Shared decision making & patient empowerment

By Tatjana van der Krabben

Names and figures are lacking here and there, which I didn’t get around to copying that day. However, this doesn’t affect the thought behind this blog. Also, the opinions and goals expressed at the congress stem from the Dutch healthcare system with mandatory health insurance and significant coverage as it is, compared to countries like the U.S.A. Therefore, I aim to limit myself to mechanisms and thought processes that translate more widely.

It takes 2 to tango, Duet between patient and care provider, congress by NLNet
Image by NLNet

Saturday I attended a congress on lipedema and lymphedema by NLNet, Dutch foundation for lymphedema and lipedema patients. About 200 people attended, both patients and therapists, as well as a few specialists. However, this time I can’t offer you the habitual overview of new research and insights. The theme was entirely different: It takes two to tango – debates between patients, care providers and health insurance regarding patient care. More specifically: (the feasibility of) shared decision making, a situation where the care provider and patient go over treatment options together and reach a joined decision on the course of action to be taken.

Self-management of chronic conditions

The outline of today’s healthcare for chronic patients is that the main focus of care is on clinical healthcare and only a small portion is reserved for self-management: an upside down pyramid. The aim is to topple the pyramid for chronic patients and make healthcare more so about self-management.

After that statement there was some uneasy shifting in chairs and sharp whispering, because we can all see the danger in that: being sent home with a few tips and tricks, being told to do your best and that would be that. Essentially what we already have when it comes to lipedema. But the speaker clarified that should also imply the majority of funds would also go toward facilitating self-management. Now we’re talking.

The need to shift more toward self-management makes sense to me. Healthcare in hospitals and clinics is largely cookie cutter healthcare targeted at immediate issues and has only so much room to provide individual, long term care. Also, as research shows more and more, a lot of issues can’t be fixed with a pill, a shot or surgery. A lot of it is about exercise, diet, adapting. Things you can and need to address in everyday life.

Shared decision making in health care

Ideally, the care provider and the patient would both go over the different treatment options. The patient would give feedback. Together they would decide on a treatment plan. The thought behind this is that patients feel more content with the outcome and are more inclined to stick with the prescribed therapy as intended when they feel heard and were given the opportunity to voice their own views and experiences.

Reality is a very unpleasant lady

Mind you, to prove the use of shared decision making, research in the context of treating lower back pain was presented. See where I’m going with this? Charted conditions with multiple treatment options are ideal for shared decision making in healthcare. Lipedema is neither fully charted, nor are there multiple treatment options. Well, there are, albeit not comprehensive, but they are not offered everywhere, let alone widely known and covered.

Like many from the audience brought forward there’s another complication. You need empowered patients. When the patient is still in the learning stages, just after diagnosis, it’s a lot to ask of them to provide input on the best course of treatment for them. You also need doctors willing to listen. Not only listen, but also willing to present you with the best treatment options, not push something on their patient. Oh, and time. How often do we feel rushed through our consultations?

Many patients indicated that they felt that a suggested treatment was not always in their best interest. The speaker in question was a little shocked. She saw these reservations in terms of greed and such unethical issues. That was too big a leap if you ask me. I mostly see a more subtle process influencing the outcome of your consultation.
When you see ‘a’ dermatologist, for instance, that dermatologist has certain specialties. Can’t be avoided. Nobody can be trained for everything, even in a relatively limited area of expertise. That and the facilities that clinic may or may not have will  influence the treatment options offered. He or she may have just been trained with a nifty new procedure they think highly of and you happen to walk into the office while he/she is aching to stumble upon a good candidate. He/she offers the treatment. Had you walked into that office a month ago he/she wouldn’t have. Is that bad? Not per se, but things are not that independent as implied. We’re all people, bringing our individual views, training and experiences into the room. This applies to both care providers and patients. The less charted the condition, the trickier this ‘dance’ gets.
I also think patients raising the issue of not getting the best possible care hinted at liposuction. The Dutch lipedema guidelines present it as a last resort type of option. It’s covered only in very few, extremely well documented and severe cases, and only when prescribed by a handful of specialists in the country. Patient perception often is that they’re aware of this treatment option, feel like crap and are convinced that their prognosis with liposuction is much better. Yet, it’s not being offered to them. Not quite the same dilemma as the lower back pain case shown in a video where the options physical therapy and massage therapy were debated, but where the predicted outcome would be pain relief either way.

Evidence based care and Patient Reported Outcome Measurement

The liposuction dilemma led us straight into a new fiery dance: not evidence based. Not yet. Not even manual lymphatic drainage is considered an evidence based treatment! As it turns out the therapists’ best efforts and practical attitude to accommodate us with tailored treatment makes it challenging to quantify what they do. You can’t add up or compare apples and oranges.

Research is key. Here we go again, but the speaker on behalf of the health insurance companies did offer another option: Patient Reported Outcome Measurement (PROM). PROM type of research is about the patient’s experience with a treatment. They evaluate and score the effects. Now, before you bring out your personal spreadsheets, like I know many of you have, this does need to be formalized to make it count. Or else it’s apples and oranges all over again. What happens when you need to formalize stuff? Exactly, our DIY measurements suddenly cost money to make it happen. One of those ‘oh…’ moments. However, the speaker did see room for patient organizations to make this happen. Patient organizations generally move faster than formal bodies and institutions. Also, patient organizations are trained to make things happen on a budget. PROM as a method to gather data on treatment outcomes could definitely be thing.

