Real PT

John Fuller Beckwith5/14/2025

A number of years ago I was working at a medium-sized hospital in a large metropolitan region, working as a lymphedema specialist in the outpatient department. I was one of several CLTs and the most senior. I saw only lymphedema patients, we had a long wait list and I hadn’t seen regular physical therapy patients in at least 10 years. One day one of the other senior physical therapists said to me, “You’re not a real physical therapist.” I think it was half in jest and said with an audible laugh, but also a serious dig. I had a good reputation as a CLT and perhaps this was a reminder to me that I wasn’t, “all that.” Fair enough. However, with apologies to my esteemed OT colleagues who are great CLTs as well, I believe lymphedema therapy is, “real,” physical therapy.

What is it to be a physical therapist? We work in the medical field, specifically in the Rehabilitation discipline. Our role is to, using physical measures, restore health when specialized physical measures are indicated. Much of the focus of those physical measures involve using the knowledge of musculoskeletal anatomy to impact pain, posture, balance and physical function, so there tends to be a focus on exercise and muscle function. Yet what are all the medical domains of physical therapy? PT encompasses 5 general domains: musculoskeletal, neuromuscular, developmental, cardiopulmonary and lastly, integumentary. Physical therapists use physical measures within these domains to mitigate and improve the health of individuals. Many physical therapists in their careers gravitate to one or another domain, as there are pediatric specialists, neuro specialists and ICU specialists (who can be said to be specialized in the cardiopulmonary domain). Lymphedema lies firmly within the integumentary domain. We apply physical measures skillfully and individualized to each patient that require specialized knowledge of not only lymphatic anatomy and pathophysiology, but also the interaction of that with other systems. We use our knowledge of systemic diseases in order to mitigate how treatment might or might not impact other systems. We have to be aware of precautions and contraindications to avoid adverse reactions and outcomes, so that our core physical therapy education underpins treatment implementation. We do manual work, we impact body systems with our hands, we educate and instruct, we use specialized knowledge of techniques and adapt them to each individual. In short, we do actual physical therapy.

But what about how physically hard we as CLTs work when compared to our more typical outpatient therapy colleagues? When we see a patient, we immediately engage them to elicit feedback and information and set the stage for individualized education (obviously, that is not different than all therapists do), but also immediately we get to work physically, undoing the skilled compression bandage we applied yesterday, assessing and inspecting closely for integumentary changes (improvements, adverse skin signs), cleanse the limb, go directly to MLD sequence for 30 - 45 minutes, then newly apply the skilled multilayered bandage, modifying as indicated so that we can sustain progress. Applying the bandage is focused and intensive physical effort, many of us have to take a moment to recharge after bandaging a full leg but especially after bandaging two full legs at the end of a complete treatment session. What we don’t have here is time to stand aside and do notes. We are engaged with our patients constantly, hands on constantly and when we finish with our 70 or 85 or 95 minute treatment, only then can we sit down to document the visit, the changes in the patient, the education provided, the modifications to the treatment.

Our colleagues in the outpatient setting are often supervising (read: standing by, watching) as their patient completes the prescribed repetitions of an exercise routine, or the therapist is completing part (or all) of their note as the patient performs the billable intervention. While we are busy physically throughout the treatment session, our colleagues are often sitting or standing and… well… not actually doing anything physical. (I can recall countless times observing my ortho colleagues standing with arms crossed or hands on hips or sitting by on a treatment stool chatting while the patient completes their reps and sets.) My former colleague, new and young (in her thirties) expressed concern about the wear and tear of lymphedema work on her body, as compared to other types of therapy work.

So, Yes, we are real physical therapists doing real physical therapy and Yes, I will go there and say we work harder than our colleagues. How about a little respect?