Is 60 Enough?

John Fuller Beckwith10/4/2025

In the US the paradigm for outpatient physical therapy does not match the European paradigm for treating lymphedema. In the US PT is generally is 30-45 minutes per session. We won't even bring up frequency of visits in this discussion. In the classic (and still best) CDT courses for therapists the framework for treatment that is taught is one to two hour treatment sessions so that all the components of CDT can be applied each day. Yet we can see around the country what amounts to a compromise: clinics may grant up to 60 minutes for each treatment session and we are supposed to consider that as a generous middle ground - and to be content with it. Clinic managers may consider this a concession. Therapists may feel, ‘well at least I have this much time, let me do the best I can with this hour, as long as its not only 45 minutes.’

How did we get here? That may be a difficult analysis to parse out, but basically revenue-focused managers of hospitals and clinics appear to have determined that less than 60 minutes and less visits per week is a better business model - i.e., produces more revenue. So they pushed against the CDT model. If lymphedema treatment is looked at from this perspective, then 60 minutes can seem a decent compromise.

But is 60 minutes enough time? Maybe. In a small minority of cases. If all factors in a patient’s case line up just right. Another essay in this collection differentiates ‘Pretty Lymphedema.’ These might be the patients with early stage lymphedema, typically of the arm and related to breast cancer, with no significant co-morbidities, typically successful socially and economically and with a well-paying commercial insurance - ergo, simple lymphedema with no limiting factors and best for revenue production. These patients arrive early for their scheduled appointment, they can remove their own bandage and cleanse the limb quickly so that the CLT can get right to MLD. In this case a 45 minute sequence of MLD for unilateral arm lymphedema can include the full supine and prone positions. The bandage is a relatively simple arm bandage that can be completed easily in 5-10 minutes. In short, the ideal, best scenario patient for the clinic. (This may be the reason many clinics around the country only treat cancer-related lymphedema - less complicated, more straight forward, better paying - an optimal business model).

These may be some lymphedema patients but this is not most lymphedema patients. Even if we take the insurance payment factor out of the equation, most lymphedema patients have more advanced lymphedema, with more co-morbidities and with concurrent complicating mobility or social factors. And we have to acknowledge that many patients have been progressively suffering under a lack of recognition of their lymphedema for years, or even decades, so that what might have been an early stage lymphedema that could have been easily treated in 60 minutes has now become a very advanced, later stage II or stage III lymphedema that requires more intensive treatment, more time per visit, more modifications and customization of the compression bandage and perhaps more time for the MLD in order to target problem areas.

My personal experience over almost 30 years of doing this work is that 60 minutes is inadequate. For 12 years I always had the freedom to set my own clinic schedule and was always allowed 90 minute appointments. But unfortunately at one clinic where I worked I had to compromise, the feckless manager allowed 60 minutes and I was forced to acquiesce to this if I was to work at all. So I did. And for the early stage breast cancer patients, indeed 60 minutes was manageable and I was able to do a pretty full MLD sequence and bandage. (The exercise component of CDT has always seemed to me something that could be instructed during one visit and then performed at home, and so not taking clinic time.) But most of my patients were more involved, lower extremities, often bilateral lower extremities, with more involved compression bandaging, often with wounds or involved skin care issues. For these patients 60 minutes was clearly not enough and I often went over the allotted time despite feverish efforts to work through the treatment as quickly as I could. Many times it was all I could do to remove bandages, do the meticulous skin and nail care, manage lymphorrhea and/or open wounds and then reapply the bandages. So for most of the 4 regrettable years in that clinic I had to omit the MLD and do the unprincipled thing and have the patient do their MLD at home (All patients know that MLD in the clinic is much, much more effective than self-MLD at home, this isn’t really open to debate). This is not CDT, comprehensive lymphedema therapy, it is barely adequate decongestive therapy, or BAD-t.

But, you might say, the gold-standard schools now state that 60-minute treatments are okay. Maybe not ideal or to the European standard but good enough for us here in the US. However, consider the context here. The leaders of these schools are dependent on getting new students from the various clinics around the country. The school owners don’t want to alienate the market for new students. So they give lip service to the idea that 60 minute appointments are reasonable. I am quite sure that in an honest conversation they would probably admit that of course they would prefer to expect longer treatment times.

The point here is that, except for the early stage lymphedema uncomplicated breast cancer patients, if appointments are 60 minutes, then something is omitted. And CDT by definition is comprehensive and complete. It includes all interventions, performed daily. If the scheduled 60 minute appointment forces one or more key interventions to be omitted or pushed prematurely to the patient to do at home, then it is not CDT. And if it is not CDT, it is not supported by the many studies that show how well CDT actually works since in those studies each treatment session included all interventions and therefore took more than 60 minutes. Full lymphedema therapy takes more than 60 minutes.

No, 60 is not enough.