Shall We Squander the Gift?

John Fuller Beckwith3/14/2024

Forty years ago Michael and Ethel Foeldi created Complete Decongestive Therapy (CDT) as a comprehensive treatment for lymphedema. They created it out of their passion for the subject and their compassion for their patients. They researched historical treatments and understanding, explored beyond the current knowledge, risked a lot, invested more and ultimately created one of the truly eloquent treatments in medicine. It wasn’t easy, they didn’t take the path of least resistance, they didn’t give up when institutional support evaporated. When they lost support they persevered and stayed true to a vision. When success was attained, they did not trademark it, or trade on their success for their own benefit. Rather they freely shared it with the world. Their comprehensive system of understanding, grounded in rigorous study and tested in real-life application, carried medical science forward from a place of partial understanding to life-changing interventions for a debilitating disease. Their accomplishment was not a small step forward, but a great leap. Like great composers, who see the same notes but in a new and brilliant combination, they could see possibilities that were not visible to their peers They brought these possibilities to life, making them real and accessible to anyone. In this way, what they created is a gift to the world of lymphedema treatments, brought to life by their genius and shared through their generosity so that all could benefit.

We in the United States are the beneficiaries of this gift. We have been thoroughly instructed and guided. All aspects of the body of knowledge around lymphedema that was created and packaged by the Foeldi’s has been made available to us. Nothing has been held back. And we have then delivered this gift to our patients. We have seen patients lives changed, we have seen the scary specter of lymphedema brought under control so that while it may remain a mild chronic disease, it is manageable and under the control of the patient. Persons with lymphedema have hope where previously they felt no hope. If we are fortunate enough to be providers who have been instructed in CDT, we feel grateful to be able to administer a therapy that is so life-changing. But we recognize it as a gift bestowed upon us and not a reflection of our own mastery. Like the pianist who can play the music of Beethoven or Mozart, we did not create the music nor do we take credit for it, none of us is a ‘superstar.’ We are mere conduits. Our task is to play the composition in a way that is true to the creation. In this way the genius of CDT manifests itself in the outcomes achieved by our patients.

What is the full extent of the gift? Do we even recognize it as a gift? To appreciate the gift we must identify true CDT. What is authentic CDT? It is the component parts, certainly, so the full gift would include all the component parts. In fact, CDT is as successful as it is, and most successful, when all the components of the system are engaged in the intervention. Yes, the parts of CDT are MLD, compression, skin care and exercise. But the value of CDT is greater than the sum of its parts. Beyond that, daily visits applying this combination of interdependent interventions makes sure gains are consolidated and allow for continued progress. Dr. Foeldi says in his Textbook of Lymphology that CDT never fails (which in 25 years I have found to be true), unless: the diagnosis is incorrect, the patient fails in their duties for the treatment, or… the therapy itself is performed inadequately. We all lean on the great studies that demonstrate the efficacy of CDT. But what underpins and brings together the results of those studies in mutual support? In those studies the delivery of CDT as designed in its complete form: daily, comprehensive, skilled.

The question, now, decades later, is: Are we squandering this gift? Some might ask: do we need to even pose the question? Some might say CDT has spread far and wide, it has inspired new attention for lymphedema, that new expert practitioners are trained monthly and sent out to do the good work of CDT. In that sense the answer is: Yes, more therapists trained, more clinics offering a lymphedema service,…but more importantly and more accurately the right answer is: No, the service delivered in a good portion, even a majority of clinics is not the gift that has been shared with us. It is something less, often much less. How so, might be asked?

When is lymphedema therapy not CDT? When it is not complete, not comprehensive, it does not fully engage all the components of the gift. How might this Incomplete Decongestive Therapy look? First, by diluting or omitting essential components of CDT. This occurs when a patient with measurable lymphedema is just fit to a compression garment and provided with MLD – no skilled bandaging, so there is no way to know what a full reduction would look like. Akin to not applying the skilled bandage at all is the approach of having the patient bandage themselves. This removes the therapist’s skill and experience from compression bandage application (and modification as therapy progresses) and will not result in the best outcome. The patient does not have the skill or ability to modify the bandage as needed not only for better and targeted reductions, but also avoid adverse outcomes.

Squandering the Gift occurs when the therapist just puts the patient in a velcro compression garment with the intention that it will reduce the lymphedema effectively. This implies that any compression at all is good enough. Part of the Foeldi genius is the formulation of layered lymphedema compression bandaging. It is not generic, it recognizes the superior effect of short- stretch bandaging, the beneficial effects of different density foams, it realizes the importance of the Law of LaPlace such that the bandage can be used, as Steve Norton well states, to, “sculpt the limb.” Why apply just any compression when you can apply the best compression? Why be satisfied with a partial benefit when you could get the maximum benefit?

Squandering the Gift occurs when a patient is taught to perform self-MLD, rather than have it applied by the therapist. The patient can not apply the strokes from the position the therapist applies the strokes. The patient certainly can’t do all the Vodder techniques. To say the stationary circle technique can be done in all parts of the body is to devalue the full array of Vodder strokes, which are designed to work best of different parts of the body. To have a patient do self-MLD negates the specialized training and accumulated experience of the therapist. Again, why be satisfied with a partial benefit when a person suffering from lymphedema could and arguably should receive the maximum benefit?

To those who would argue that teaching the patient to bandage themselves and to do self-MLD during the intensive phase is adequate, I would ask: don’t you think if that worked the Foeldi’s would have done that? Do you think during their exploration of the optimal way to treat lymphedema they would have chosen twice per week treatments if that actually worked? They did not arrive at a frequency of twice per day six days per week just because they wanted to work hard. No, through a rigorous process of trial and error they arrived at the approach that actually works best.

CDT is by definition a skilled therapy intervention. Not seeing patients daily, reducing treatment times which necessarily means omitting parts of CDT (can anyone say “45 minute treatments twice per week?”), having patients bandage themselves rather than the specialist-trained therapist administering this key intervention. Same with MLD – having the patient perform it to themselves rather than the skilled therapist applying comprehensive MLD, substituting garment for the short-stretch bandage during the intensive phase of CDT. Each of these approaches diminishes the gift and shortchanges the patient.

CDT is indeed a gift to the world. And this is how the gift is squandered, to call what we do CDT but then to not administer it as we have been instructed to deliver it. We are not providing to those who need it the full gift we have been empowered to give. We do a disservice to our patients when we imply we are providing the full gift, but don’t give it comprehensively. Aren’t we also doing a disservice to the selfless generosity of the Foeldis? Having made so much progress, shall we squander the gift?