A doctor’s two cents

That leaves the good doctor. There’s some nuance here, too. Like explained, the doctor can be enthusiastic about a treatment all he wants, if it’s not evidence based, his/her hands are pretty much tied. Like with liposuction in the Netherlands: permission has been given to specific specialists to do a small scale experiment. Those treatments are covered. The experiment status is the loophole here, but only for a very limited number of patients.

I also loved this quote by a doctor: "Clinical experience does not lead to improved communication."

This doctor, not present, only quoted, argues doctors need training when it comes to communication, if we want to move toward shared decision making. A specialist present brought in that we should speak up, not feel intimidated. “We don’t bite”, he said. “It’s not the patients that give me a burn out; it’s the rules, regulations and paperwork.”

This sort of thing is good to hear. The gap between patient and care provider if often not as big as we perceive it to be. Don’t dismiss your doctor before you’ve even invited him to the dancefloor.

What I got out of this day

Research matters. It’s a bit of a pet peeve of mine that a big chunk of the lipedema research is about treatment, while we don’t even know exactly what lipedema is, what causes it and what causes it to progresses. That’s like playing darts blindfolded. However, we need that type of research to get treatments covered or even to have doctors willing and able to prescribe the treatments. We can’t go without any and all treatment until we finally figure out what it is. I see that now. But to sum things up: research. We need more research. We qualify as a ‘small domain’, according to health insurance companies and all those with influence in this debate. We’re not a small domain at all, but, again, we need research to even prove that. 

Research, research, research, or we’re screwed for another generation. Could PROM be a fix for that massive gap we need to bridge? Well, it’s an opening. Until then I largely see shared decision making as a lovely ideal. Because with few evidence based options there’s little to share, let alone to decide. Oh, wait, hold on, more support for self-management for chronic patients is music to my ears. For sure!

What to consider when searching for a surgeon to perform liposuction

This blog could never cover everything relevant, but it's a start, coming from personal experience and what else I learned along the way. I do not recommend liposuction. This blog does not provide tools to assess whether you should have liposuction. However, I receive many questions on where to start when considering liposuction and in that context I offer this information as food for thought. Preferrably, in an ideal world, you would be going over these issues with your informed doctor, or better yet with a specialist in a multidisciplinary institute, where they could answer all your questions and offer the treatment when considered a good candidate.

Learn what exactly you are looking for.
Liposuction, liposculpture, WAL, PAL, tumescent: are you still with me? It's ALL liposuction. All of it. And it's all tumescent. I love this quote of dr. P. Aldea:

"Tumescent liposuction is nothing but the universally performed pre-liposuction infiltration of the fat to be suctioned with a dilute solution of a local anesthetic (lidocain, marcain etc.) and adrenaline (epinephrine) which increases the accuracy of fat removal, largely reduced blood losses AND increases patient comfort."

Source: http://www.realself.com/question/tumesecent-liposuction-general-local-anesthesia

As dr. Aldea puts it: the anesthesia is supplemented. Meaning: tumescent infiltration of the area to be suctioned is a given, but the type of anesthesia is a matter of choice. But mostly not the patient's choice. I'll get back on that.

PAL, WAL, UAL, LA etc.
Along with tumescent, there often are additional specifications regarding the technique a surgeon applies. They can use a specific suction device like Power Assisted (PAL) or apply a thin water beam to help losen the fat from the tissue: Water Assisted Liposuction (WAL). There are more flavors out there. I highlighted PAL and WAL, because lately these are frequently mentioned on patient forums. However, as you can read through the link, these are not the only options.

As you can read they all are presumed to have their merits and do something specific to spare the lymph, do minimal damage, minimize risk etc. Ask a surgeon which is best and you'll get an answer. Ask another surgeon and you'll get another answer.

As a layman I noticed the difference of opinion between professionals and let it be. A certain surgeon prefers a certain technique. Well, apparently that technique suits him/her best. My personal choice was to get over the various terms which I could only ever understand superficially and looked at the surgeon's track record instead: knowledge of lipedema and years of experience. After all: the tool doesn't define the result; it's the surgeon's skill in using the tool.

Note: there's more research out there now compared to the time I had my procedures. If you want to know more about a particular technique and how it works compared to an other or the "plain" technique, there's far more information to be found. Go straight for the "boring" stuff: formal publications, in order to avoid information designed as a scientific-looking piece of marketing. The quickest way to cut to the chase is to search through Google Scholar. It only contains scientific publications.

Plastic surgeon or cosmetic surgeon
A plastic surgeon is trained in hospitals by professionals and has completed related residencies. Cosmetic surgery is not taught through residency programs. Doctors seeking to learn cosmetic surgery typically get their training after their residencies. This pretty much means a doctor would need to organize his/her own training and has a certain freedom the raise the bar to his/her liking. Cosmetic surgery is practised by doctors from a variety of medical fields. Read more about the differences here.

