Where to refer a patient with lymphedema for treatment?

Where to Refer Patients with Lymphedema

Refer patients with clinical symptoms or swelling suggestive of lymphedema to a therapist knowledgeable about lymphedema diagnosis and treatment, specifically a physical therapist, occupational therapist, or certified lymphedema specialist. 1, 2

Primary Referral Pathway

For most lymphedema cases, the appropriate referral is to:

• Physical therapists with lymphedema certification 1, 2, 3
• Occupational therapists with lymphedema training 1, 2, 3
• Certified lymphedema specialists/therapists 2, 3

These specialists provide complete decongestive therapy (CDT), which consists of manual lymphatic drainage, compression therapy, exercise, skin care, and self-management education—the cornerstone of lymphedema treatment. 2, 4

Site-Specific Referral Considerations

Head and Neck Lymphedema

Refer to a rehabilitation specialist for treatment consisting of manual lymphatic drainage and, if tolerated, compressive bandaging. 1 A collaborative strategy should be developed between the primary care physician and head and neck cancer specialist to maintain surveillance for signs and symptoms. 1

Breast Cancer-Related Lymphedema

Refer to a vascular specialist or vascular clinic if lymphedema is present in breast cancer survivors. 3 Additionally, refer to therapists knowledgeable in lymphedema management (physical therapists, occupational therapists, or lymphedema specialists). 1, 2

When to Consider Advanced Referrals

Surgical Consultation

If conservative treatment with complete decongestive therapy is not sufficient after adequate trial, refer to a plastic reconstructive surgeon or microsurgeon experienced in lymphedema procedures. 2, 5 Microsurgical procedures including vascularized lymph node transfer (VLNT), lymphaticovenous anastomoses (LVA), and suction-assisted protein lipectomy (SAPL) have shown effectiveness for refractory cases. 6

Physical Medicine and Rehabilitation (PMR) Specialist

Consider referral to a PMR specialist for comprehensive evaluation, differential diagnosis, and tailored management strategies, particularly for complex cases. 7 PMR specialists can coordinate multidisciplinary care and address associated complications like neuropathy and chronic pain. 2

Critical Timing Considerations

Early referral is paramount—lymphedema may be reversible or more effectively managed with early physiotherapy intervention. 2 Do not delay referral waiting for progression, as early detection and intervention are critical to preventing irreversible tissue changes. 2, 3

Common Pitfalls to Avoid

• Do not wait for lymphedema to worsen before referring—early intervention provides better outcomes 2, 3
• Do not refer to general physical therapy—ensure the therapist has specific lymphedema certification and training 1, 2
• Do not assume physical activity restrictions are necessary—supervised progressive resistance training is safe and beneficial, contrary to historical advice 1, 2
• Do not prescribe diuretics—they are generally ineffective for lymphedema management 2
• Do not neglect infection management—prompt antibiotic treatment is essential, as infections worsen lymphedema 2

Additional Supportive Referrals

• Registered dietitian: For weight management counseling, particularly for overweight or obese patients, as obesity is a significant risk factor for lymphedema development and progression 1, 2
• Neurologist: For patients with chronic pain related to lymphedema that is not adequately managed 2
• Podiatrist: For neuropathy associated with lower extremity lymphedema 2