VI. News on Lipohyperplasia Dolorosa [Lipoedema]

Abstract

Manuel Cornely¹, Gabriel Faerber², Nina Huettinger^{3, 4}, Pamela A. Nono Nankam^{5, 6}, Claus C. Pieper⁷, Anette Goerg⁸, Christine Hemmann-Moll⁹, Tanja Lenk-Killinger¹⁰, Christian Ure¹¹, Chieh-Han John Tzou^{3, 12, 13}

¹LY.SEARCH gGmbH, Duesseldorf, Germany

²Centre for Vascular Medicine, Hamburg, Germany

³Department of Plastic and Reconstructive Surgery, Department of Surgery, Hospital of the Divine Savior, Vienna, Austria

⁴Ordination Huettinger, Vienna, Austria

⁵Clinical Obesity Research, Helmholtz Institute for Metabolism, Obesity and Vascular Research (HI-MAG)

⁶Helmholtz Zentrum München at the University of Leipzig and Leipzig University Hospital AöR, Leipzig, Germany

⁷Clinic for Diagnostic and Interventional Radiology, University Hospital Bonn, Germany

⁸LIPOCURA, beethoven 5.13 Clinic, Cologne, Germany

⁹Master bandagist, Bad Rappenau, Germany

¹⁰Wittlinger Therapiezentrum GmbH, Walchsee, Austria

¹¹Wolfsberg Lymphology Clinic at the LKH Wolfsberg, Austria

¹²TZOU MEDICAL., Lymphology Center, Vienna, Austria

¹³Faculty of Medicine, Sigmund Freud University Vienna, Austria

The final block of the 5^th International Lymphology Symposium, which will be held from November 21^st to 23^rd, 2024 is dedicated to the latest information on lipohyperplasia dolorosa, commonly known as lipoedema.

The responsible coordinator of the German S2K guideline for lipoedema, Gabriele Faerber, summarises in her presentation the experiences and reactions 8 months after publication of the guideline and emphasises that the English version of the new current guideline on lipoedema (LiDo) has been available since August 2024. This paper met with a mixed national and international response, as the classification into stages used internationally based on morphological criteria is no longer to be applied. Irrespective of this, ICD coding is still a necessary option. Nevertheless, the current stages are not suitable for reflecting the severity of the disease, differentiating from other symptoms, recording pain, or even quality of life. Regarding therapeutic options, the guideline also recommends moving away from staging and placing the severity of symptoms at the centre of therapy. Even if the objectification of pain assessment is still a “work in progress”, the treatment of LiDo patients should be based solely on the assessment of pain. The volume of the extremities plays no role, nor does the quality of the skin surface, which is described in stages.

The recommendations on manual lymphatic drainage are further dissonant: the guideline can only give a weak recommendation in favour of manual lymphatic drainage. The old therapeutic procedure should only be used if compression alone is not tolerated or effective enough. The use of MLD to improve the quality of life in LiDo can be considered.

Nina Huettinger takes up the topic in more detail in her presentation and talks about the treatment options and necessities in LiDo. She recommends considering treatment if the level of suffering due to pain, restricted movement and psychological stress caused by the altered appearance is considerable. Suppose the quality of life is impaired in this way. In that case, she recommends liposuction to completely remove the painful fatty tissue, in addition to conservative measures. She emphasises that the previous classic two-pillar principle of conservative versus surgical treatment should be expanded to a multimodal therapy approach.

Pamela Nono Nankam reports on her research into the adipocytes of lipoedema. She describes the disproportionate differences between the symmetrical accumulation of white fat (WAT) at the extremities, which, unlike adipocytes, is resistant to lifestyle changes in obesity. She describes the disproportionate differences between the disproportionate symmetrical accumulation of white fat (WAT) at the extremities, which, unlike adipocytes, is resistant to lifestyle modification measures in obesity. The pathophysiological mechanisms behind this were investigated in a study on gene expression patterns, tissue structure and altered signalling pathways in LiDo patients. Evidence of increased mitochondrial activity and adipocyte differentiation in LiDo and downregulation of inflammatory genes indicated decreased inflammation in WAT. Increased metabolic activity in adipose tissue of LiDo patients may be a key mechanism supporting continuous tissue expansion at a constant metabolic state in lipoedema.