However, deciding between a plastic surgeon or a cosmetic surgeon based on the title only is a trick question. Plastic surgery does NOT equal (knowledge of) liposuction. There are numerous specialties within plastic surgery. Plastic surgery is first and foremost focused on reconstruction of defects due to disorders you are born with, trauma, burns and disease. Lipedema qualifies as a 'disease'. Care to guess how many hospitals acknowledge the condition and offer liposuction as a treatment option? Few. Very few. As a consequence there are few well-trained and informed plastic surgeons out there. For reference: tumescent, which is raved about as a major improvement to liposuction surgery, is invented by an American dermatologist, dr. Klein.

When considering a surgeon you best look at expertise and experience. While you're at it, also look at client/patient reviews. In that context, beware of posers, pretending to be content patients. In the past some clinics have used this despicable method to lure clients. It may still occur...

To improve cosmetically or to improve mobility and reduce pain
This is not about starting a debate. Your body, your choice. It's just very important to find out where your priority is and whether that priority matches with the surgeon you're considering for the job. It's not either/or per se. It can be a little of both. But trust me: there are surgeons out there with a 100% focus on mobility and they will NOT be open to a post-op debate over looks. Even when the result is very uneven and/or irregular. There's also the patient who, in her heart, wants killer legs (back). Again, not judging. Just make sure you set out for a realistic goal with a surgeon who is able and willing to help you strive for that goal. Strive, yes. We're quite the canvas to work with. It's no exact science.

You want a good or even super cosmetic result?
Ask. Ask for pre-op and post-op pictures of women much like you: size, build, with lipedema. Don't let the surgeon just show you his/her best work ever on young ladies with little excess fat and lovely elastic skin. There's skin elasticity and the condition of your connective tissue to consider. Ask about your personal possibilities and impossibilities and, if needed, try to adjust your expectations. It's better to know before than after when there's no going back.

Look for a surgeon with knowledge of lipedema
Typically, those seeking liposuction for purely cosmetic reasons need to have little fat removed. It's not designed as weight loss surgery. Many surgeons even refuse to operate when the BMI is on the high end. Many of these surgeons commonly remove 1 liter, maybe 2 per surgery. A drop in the bucket for most of us. We need someone who can and will remove more.

He/she would have to be aware of the fact that we need to be especially careful with our sluggish and sometimes already compromised lymphatic system. As well as: possible poor skin elasticity, weak connective tissue and possibly slower healing.

General anesthesia or local
General anesthesia in itself poses a (small) risk, on top of the risks inherent to liposuction. You can draw the line there or you can reason that didn't stop you in the past to, say, have your appendix removed.

General anesthesia burdens your body. When I insisted on general anesthesia myself in an entirely different procedure, my surgeon warned me it would take me more time to recuperate afterwards compared to undergoing the same procedure with an epidural. It simply adds to what your body needs to process when healing. Local anesthesia is also favored by some to have the patient able to move and, if need be, stand to assess the evenness of the result. On the other hand, the prospect of enduring the procedure wide awake can be stressfull. Maybe too stressfull for some.

If you are to opt for general anesthesia, you may need to look a little harder for a suitable surgeon. Many clinics can't or won't offer general anesthesia. It requires additional facilities, knowledge and assistance during the procedure. If not that, some surgeons truly want you awake to monitor your wellbeing themselves and have you participating by moving during the procedure.

Pre-op and post-op care
What is being checked and looked into to dertermine you are a suitable candidate? Is it thorough? Do you have a good feeling about this? Do you know the basics and were provided with information on how to prepare for the procedure, what to expect and how to arrange care post-op? How can you reach the clinic when you (feel) you need to? What if post-op complications arise? Who covers these expenses? Where can you turn to? This is particularly relevant if your surgeon is far from your home and you travel back soon after the procedure. At the same time: don't wait to be asked about specifics. Share your medical history and use of medication in detail.

Do inform your primary, even if he/she doesn't support the idea. Make sure they understand what you embark on so they can help in case of problems.
Obvious stuff? Sadly no. I still read about questions like: "Is it normal to still have swelling after a week" and "Is it normal the cuts ooze". That's basic stuff. You should be told about this sort of thing in advance.

Insurance
In rare cases the procedure is covered. Ask around on forum if someone from your country managed to get it covered and what they did. Even if the odds are slim, consider trying. Health Insurance companies need to become aware of lipedema and liposuction as a serious treatment option.

Also, think how far you want to take this. Going ahead with the surgery while still butting heads with your health insurance may ruin your chances of coverage. It may also lead to a road where you can't have the procedure done by your surgeon of your choice. Ask around. Patient forums on for instance Facebook are a wonderful source of practical information.

Lipedema is NOT obesity

By Tatjana van der Krabben

Lipedema is not obesity. It's like comparing apples and oranges. We say apple - or rather pear - to our doctor, he/she replies orange. We've been going around in circles for some time. Some anomalies in our fat cells have already been reported, like hyperplasia of individual fat cells. The fat distribution in lipedema is also very distinct. Yet, we lose our primary at the word 'fat'. There wasn't much else to prove it's apples and oranges, not just oranges. The fact that our blood sugar, blood pressure and cholesterol is mostly normal? Dumb luck and ticking time bomb. Those who did have elevated values? Aha, they proved our doctors' point.

