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Compiled by an internationally renowned pioneer in the field of lymphology with contributions from leading experts, this textbook explores all aspects of lymphological science, including the causes, diagnoses, prognoses, and treatments for primary and secondary Lymphedema. Comprehensive discussions address all the essential topics relevant to lymphology, such as anatomy, physiology, and pathophysiology.

Therapists will benefit from practical information on clinical findings as well as instructions for performing manual lymph drainage.


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Provides a detailed presentation of the anatomy and physiology of the lymphatic system. Explores the causes, diagnoses, therapies and prognoses of all lymphological conditions from a physician's perspective. Includes a well-founded and practical discussion on the techniques, effects and implementation of Complete Decongestive Therapy CDT. Fundamentals of Comparative Lymphology. Physiology and Pathophysiology of the Lymphatic System.

Lymphostatic Diseases. The uneven distribution of tertiary level physicians was not only present at a global level, but also within single countries. Concerning filarial lymphoedema, only 40 specialists could be mapped. Our search led to just two medical specialists dedicated to podoconiosis.

Lymphedema management: Manual Lymph Drainage for lower extremities

This is also true for North America. Our search regarding professional societies and institutions dedicated to this field of medicine showed that the leading single country is the U. European countries altogether have societies mentioning lymphoedema as one of their points of interest, all specialties included, but oftentimes the professionals involved in these societies or institutions are the same at regional, national and international level. Additionally, some Asian countries as India are well organised in this field with a total online track of 96 Indian societies.

Table 4 also shows where industrial companies dedicated to lymphoedema products are located. Leading countries are the U. Developing countries are virtually depleted of industrial companies in this field, forcing them to import needed products or simply failing to provide them. The social burden of the lymphoedema pandemic is inversely proportional to the low number of medical professionals dedicated to its management or research.

It is translated in inadequate prescriptions, poor management of health resources, as well as time of work absenteeism, social exclusion and stigma of patients [ 12 , 18 , 19 , 25 , 26 , 27 ]. The conducted study aimed at a semi-quantification of the problem by showing where medical professionals can be found, and where their coverage must be expanded.

One possible limitation of our study resulted from restricting our search to the internet. Certainly, local offers of lymphoedema management exist that were not visible online. Especially in developing regions patients still seek advice from traditional healers [ 29 , 30 , 31 , 32 , 33 , 34 , 35 ]. This is supported by reports from the Caribbean, showing that most patients only seek care from university-trained but more expensive healthcare providers when traditional treatment has shown to be ineffective [ 26 , 27 ].

If patients and their communities are taught about their disease, it has been shown that a loco-cultural understanding of the disease can coexist with the biomedical one [ 36 ]. Therefore, additional low-cost programs should be established, as they improve lymphoedema outcomes, even leading to an important economic benefit as patients are able to work again or work more [ 24 ]. Examples of low-cost interventions are training of communities on hygiene measures of the lymphoedema limb as well as demonstrations for the application of topic antibiotics on secondary wound infections and bandaging.

This demonstrates the importance of understanding the cultural background when planning health resources in these societies [ 37 ]. The online selection bias might nevertheless have the advantage of listing only professionals that have reached a certain degree of impact, at least at regional level.

Földi's Textbook of Lymphology (3rd ed.)

This study therefore mimics the barriers encountered by lymphoedema patients seeking healthcare providers with the support of online search engines but might not be exact concerning the current local healthcare measures provided by the communities. Considering the language barrier, the analysis was limited to six languages spoken by the main authors. Regions of the world not using the latin alphabet were impermeable to our search thus creating false negatives mainly in the data on Asia and North Africa. Therefore, although our search was thoroughly performed with the name of every single country in the world, the fact that we were using western languages in our search reduced our scope of investigation extensively, especially considering that Asia is an extremely populated region of the world.

Retrospectively, most countries failing to provide any online information were small in size and population. Additionally, some of these countries use specific local terms to name lymphoedema. These alternative terms might have led to incomplete listing of involved professionals in the respective regions of Africa, Central America and Asia. General analysis of the absolute number of professionals qualified at tertiary level in this field reveals a great need for Asian, North American and European countries to organise training offers.

In the reminiscent regions, countries do not seem to possess enough professionals to offer the whole spectrum of medical training on lymphatic diseases Fig. Therefore, it is paramount that healthcare providers in Asia, North America and Europe embrace this challenge, take responsibility and promote training offers to improve global geographical coverage. Lymphology should already be taught in undergraduate medical school in order to close the knowledge gap [ 11 ]. One could postulate that if financial resources invested in humanitarian treatment of disease in developing countries in the past had instead been used for medical training, the present situation might not be as unbalanced.

In these countries, in spite of an established prevalence of 40 million patients affected with lymphoedema as a consequence of lymphatic filariasis, few are able to receive proper medical support and treatment [ 9 , 10 , 40 ], especially as the patients are more likely to get the disease if they have a low or medium socioeconomic status and might therefore not be able to afford treatments [ 41 , 42 ].