How does manual lymphatic drainage affect the tissue of LiDo and lymphoedema? Claus Pieper's study investigates this question, which has never been examined using objective imaging techniques. The focus is, therefore, on the oedema component of the disease of the fatty tissue of the extremities. The prospective multiparametric MRI study of eleven patients with lipoedema and eleven patients with lymphoedema shows that the mean T2 relaxation times and the sodium levels in SAT and skin are increased in lymphoedema and to a lesser extent in lipoedema, which indicates an accumulation of sodium-rich fluid. After manual lymphatic drainage, a significant decrease in the parameters is observed in both clinical pictures.

Conclusion: Manual lymphatic drainage has a measurable effect on the oedematisation of the interstitium in an MRT.

This session of the congress will also include case studies. Anette Goerg presents two clinically outstanding cases:

I. Formation of lipoedema in monozygotic twins with the question of genotype versus phenotype

In the twin pair, only one of the sisters is a phenotypic LiDo patient; the other is not. Görg finds no explanation for this in the scientific literature and consequently points out that investigations into the genotype and phenotype must urgently be initiated.

II. Adenopathy and lipoedema

Her second case concerns a 23-year-old female patient with generalised lymph node swelling. This raises the question of co-incidence with primary lymphoedema in generalised adenopathy with phenotypically clear LiDo, but with tenderness also on the abdomen, back and flank, as well as on fat pads in the area of the cranial thoracic spine. The generalised adenopathy was discovered during a CT scan performed following a car accident. Malignancy and all the usual autoimmune diseases were ruled out.

Four speakers present their theses on the crucial question of “Visualisation, measurement methods and their assessment in lymphology. Which methods are reliable?”. The topic will be debated in a panel discussion chaired by Erich Brenner.

Manuel Cornely kicks things off with his report on non-contact measurement using the 3D-scanner and explained the unique features of the process made possible by Scaneca's 3D body analysis system. The analysis levels on the virtual twin, the avatar, can be focussed on regions of particular interest. The entire body's height, weight, and circumference parameters are scaled according to standard values. Including the whole body - particularly in the co-incidence of LiDo and lymphoedema with obesity - in the earlier exclusively extremity-focussed documentation of lymphology findings is a new way of avoiding incorrect interpretations due to co-incident obesity. Post-bariatric treatment courses are thus better recorded. The lymphoedema-typical cutis thickening, which can account for up to 17% of the volume of the affected side in stage III lymphoedema, can also be better recorded with the scanner which measures around the whole body than with measuring systems which are only centred on the extremities. This electronic documentation allows the values to be compared in follow-up examinations.

Christine Hemmann-Moll explains the advantages of measuring with a tape measure, i.e. the conventional method. Methods such as PeriKit, scanner or perometry would not allow any conclusions to be drawn about the consistency of oedema, mobility and possible soft tissue displacement in different positions. Increasing obesity and resulting oedema also pose challenges in the day-to-day practice of bandaging and compression specialists, who can only be helped by measuring with a tape measure. Length, circumference, and tension measurements are taken on the decongested extremities, and fibrosis and skin and skin folds are also examined by palpation. The intensive contact with the patient through manual work should not be underestimated. This provides good compression and forms the foundation of compliance and adherence, the elementary pillar of conservative oedema therapy. It is only successful if the compression is tolerated and worn by motivated patients. Therefore, attention to the patient is also an essential element when using the tape measure.

Tanja Lenk-Killinger presents the PeriKit-system. As a standardised measuring instrument, it is also used for documentation and therapy monitoring for MLD, compression or IPK. As an innovative further development of the classic tape measure, PeriKit is supported by an app in which the volumes are graphically displayed and documented. The isotonic spiral, a significant improvement on the PeriKit, ensures constant tension in tape measuring. The device is cost-effective and space-saving and can be used wherever tape can be used to measure circumferences and calculated volumes.