Times are changing. Research is changing. Recently I attended two lectures on studies that specifically compared lipedema and obesity and they found clear differences.

Smeenge, Damstra and Hendrickx found that patients with lipedema have muscle weakness. We have 30% less muscle strength compared to what is considered 'normal'. The obese control group didn't share this muscle weakness. This is unpublished at this point, but you can find a summary in English here.

Hoelen, Van Zanten and Bosman looked at the value of ultrasound as a diagnostic tool in lipedema. Again, in the control group obese women were included. I've seen the slides at the lecture in May. It doesn't take a medical background to spot the differences between the scans that were showed of a person with lipedema and of a person who is obese. Also, it was found that the BMI of lipedema patients doesn't match the circumference of their waist; it was smaller than you would expect based on the BMI number. Meaning: BMI doesn't add up for lipedema.* Again unpublished at this point, but you can find some information on this research in English here.

Lipedema is NOT obesity and some proof of that is finally coming our way. Why is that such a big deal? If you are on team obesity, you are, but if you're not, they should be looking at the issues you DO have, not what they assume they would be. They can't help us or think with us, if they don't see us for who we are.

In all fairness, I've seen studies in the past pointing at lipedema-specific pathology, but these studies are all but forgotten. Fingers crossed these studies get the attention they deserve and stick.

*Get in line, because BMI doesn't add up for a lot of different groups of the population. Also see my blog on BMI.

Lipedema conference - Part 2

By Tatjana van der Krabben

Saturday May 17th the Stichting Nederlandse Lipoedeemdag (Dutch Lipedema Day Foundation) had their 4th lipedema conference. This is not a meet, but lectures only. Stichting Nederlandse Lipoedeemdag offers accredited attendence for medical professionals, mostly physical therapists, but patients can attend. It's impossible to cover the entire day, but I will touch upon some of the highlights or otherwise remarkable quotes and finds.

The third lecture was by Wouter Hoelen, MSc, a therapist and one of the researchers involved in a study using ultrasonography for diagnostic purposes. With lipedema often being confused with obesity, this study focused on the question whether you can use ultrasonography to differentiate between obesity and lipedema. A nice touch: almost two years ago, at a Dutch lipedema meet, these researchers were given the opportunity to see test subjects on site. Those attending the meet had the opportunity to participate in the research if they wanted to.

Mr. Hoelen walked us through various slides, showing that you do obtain a remarkably different picture in lipedema compared to obesity. The fascia or connective tissue should reveal a layered image. The fat, as seen on an ultrasonographic scan, normally shows horizontally stacked little layers, marked by white lines. When showing a slide of a scan of lipedema tissue, the layers where fewer and not so neat. The fascia in lipedema shows less structure. The question was being raised whether that's (trapped) fluid. Another question that was raised was if this could explain lipedema pain and tenderness. The other matter being that this layered section of your fat is supposed to be flexible and mobile. This is now being hindered. For this, stretching was recommended.
In his lecture he brought up two more interesting points:

1. Despite lipedema being linked to puberty and beyond, he has observed suspicious characteristics in younger children.
2. They also found that BMI was not in sync with waist circumference in lipedema. Based on the calculated BMI you would expect a bigger waistline. (personal note: HA!)

Joyce Bosman, edema and physical therapist, explained about a new device called the indurometer. It's not on the market yet and she was among the happy few who got to test it for diagnostic purposes.

Lipedema and lymphedema cause changes in the tissue. The lymphedema skin tends to become tougher, the lipedema skin spongier. The indurometer measures to what extend the skin can be compressed to see if the skin has become either tougher or spongier.

Hopes are that the more accurately progression can be measured, the better treatment plans can be drawn up.

She truly stepped on it in this lecture, to allow for a little bit of time for a fellow board member of the foundation NLNet, Barbara Boots, to talk about the Dutch lipedema information film and show its trailer. A nice intermezzo - yes, I'm biased. This is the Trailer of the Dutch Lipedema Film with English subtitles. Note: it will only play on laptop or pc due to music rights that apply.

The fifth lecture was from three physical therapy students. The Dutch Lipedema Day Foundation had provided them with a research project as a graduation project. They set out to research appropriate exercise for lipedema and work towards a directive. It's all theory at this point, but they incorporated working on loss of strength and Graded Activity, to name but a few things.

The best part of it would be that the Dutch Lipedema Day Foundation has turned the tables. They don't only approach researchers to present their research, they also encourage research and point out where research is much needed. That brings me to their latest endeavour. Research is not only time consuming, it's costly. Everybody needs funds, few get it. The Foundation has introduced awareness bracelets and key chains at the conference to help raise funds for lipedema research. There are more lipedema events coming up in the Netherlands next month. So for starters they will be offered there.

The bracelets and key chains are grey and yellow. Grey for the large grey area regarding knowledge about lipedema. Yellow for the light, hope and progress that is being made. Not coincidentally the colors of the foundation. The text reads: Lipedema awareness and support. If you want to know more about the bracelets, please let me know in the comment section and I'll get back on that.

