The authors are appreciative of the letter to the editor by Drs Baklaci and Eyigor regarding our article, “The beneficial role of complex decongestive therapy in patients with symptomatic chronic iliofemoral venous obstruction with phlebolymphedema.”1
Regarding the components of complex decongestive therapy (CDT), note that, in our practice, this includes compression therapy, focused exercises, skin care, and patient education during both the intensive and maintenance phases. The patients in our study underwent this regimen and were excluded if they were unable to pursue any component of the regimen. We have sought to clarify this through the following erratum:
Complex Decongestive Therapy
CDT involved the use of manual lymphatic drainage (MLD) for two to three sessions each week for 6 to 8 weeks as determined by a certified lymphedema therapist. During this intensive phase of CDT and subsequently in the maintenance phase, compression therapy, focused exercises, skin care, and patient education were also pursued. The intensive phase was followed by the maintenance phase during which time a lymphedema pump (sequential pneumatic compression device) that extends from toes to the groins was used twice daily (1 hour each time) in conjunction with compression stockings or compression wraps (pressure, 20-30 mm Hg). Leg elevation alone (without compression) was recommended at night.'
With regard to calculation of limb volume, although this metric is useful, there is no gold standard of limb volume measurement.2,3 Additionally, such instruments (water displacement volumetry, tape measurement, perometry, and disc model among others) have associated problems, including being cumbersome and prone to error based on the methodology used to calculate limb volume.4 A recent systematic review3 noted that, in addition to considering reliability and validity, the choice for a measurement instrument for lymphedema should also depend on feasibility, cost, and the stage of lymphedema being evaluated. The authors recommended the use of bioimpedance spectroscopy for stages 0 to 2, volumetry for stage 2, and tonometry for stage 3, clearly noting that the instruments are not interchangeable.3 Work on use of imaging studies (subcutaneous tissue ultrasonography,5 computed tomography scans,6,7 and magnetic resonance imaging8,9) to make a diagnosis of lymphedema is also being pursued, but await standardization of diagnostic criteria, besides problems related to access to such imaging, cost, time required, and radiation exposure.
Furthermore, besides measurement of limb circumference, we have also used multiple other metrics in our study including grade of swelling, assessment of leg pain, quality of life evaluation through the lymphedema life impact score and determination of extent of impairment. After CDT, there was a statistically significant improvement across all these metrics. Given that lymphedema is primarily a quality-of-life-impairing condition, the positive change in lymphedema life impact score and percent impairment are particularly important because they reflect improvement from the patient's standpoint.
Disclosures
None.
References
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