On the other hand, the treatment of filariasis constitutes one of the success stories of mass drug administration Global Programme to Eliminate Lymphatic Filariasis - GPELF with decreased primary infections following the global programs of eradication [ 43 ]. Community healthcare workers carried out the pharmacologically driven programs.

Nevertheless, healthcare workers were not specifically informed about lymphoedema and lacked the clinical expertise of tertiary level professionals to diagnose this condition as a possible corollary of filaria infection. This constituted a lost opportunity of broad geographic impact perpetuating inadequate management, poor treatment and failure to meet the specific needs of patients with lymphoedema after filarial infection [ 26 , 27 , 31 , 44 , 45 ]. But, even so, substantial health and economic benefits have risen from the program, especially in what concerns lymphoedema prevention by treating the causal worm [ 42 ].

National strategies are often followed by new investments. An important addition to national strategies would be to collect statistical data on the current prevalence of the disease and apply epidemiologic information in the creation of medical support where help is needed [ 46 , 47 ]. The heterogeneity of medical training is not restricted to developing countries.

A lack of specialised physicians especially exists in poorer, more rural and remote areas as described for Australia [ 48 ] and similar findings were postulated even across the U. In the case of Spain, most mapped physicians were located in cities. Lymphoedema consultation services are mostly based in hospitals and for public insurance patients the access is restricted, making it more difficult to seek qualified treatment [ 8 ]. With the exception of some regions of Germany and Switzerland, professionals specialised in lymphatic diseases were very seldom general practitioners, rendering this distributary problem a characteristic of most countries worldwide.

Regarding the data on the number of researchers dedicated to lymphoedema, one of our main difficulties during our search was to identify if these professionals were physicians, or belonged to other professional branches e. Nevertheless, this academic distinction has little influence on the capacity of researching solutions for a disease, as this plurality might be beneficiary for innovation.

Most researchers originate from continents with developed countries such as Oceania or Europe. Awareness and public funding of research are still low on upcoming continents such as South Asia although things have started to change [ 49 ]. Young researchers are less attracted to investigate a field they have never heard about as most of their universities have failed to include lymphatic diseases in the university curricula.

An important milestone of a global strategy to address the problem of medical care of lympho-vascular diseases should also include measures to break the vicious circle of the lack of research. This has to be achieved outside of the laboratories at sub graduate level through innovative training offers. Patients trying to find qualified medical healthcare professionals online, will be confronted with similar limitations encountered in this study.


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  • Nevertheless, patients express a deep need for guidance and information [ 50 ]. A medical doctor with expertise in lymphatic diseases that cannot be found by patients searching online is equivalent to a very localised resource. Therefore, we also analysed the number of professional societies, as they play a paramount role in providing information on the spectrum of expertise of their members. Physicians were easily found in South America as the Pan-American Society for Lymphology and Phlebology published a list of physicians.

    Other examples of societies providing well-structured information are to be found in Germany and Switzerland. There was no clear correlation between the number of professionals specialised in lymphology in a region or country, and the number of professional societies active in this field.

    But most problematic was the complete lack of independent societies for lymphatic diseases in most countries of the world that could contribute to high level postgraduate education and facilitate discussions about diagnosis and treatment guidelines.

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    In our analysis of the distribution of industrial activity connected to lymphoedema, North America and Europe were the leading continents. The associated industry is currently not pharmaceutical but mainly biotechnological focussing on measurement devices, surgery microscopes and compression garments. Similarly to pharmaceutical companies, biotechnology companies show less interest in e.

    Africa or South America most likely due to poor distribution networks and low profit margins. It is somewhat striking to see this disparity of numbers of specialised physicians in developed countries. We believe the reasons for their relatively high number in some countries as e. Belgium or Germany to be historical. The first lymphoedema clinic was founded in Germany and already in the late seventies, German healthcare insurances started reimbursing lymphoedema therapy modalities. Although many physiotherapists in Germany are trained in manual lymphatic drainage, only medical doctors are entitled to prescribe it.

    Therefore, there is a positive peer pressure between both professional groups.

    This leads to some degree of medical training in this field [ 51 ], mostly of general physicians as well as doctors in physical and rehabilitation medicine [ 52 ]. Why do other developed countries with a similar number of lymphedema patients still lack specialised human health resources? Improving the quality of management of this disease in Germany and the Benelux was not solely due to medical professionals in itself but mostly to the professional group of the physiotherapists. Here, reimbursement of lymphoedema treatment was adequate, but only allowed to those physiotherapists having undergone validated specialised training.

    The medical chamber of doctors in Germany failed until now to recognise a medical subspecialty in lymphatic diseases, although reiterated proposals have been delivered by professional societies since the nineties. Until today, all physicians are entitled to manage lymphoedema patients.

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    Also, the reimbursement for this medical act is very low and calculated for periods of three months regardless of the number of times the patient has to be seen in that time interval, leading to low motivation to treat this chronic disease. Paradoxically, European policy makers do not seem to be aware of the costs of fail prescriptions and poor management. In the U.