Oral History, Medical Research and Grassroots Participation in Finding a Cure for Lipedema

by Maggie McCarey

When we fall into lipedema hell where signs on the wall say “do not expect a solution, do not expect a cure, and do not try to escape,” we immediately need a crash course in lipedema vernacular.  Unfortunately, because the medical profession signed off on us as incurable before one clinical trial was completed (and if you don’t count individual case studies, one has yet to begin), we depend, share, and believe in a knowledge base riddled with assumptions. We do not even know what lipedema means before we join forums where the only real advice we receive comes from shared information collected via articles written by doctors synthesizing other articles that evolved also from even earlier articles. We then share this blend of experience and information orally among forum members as if it were the truth, and we pass it on as truth as well. In this way, we who have discovered lipedema perpetuate the bad medicine that keeps us from finding solutions.

     While I am not an expert in the medical field, I am a college professor who taught research and I am an expert on oral tradition, fact, inference and opinion. That women on forums learn to parrot information about lipedema without questioning its scientific basis or logical reasoning is a fact. Consequently, our forums are often unwitting promoters of a belief system based on oral tradition rather than a factual foundation upon which to build a cure. Sadly, as with all belief systems, leaders emerge to keep the fixed system up and running to the determent of visionaries who threaten change or, in our case, cures, if the leaders cannot retain control. Groupthink always creates leaders who hand pick their team members. The leaders’ job is to destabilize the creative process in order to maintain a specific belief in a closed system.  This is survival of the fittest. Conquerors win and the conquered either assimilate or are driven away.  It is the way of history. It is the way of groups. It is the way of all worthwhile struggles that aim to serve humanity with purity of motive.

     Proper medical research is very specific in its components and has nothing to do with power or entrenchment.  It is always evolving as information brings the possibility of a  hypotheses or idea to grow the science of a disease.  The logic of the medical research article also defines the necessary components of research:

As do all forms of science, medical theories have a factual as well as a logical basis. New information is presented in medical research articles. These papers have three separate arguments: the argument of the hypothesis, the argument of the experimental protocol, and the argument of the hypothesis's judgment. These arguments may be examples of the hypothetico-deductive or confirmational model of scientific interference. The logical form of these arguments is informal and inductive rather than formal and deductive. Understanding the nature of the logic of the medical research article may help avoid erroneous conclusions.

(Velanovich, L. www.ncbi.nlm.nih.gov/pubmed/8259532‎

      So far, lipedema research is a two-legged stool trying to strike a theoretical balance without a third leg - the argument of the experimental protocol (laboratory research).  Without the experimental protocol, researchers have no means of self-correcting or making progress towards a cure.  Every doctor I read, unfortunately, has looked at lipedema and hypothesized astraddle the two-legged stool of incurable. This hypothetical judgment, the third argument of medical reasoning, is reached without empirical research and has been passed from one medical generation to the next based primarily on case studies that confused and interposed Dercum’s disease (1892) and lipedema for half a century before Allen and Hines differentiated lipedema from Dercum’s disease in 1941 and that conclusion determined by one patient history.  The medical community has thus had 211 years littered with relentless misogyny to come up with something besides fat to describe lipedema. “Do not expect a solution, do not expect a cure, and do not try to escape.”

     Before we take their collective lack of interest personally I would remind you of the history of the hysterectomy.

            Vaginal hysterectomy dates back to ancient times. The procedure was performed by Soranus of Ephesus 120 years after the birth of Christ, and the many reports of its use in the middle ages were nearly always for the extirpation of an inverted uterus and the patients rarely survived. The early hysterectomies were fraught with hazard and the patients usually died of haemorrhage, peritonitis, and exhaustion. Early procedures were performed without anaesthesia with a mortality of about 70%, mainly due to sepsis from leaving a long ligature to encourage the drainage of pus. Thomas Keith from Scotland realized the danger of this practice and merely cauterized the cervical stump and allowed it to fall internally, thereby bringing the mortality down to about 8%. (C Hutton.  Hysterectomy: A Historical Perspective. www.ncbi.nlm.nih.gov/pubmed/915593300)

Truly, lipedema is in its infancy.  We are at the start of our campaign and most of us will not reach the land of itty-bitty skirts and knee high boots in this lifetime.  Our place in the history of lipedema is likely to be judged on how well we engage the medical community in our struggle, not on how well we harangue doctors to produce immediate solutions they don’t have.  Rather, this first generation will be known for its success or failure by its ability to create a sisterhood with one unified goal: a lipedema cure.  No leaders.  No followers. No ego. No names but one. YANA.

    George Milbery Gould (1848-1922) was a physician, lexicographer, and  the first president of the Association of Medical Librarians (now the Medical Library Association.  In 1903, he addressed the issue of medical discoveries. He wrote in the preface of an abstract titled Medical Discoveries by the Non-Medical:

I have been struck by the fact that the majority of great medical discoveries, truths and instruments, have not been made completely and suddenly, but have been led up to by preliminary and progressive steps, and that the layman has so often made these discoveries prior to the medical practitioner. This great medical truth is, indeed, but an illustration of the general law that all professional progress, in whatever branch of study, is somehow or other a result of stimulus from without. There is so much interest, and there are so many lessons to be drawn from such observations in medical history, that I have in late years kept minutes of this class of truths, from which I make the following selections.