The measurements with perometry are recognised as a valid measurement method, as the deviation specified by the manufacturer is a maximum of 2% with respect to reproducibility of the measurement results. Christian Ure emphasises the reliability of the perometer. A central component of the proof of performance of successful lymphological rehabilitation is the monitoring and measurement of the success of therapy through volume reduction. The non-contact perometer measurement is suitable, even when participation-orientated rehabilitation is the central therapy goal. The parallel-aligned LED light sources s are mounted in a measuring frame that is passed over the limb without contact. The resulting light curtains measure the extremities and their position within the frame, allowing three-dimensional representation of the extremity volume to be calculated.

Number: 35

Eight months later: S2k guideline lipoedema: what are the reactions?

Gabriele Faerber

Center for Vascular Medicine, Hamburg, Germany

Introduction/Background: The new S2k guideline lipoedema, released at the end of January 2024, with the full English version available since August 2024, has met with a mixed response nationally and internationally.

While this long-awaited guideline was generally greeted with approval, it nevertheless evoked some concern, mainly regarding the discontinuation of the internationally used classification based on morphological stages, also commonly used in literature, and the difficulty resulting from the fact that the diagnosis, as well as all therapeutic measures are to be based on pain as the key symptom and not on the morphological stages. It is important to clarify that the morphological stages can still be used in a descriptive way and indeed have to be applied for ICD codification. However, they are neither appropriate for assessing the severity of the disease, i. e. of pain and other symptoms, nor do they allow for any conclusion on progression which depends on various factors like weight gain for volume increase or hormonal changes for symptoms.

The guideline clearly states that the indication for all therapeutical options must be based on the severity of the symptoms, not on the stages. However, no objective and reliable tool is available yet for assessing pain. Moreover, to date, and contrary to the recommendations in the guideline, covering the cost for flat knit compression is often refused by the insurance companies unless stage 2 is diagnosed. In Austria, the indication for liposuction depends on stage 2 being diagnosed. Furthermore, the recommendations regarding manual lymph drainage have also evoked divided reactions both from those who do not and those who do see specific indications for MLD, since there is only a weak recommendation for MLD if compression is not tolerated or not effective enough. But MLD should be considered for improving quality of life which again poses the question how QoL should be assessed.

Number: 36

Why and when should lipoedema be treated?

Nina Huettinger^{1, 2}

¹Department of Plastic and Reconstructive Surgery, Hospital of the Divine Savior, Vienna, Austria

²Ordination Huettinger, Vienna, Austria

Lipohyperplasia dolorosa (LiDo), also known as lipedema, is a chronic, painful fat distribution disorder that affects women. It is characterised by symmetrical fat accumulations on the legs and arms, often accompanied by swelling and increased tenderness.

Treatment should be considered if the level of suffering is significant due to pain, movement restrictions, psychological stress due to the changed appearance and/or impairments of quality of life.

Frequently used therapeutic approaches are conservative measures such as compression therapy, manual lymphatic drainage, and exercise. In the surgical approach, the painful fatty tissue is removed using liposuction. To optimise quality of life in the long term, a rethink is necessary in the treatment of the previous classic two-pillar principle of conservative versus surgical to a multimodal therapeutic approach.

Number: 37

Report from the laboratory: Browning fat

Pamela A. Nono Nankam^{1, 2}

¹Clinical Obesity Research, Helmholtz-Institut für Metabolismus-, Adipositas- und Gefäßforschung (HI-MAG), Helmholtz Zentrum München an der Universität Leipzig, Germany

²Universitätsklinikum Leipzig AöR, Leipzig, Germany

Introduction/Background: Lipedema is a chronic disorder characterised by abnormal disproportionate and symmetrical accumulation of white adipose tissue (WAT) in the lower extremities and arms. Unlike obesity, lipedema mainly affects women, and the affected WAT resists lifestyle interventions. However, the pathophysiological mechanisms remain poorly understood. This study investigated gene expression patterns, tissue structures and altered signaling pathways in lipedema-affected WAT.

Material and Methods: Comprehensive RNA-sequencing and histological analyses were conducted on WAT samples obtained from the arms, abdomen, and femoral region of lipedema patients and healthy controls.

