to their clinical, experience-based expertise in clinical reasoning.
CPGs are developed and used by many health care disciplines. They are commonly defined as: systematically developed statements of recommended best practice in a specific clinical area. Best practice guidelines are developed through a process of consensus of expert opinion and are based on current available evidence. In the case of the ILF documents, multidisciplinary clinical experts from Europe, Australia, India, Japan, Canada and the United States met to discuss and critically review the evidence and create the ILF Best Practice Guidelines The first edition was published in 2006 and
Few lymphedema therapists across Canada have the good fortune to work within a multidisciplinary team setting, the ideal for provision of optimum lymphedema care. Many others, however, work in more solitary situations, and are often the only lymphedema therapist in a community. CPGs can be very useful in aiding us in our everyday practical decision-making process, answering such questions as: how to determine the appropriate level of care for an individual patient with or at risk of lymphedema; if compression garments are unsuitable for managing a lower limb lymphedema what steps need to be taken to assess and treat this patient? How do the guidelines work? Importantly, the ILF guidelines are based on six standards for lymphedema services. While these aims are for lymphedema care provided within an institution, the principles can certainly be applied to community-based practices. The original first three standards are: 1) identification of people at risk of or with lymphedema; 2) empowerment of people at risk of lymphedema; 3) provision of high quality clinical care that is subject to continuous improvement and
Pamela Hodgson RMT, MSc, is a retired lymphedema therapist who worked in private practice in St. John’s, NL then at the McGill University Health Centre Lymphedema Centre with Dr. Anna Towers, where she participated in both research and clinical care. She’s been involved with the CLF since its inception.
integrates community, hospital and hospice based services. The final three standards concern provision of care for cellulitis/erysipelas, compression garments and multi-agency health and social care. It is interesting to note that in many Canadian communities the lymphedema care available does not yet meet any of these six international standards. CPGs provide definitions and detailed guidance through the use of algorithms. Clinical care algorithms are descriptions of sequential clinical decisions and interventions and are used in medicine to improve and standardize decision-making procedures, and overall care.
Best practice for the management of lymphedema
This 54 page document outlines all the basics of lymphedema identification, assessment, treatment and treatment decisions and provides references and appendices. It follows the International Society of Lymphoedema (ISL) method of staging lymphedema (stage 0 – III). For classification of severity of unilateral limb lymphedema, it uses mild (less than 20% excess volume), moderate (20-40% excess volume) severe (greater than 40% excess volume). Functional, psychosocial and pain assessment are included along with information on skin care, cellulitis, lymphatic massage, intermittent pneumatic compression, multi-layer inelastic lymphedema bandaging, and compression garments. Surgery and other treatments are briefly mentioned (a 2nd edition entitled ‘Surgical Intervention’ is separately available). Algorithms are given for initial, intensive, transitional and long- term management. The algorithm for the initial management of lymphoedema is reprinted here with permission from the ILF. LP