                                                                (Journal of American Medical Association. 903;XL(22):1477-                                                                                                             1487. doi:10.1001/jama.1903.92490220001001)

And what example might Gould been thinking of? How about 18th-century poet, chemist and inventor Humphry Davy who was also an alcoholic and drug addict?  One day Davy found himself with a raging toothache. He sucked on a little nitrous and his tooth pain went away.  At the end of his paper Researches, Chemical and Philosophical; Chiefly Concerning Nitrous Oxide, Davy offered one line suggesting the gas could be used for painless surgeries.  At that time doctors believed that pain aided the healing process.  Forty years later, some medical researcher tried Davy’s solution and the rest was……well, you know…history.  Tally-ho

What was up after Allen & Hines (1940)?

By Tatjana van der Krabben

When you zoom in on lipedema literature, you mainly find Allen & Hines (1940) in the USA and a huge leap towards the late nineties. That’s where it seemingly resurfaces in Europe, mostly in the German context of descriptive cases and liposuction. This blog is an attempt to partially bridge this gap. I’m jumping from one paper to the next to see where it takes me. Obviously I found heaps more. In this blog I highlight the more interesting finds.

Other research on lipedema in the US

My first lead was L.E. Wold, who published with Allen & Hines on lipedema. He too vanished into thin air together with Allen & Hines.  The last reference being a publication by Hines (1952): http://www.researchgate.net/publication/8750774_Lipedema_and_physiologic_edema.

 J. Beninson and J.W. Edelglass from the Henry Ford Hospital in Detroit, Michigan published on it in 1984. The paper has an intriguing title: Lipedema: the non-lymphatic masquerader. They already observed it may be (part) hereditary. They also mention treatment with diuretics was unsuccessful and they actually refer to the extraction of fat: “Rank and Wong have had some success with surgically debulking some fatty tissue.” Alas, no other publications I could find on lipedema by these gentlemen. Plenty on lymphedema, though.

I also found G.H. Rudkin and T.A. Miller from UCLA School of Medicine. This is the abstract of their paper: http://www.ncbi.nlm.nih.gov/pubmed/7972431. While looking into lymphedema, they also found lipedema cases (1994). The lipedema paper was unfortunately a onetime thing. For the both of them, as far as I can tell.

There were a few other dotted incidents, mostly of a descriptive nature, expressing surprise on the existence of lipedema and/or debating the name tag. Like Eisman and Swezey from the University of California (1979) advocating the term ‘juxta-articular adiposis dolorosa’ or JAD for short, mainly making an issue of fat hindering the joints – with good reason, it being a source of pain and damage to the joints. Yet it just never quite sticks anywhere, not until much later when dr. Herbst picks up on the subject – nothing within that gap until the mid-nineties.

From mostly descriptive stuff to some serious content

“We found cases of women with fat legs etc.” I found enough papers from ‘the gap’ along those lines to wallpaper my entire house! I pushed onwards, trying to get to the good stuff. My definition of that? A doctor looking beyond quoting Allen & Hines and trying to learn or find something new on lipedema.

The first I found from ‘the gap’ was in German, but…from Switzerland, official translation of the title: Vascular diseases in lipedema of the legs. Special symptoms, common therapeutic results, viewpoint on vascular surgery, by U. Brunner (1982). Brunner seemingly also had a non-sticking attitude towards lipedema: no other publications on the subject. It’s a vital piece, (already) warning to take particular care when proceeding with vascular surgery in case of lipedema.

Next, I found a real treat: Experimentelle Untersuchungen zur Frage akrocyotischer Zustandsbilder by Moncorps, Brinkhaus and Herfeld-Münster. It mentions the specification on the ‘Moncorps’ type of lipedema. I knew of the Moncorps type – was diagnosed with that myself – but never saw the details of the relevant publication. Currently not really en vogue anymore, but reference to lipedema nonetheless. This is the fun part: published in Berlin in…1940!

I still have a gap to look at, but apparently the Germans never jumped on the train, they were already on it from the start.  

Finally a pattern started to emerge. Scattered across Europe, tucked away between a long list of mostly descriptive papers, I found more in-depth research. Bilancini et al (1995) touch upon a long list of significant references regarding research on our lymphatics and veins. They boldly call lipedema a chronic vascular disease and quote German, Dutch, French and Italian literature from the eighties and early nineties. A theme, cross references and a subcutaneous sneak peek! In short, in the 1980’s it picked up speed, mostly in Europe. Not just Germany.

Very vital findings available on healing issues after surgery (Tiwari et al, 2003 and Macdonald et al, 2003, Brunner, 1982), our lymphatic and venous functions (for instance Harwood et al, 1996 and Wittlinger & Wittlinger, 1978) and the use of scans to help differentiate lymphedema en lipedema and other conditions leading to swollen legs (for instance Boursier et al, 2004 and Dimakakos et al, 1997). A pleasant surprise among all that European input was ‘CT of swollen legs’ by Australian B.F. Vaughan (1990). Unfortunately these efforts received far less attention than the descriptive stuff and liposuction.