Results: Adipocytes from lipedema-affected WAT are significantly larger compared to controls, especially in arm and femoral fat (p <0.0001). Moreover, femoral SAT in lipedema is composed with higher densities of both small-size and very large adipocytes compared to the control group. Across all three WAT depots, the top upregulated genes and pathways suggest increased mitochondrial activity and adipocyte differentiation in lipedema. In contrast, downregulation in inflammatory genes and enriched pathways related to inflammatory processes observed in lipedema SAT depots pointed toward a decrease in WAT inflammation.

Conclusion: Despite adipocyte hypertrophy, thermogenic and browning factors are activated in lipedema-affected WAT and indicate elevated metabolic activity in lipedema tissue. WAT mitochondrial function might be a key mechanism supporting continuous tissue expansion alongside a preserved metabolic state in lipedema.

Number: 38

Manual Lymphatic Drainage in Patients with Lipedema and Lymphedema: Preliminary Results of a Prospective Multiparametric MRI-Study

Claus C. Pieper

Clinic for Diagnostic and Interventional Radiology, University Hospital Bonn, Germany

Purpose: Patients with lipedema often report symptomatic relief from manual lymphatic drainage (MLD), though its effect remains largely unproven. This study, therefore, aimed to evaluate whether MLD has measurable immediate effects on MR-based tissue characteristics in patients with lipedema and lymphedema of the lower extremities.

Methods: 22 women diagnosed with lipedema (n = 11), or lymphedema (n = 11) were prospectively included and underwent MRI-examinations, including T2-(±fat suppression for subcutaneous adipose tissue [SAT]) and sodium-mapping immediately before and after MLD. A certified physiotherapist performed standardised MLD. Region-of-interest-based measurements of T2-times and sodium content were performed on SAT and skin. Data were analysed to assess values pre-MLD and changes post-MLD in both group

Results: At baseline, mean T2-relaxation times of SAT and skin were 71.5 ms and 58.3 ms, respectively, in lipedema and 192.8 ms and 71.4 ms, respectively, in lymphedema with increasing values with increasing disease stage [e.g. SAT T2-time in lymphedema: stage 1: 60.9ms; stage 3: 270.3ms]. Sodium levels of SAT and skin were 13.6mmol/l and 21.7mmol/l, respectively, in lipedema and 39.4 mmol/l and 38.4 mmol/l, respectively, in lymphedema, again with increasing values with increasing disease stage. Compared to normal controls from the literature, T2-times and sodium levels were increased in lipedema and lymphedema.

After MLD, T2-times of SAT and skin decreased significantly by -4.7 ms (p = 0.005) and -9.0 ms (p = 0.003), respectively, in lipedema and by -20.6ms (p = 0.003) and -9.7ms (p = 0.003), respectively in lymphedema. Sodium content likewise decreased significantly both in lipedema (SAT: -2.7mmol/l, p = 0.003; skin: -5.9mmol/l, p = 0.003) and lymphedema (SAT: -6.2mmol/l, p = 0,003; skin: -9.8mmol/l, p = 0.003).

Conclusion: T2-relaxation times and sodium levels are elevated on SAT and skin in lymphedema and to a lesser extent in lipedema, suggesting accumulation of sodium-rich fluid. After MLD, both parameters are significantly reduced in lipedema and lymphedema.

Number: 39a

Lipoedema and monovular twins. Genotype versus phenotype

Anette Goerg

LIPOCURA, beethoven 5.13 Clinic, Cologne, Germany

Introduction/Background: Female patient with legs disproportionate to the rest of the body since puberty. Later, there was also an increase in volume in the arms. Painful to the touch. Clinically symmetrical fat distribution disorder with disproportion. Pressure pain in arms and legs with VAS 9. Lipedema: Arms stage 1 and legs stage 2.

Material and Methods: The patient is an identical twin. The sister has given birth to 2 children and has no disproportion or clinical signs of lipedema.

Results: Unfortunately, various inquiries to science have not been answered, so I cannot present any causes for this phenomenon. I want to use the plenary to present and discuss the case. I think this is an excellent case for initiating investigations into genotype and phenotype.

Conclusion: Perhaps further investigations will bring new insights into the disease.

Number: 39b

Genotype versus phenotype Lipoedema and generalised lymph node swelling. Coincidence or adenopathy?

