Physiotherapy practice in the management of lymphoedema in South Africa

Abstract

Introduction: Lymphoedema is a condition that is underdiagnosed and underestimated worldwide. The condition is characterised by asymmetrical fluid accumulation in the face, trunk, limbs and genitals due to a deficient lymphatic system. If left untreated, lymphoedema can result in cellulitis, lymphangitis and in rare cases lymphangiosarcoma. These conditions can lead to severe illness, amputation and even death. People with lymphoedema also struggle with psychological and financial burdens. The timeous diagnosis and treatment of this condition is paramount to improving the patient’s quality of life. Physiotherapists have an important role to play in the management of patients with lymphoedema.

Aim of study: To investigate physiotherapy practice in the management of lymphoedema in South Africa.

Methods: A two phase explanatory mixed method design study was undertaken. Ethical clearance was given by the Human Research Ethics Committee of the University of the Witwatersrand. The first phase was an online questionnaire which informed the second phase of the study which was online focus groups. The focus groups served to compliment and enrich the data obtained from the questionnaire. Four hundred and two qualified physiotherapists filled out an online questionnaire and nine of those physiotherapists participated in online focus groups.

Results: Physiotherapists consistently rated their knowledge as ‘fair’ when asked about perceived knowledge of certain aspects of lymphoedema and its management. Ninety-seven point three percent of physiotherapists (n= 367) indicated that they knew that physiotherapists could offer lymphoedema management, only 49.7% (n=368) knew how to treat the condition. Fifteen point eight percent of 146 physiotherapists had completed the certified 135 hour lymphoedema training. Sixty one percent of respondents reported that they receive less than 1 new referral a month (n=146), with 39.8% reporting that it takes up less than half of their patient load (n=143). Only 31% of physiotherapists offer complete decongestive lymph therapy (CDLT) (n=129). The focus group discussion revealed that the role that physiotherapists play in the management of lymphoedema is complex and requires further training, a multidisciplinary team and a biopsychosocial approach. Facilitators such as access to internet resources and social media, the founding of a lymphoedema network in South Africa, advancements in the provision of garments and consumables and good patienttherapist relationships assist physiotherapists in their management of lymphoedema. Factors such as lack of education at an undergraduate level and post graduate level, prohibitive costs for both patients and physiotherapists, time pressure and the complexity of the patient group hinder physiotherapists management of lymphoedema.

Conclusion: Physiotherapists in South Africa have a fair self-reported perceived knowledge of lymphoedema as a condition but need further education on how to manage the condition to meet international standards. Most physiotherapists receive very few lymphoedema referrals, and they do not focus on it in their practices. Those who have done the 135 hour certification have a special interest in the field and see more patients than other physiotherapists. Most physiotherapists do not offer the gold standard of care, CDLT, but still treat patients with other modalities. Patient and practitioner access to internet resources, developments in the field, the formation of a lymphoedema network in South Africa and a good patient-therapists relationship facilitate physiotherapists in the management of lymphoedema. Factors that physiotherapists experience as a barrier to lymphoedema management include a lack of education, prohibitive costs of treatment, time pressure and the complexity of the patient group.