Besides liposuction

When liposuction made medical headlines, most quotes, also among patients, evolved around liposuction papers: results, risks, long-term results, techniques. I get it: it’s the closest thing found to a cure – although it’s not a cure, but a road to relief. You get the false impression nothing much went on after Allen & Hines. The research on our veins and lymphatics got covered in dust. Bloody shame if you ask me. Most doctors are clueless you can’t just dive in with a scalpel, what people like Brunner already warned about in 1982. Now we mostly still need to warn our doctors ourselves – if we know there are increased risks of complications after surgery in case of lipedema.

Yet, there is light at the end of the tunnel. Until the 1990’s publications were highly incidental. Severely hindered by the fact virtually each researcher only touched upon it briefly, rarely proceeding more in-depth. The last few years there are many, many publications. Not just on liposuction. Research on the exploration of suspected further symptoms like hypermobility, vitamin B12 and D3 deficiency and the genetic factor, further research on our capillaries and veins, our fatty tissue: it’s happening as we speak. Either recently published or about to be published. The abundance of papers gives me hope it will percolate its way into medical praxis more broadly.

Love and Relationship with Lipedema

by Scott Routon as told to Christina Routon

I met Christina in third grade. She'd moved to my small town in Georgia after her father separated from the military. I was fascinated first by her hazel eyes and by the fact that she was wearing a skirt when most other girls in school wore jeans every day.

We became best friends, and on Valentine's Day in third grade Christina asked me to marry her, and I said yes.

We had some growing up to do, of course, and as time went by and I switched schools we saw less of each other. Then one day this beautiful young woman stopped her car and asked if I needed a ride. We spent the afternoon together and ended up dating for the next two years before getting married in 1990. I was 19, Christina was 18.

There was a sexy librarian-sharpness about her that intrigued me. She's one of the smartest people I know. There was something I found fascinating about her, I can't put it in words. We did have our differences and our issues, though, and while I was in the military and away from home I sent her a break-up letter. I had second thoughts, though, and called her. I couldn't imagine being without her, and I didn't want her to be with someone else, and this time I asked her to marry me.

When I saw Christina on our wedding day, she took my breath away. She was beautiful. When we did the garter toss, I did notice she'd only put the garter up to just under her knee. I didn't know why. I knew Christina had been complaining about her weight and her legs, but I didn't see anything wrong with her. I love curvy women, and I liked seeing her in dresses, skirts, shiny hose and heels. I didn't see anything wrong with her legs. They were just part of her.

Over time, I did notice Christina was gaining weight and some of the clothes she wore didn't seem to fit as well as they used to. We didn't know anything about lipedema at that time. When Christina gained weight when pregnant with our son, that's when I noticed a change in her legs. I was concerned, and I still thought she was beautiful, but we both figured that after the baby was born she would lose the weight and she'd look the way she did before. She's always had a pear-shaped, hourglass figure that I love, and I did want her to get that back.

When we moved to Alabama and Christina joined the gym, I'd never known anyone to work harder. She was going to the gym almost every day, running on the treadmill, lifting in the weight room. She and those other ladies kicked my butt in the spin class! I couldn't keep up, and that blew my masculinity to pieces. But we were both concerned when she continued working out and cutting out junk food and yet only lost thirty pounds during those two years. That was when we started to suspect something else was going on.

I'll never forget when the jerk online said something about her legs. She'd been posting on a well-known bodybuilding forum and had asked for advice about her program. Christina was discouraged because her legs weren't changing no matter what she was doing. This jerk came on the board and replied to her post, basically calling her a liar about her workout and diet and saying horrible things about a picture she'd posted on her profile page. This was one of those times I wanted to hunt someone down and hurt them they way they'd hurt my wife. She cried for a long time and came very close to giving up everything she'd worked so hard for.

This was also the event that made her want to seek out more information. She'd struggled for so many years with her weight and her legs. The way her legs looked was so tied to her self-image that it did affect our relationship and our intimacy. I've always believed she was beautiful and shapely. It didn't matter that I told her she was beautiful and I loved her shape and yes, even her legs. I hated that she didn't wear skirts or dresses anymore and wanted to hide her body from me. When she talked about seeing an endocrinologist to find out what else may be going on I supported her decision.

When Christina started taking medication and she finally started losing weight, we both had hope. I wanted her to wear dresses again. I wanted to get her a pair of boots to wear with a skirt and tights. But when her legs didn't change that much, the doctor said lymphadema. Christina, ever the researcher, began to search for answers and that led us to lipedema.

Everything she found said no cure, no treatment. I was furious, I was upset. It was unfair. It's hard to explain how crushed I was. I felt I'd never get the Christina I'd known back. I still loved her very much, but it was hard. And she'd been working so hard to lose weight and I wanted her to look the way she felt.

For Christina, it had a name and that was a relief. But I need an enemy I can fight. This was something I couldn't conquer. It was hard to accept, and I needed hope. I needed to hear something, anything, besides to accept it and get through it with God's grace. I needed to hear God can and will heal, that's there's medical treatment, something.

When Christina started the wrapping therapy, it was hard for me to see Christina go through it day in and day out, but it made me feel proactive. I felt like we were doing something and that felt good, it gave me hope, and I could let some of this anger out.

I'm still angry that there's no medical treatment or a lot of research in the United States for this. I also hate that a lot of plastic surgeons don't know about this or if they do, many won't touch it because of possible physical complications. I hate that many doctors don't know about this and continue to hurt and discriminate against women who have this disorder.

I completely support liposuction as a treatment for this, and if Christina and I have to go to Germany to have it done then that's what we'll do. Until then, we'll continue to learn as much as we can, continue to experiment with diet and exercise, and even if I have to have a pair of boots custom made, I will see Christina in a skirt and boots one day.

I ALMOST FELL OFF MY CHAIR: or, THE MARINE’S HAVE LANDED

By Maggie McCarey

I Googled “lipedema” this week and a few entries down from  #1 Wikipedia was a site for sore eyes.  It was a bonified United States government document on lipedema.  Do you know what this means, Phineaus T.? It means that lipedema has made it to the big top: the National Center for Biotechnology Information at the Department of US National Library of Medicine at the National Institutes of Health.  The document is an article titled Lipedema: a Rare Disease by Bae Wook Shin, M.D., Young-Joo Sim, M.D., Ho Joong Jeong, M.D., and Ghi Chan Kim, M.D, researchers from Korea.  They followed the medical intervention of a 60 year old Korean woman who had shown intermittent symptoms for ten years and then, the last three years before treatment, seemingly unstoppable swelling of the legs, and ultimate diagnosis of lipedema.

        

Dr Shin, et al. made some unprecedented statements about lipedema.  I will try to summarize their findings. [Note that I have quoted much directly from the article Lipedema is a Rare Disease.]

1) Success with complex decongestive therapy, pneumatic compression, and diet modification to reduce swelling in treatment of lipedema is debatable.

            

2) In examining their subject the researchers noted:

                        a. her muscle strength and sensory and muscle stretch reflexes of both the upper and lower extremities were normal

                        b. upon examination, petechiae (purple splotches) were noted in both her lower extremities and a lipoma was observed under the right knee joint. [petechiae is common among viruses carried by insects, disease, and lupus among other causes].

                        c. her greatest response to pain was along the outer thighs [which in sports medicine is called Iliotibial Band Syndrome or inflammation of the IB causing pain on the outside of the knee up the outer thigh and jabbing intermittent pain in the hip.] *I know it well.

            

3)  No abnormalities were noted upon neurological examination.

            

4) Blood tests for diseases of the thyroid gland, heart, and kidney were all normal.            

5) Three-dimensional computed tomography angiography was performed to determine whether the edema was a result of vascular lesions.

                           a. vascular lesions, including deep vein thrombosis, were not observed.                         

                           b. Technetium-99m human serum albumin lymphangiography was  conducted to assess the presence of lymphedema, but there were no abnormalities . [No lymphedema present!]

             

6) Regarding her pain, no abnormalities in the onset latencies and nerve conduction were found and there were no denervation potentials on needle electromyography. 

                            a.  doctors  suspected that her pain was due to serious edema and the increase in subcutaneous tissue rather than an abnormality of the nerve conduction velocity due to peripheral polyneuropathies .

            

7)  Complex decongestive therapy including bandaging was actively performed after the patient's tenderness on pressure was reduced. Upon symptom improvement, dietary modifications were attempted in consultation with a nutritionist in conjunction with an exercise prescription that focused on aerobic exercise.

                              a.  The treatment continued for a month.

                              b. There was no significant change in total weight over the treatment period, but the reduction in edema resulted in decreased circumference of 2.75 cm and 2.45 cm in the right and left lower extremities, respectively. 

CONCLUSIONS:

Other characteristics of lipedema include hematomas or petechiae that can easily arise from a minor shock or slight touch due to the increased fragility of the microvessels.

Serious pain on palpation is relatively common in lipedema compared to lymphedema, and it is rare to find a medical history of cellulitis.

Complex decongestive therapy cannot affect fat tissue, but can contribute to treatment by reducing interstitial  edema.

No bandages should be used until the pain subsides because, unlike lymphedema patients, those with lipedema report pain and hypersensitivity in the edema areas when complex decongestive therapy is performed.

The use of bandages after the pain disappears is helpful in reducing edema.

According to several reports, a reduction in the excessive fatty tissue in lipedema is possible if the compression stockings are worn constantly and if compression bandages are applied at night.

However, continuous treatment is critical because the edema will recur or worsen if complex decongestive therapy is stopped.

It is extremely likely that lipedema can be improved if proper treatment is applied before 35-years-of-age, but delayed management makes the prognosis of lipedema similar to that of lymphedema as the disease progresses to lipolymphedema.

     

The last interesting thing about this article is that many new researchers were named from across numerous disciplines and countries: Weisseleder and Schuchhardt in Germany;  Child, Gordon, Sharpe, Brice, Ostergaard, and Mortimer in England; Pascucci, Lynch, Rudkin, Miller, Macdonald, Sims, and Mayrovitz in America, and Szolnoky, Nagy, Kovacs, Dosa-Racz Szabo, Barsony, Balogh, Kemeny in Hungary [Hungary????**&!], all of whom have produced papers directly addressing lipedema, and all within the last few years.  If you would like read the article for yourself, go to http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3309375/

I could not be happier with the growing awareness of lipedema in the medical community. The time will come soon when our doctors will have to believe us now that even agencies of the federal government have taken up our cause.