Anette Goerg

LIPOCURA, beethoven 5.13 Clinic, Cologne, Germany

Introduction/Background: Lipedema, lymphedema and generalised lymph node swelling Coincidence or systemic disease?

Material and Methods: A 23-year-old patient comes to see us with pain in her arms and legs and an increase in the volume of her extremities after stopping the ovulation inhibitor that she had taken from age 12 to 22.

In the last six months, she has gained 15 kg, with a focus on her trunk. Diet and exercise have remained the same; a weight-loss diet has been unsuccessful.

Since she finished school, both her feet have been swollen, and they have become deformed.

Her medical history is the same as her maternal grandmother's, who has lymphedema.

Clinically, there is a symmetrical fat distribution disorder on the extremities and areas of tenderness on her stomach, back, and flanks, as well as on the fat pad over the cranial thoracic spine.

Hands free, feet deformed. Stemmer negative. Bisgaard's trajectory has been removed, knock knees, flat feet, hypermobile joints.

The patient's history shows that she had a car accident on 11/2023 and that a CT scan revealed generalised lymph node enlargement. Another CT scan revealed generalised lymph node enlargement.

A cervical lymph node was removed to rule out malignancy. There were histologically granulomatous changes. All common autoimmune diseases were excluded.

Body height 174 cm, Weight 123,8 kg

Circumferences: neck 42,5 cm, waist 121,1 cm, hip 141,1 cm

WHR 0,87, WHtR 0,71

Pressure pain NRS

Arms 8

Legs 10

Lower abdomen 7

Upper abdomen 9

Flanks 7

Back 8

Thoracic spine/neck 4, Tension headaches starting from there 2x per week

Results:

1. Lipoedema stage 2 on the arms and legs and adjacent areas

2. Suspected lymphedema of the legs

3. Generalized enlarged lymph nodes

An MRT 2/2024 showed no change in the lymph node status. Due to the diagnosis and in consultation with the oncologist, a new lymph node biopsy was unnecessary. For the oncologist, too, lipoedema and lymphedema are possible.

An MR lymphangiography was performed.

Conclusion:

The lymphedema of the legs is classified as secondary lymphedema.

Lipoedema and lymphedema can be the cause of generalised enlarged lymph nodes.

Number: 40a

Panel discussion: Visualisation, measurement and assessment in lymphology. Which methods are reliable?

The Bodyscanner

Manuel E. Cornely

LY.SEARCH gGmbH, Duesseldorf, Germany

ORCID Number: 0000-0003-3284-1659

The scanner enables non-contact measurement.

Measurement of the circumferences is essential to objectify the change in body shape caused by lymphoedema or lipoedema. Water displacement, tape, optoelectronic, or 3D body scanner methods can be used to measure volume and monitor therapy. However, Kuhnke's tape measure method assumes a cylindrical shape of the extremities and is, therefore, only of limited accuracy. The foot and hand are not cylindrical and cannot be included in the volume calculation. Water displacement follows Archimedes' principle of lifting force and displacement by volume. In this displacement measurement, the volume of an extremity is determined by immersing it in water up to a defined height. The displaced water increases the value to be read on the scale of the sample cup by the volume.

The measurement should be carried out without contact or pressure so that no fluid or tissue is displaced, falsifying calculations of circumferences and volumes.

While Kuhnke's skin measurement uses tape directly on the skin, the quality of the measurement depends on the examiner. On the other hand, volume measurement with the perometer is non-contact, using light emitted by diodes that scan the surface of the legs or arms. The volume measurement is calculated from these circumference measurements and given in millimetres per limb. Hands and feet can also be included in these perometer measurements.

The scanner also enables non-contact, although it measures the extremities and the entire body. One example of this is the 3D body and analysis system from Scaneca.

It uses non-invasive infrared cameras to create within 30 seconds precise 3D images of the body surface of the person standing on a slowly rotating platform. These 3D images form the data basis for generating a detailed virtual 3D avatar in a 360-degree view. In addition to an axially correct posture, numerous circumference and volume measurements are recorded and calculated. In addition to height and weight, the circumferences of the neck, shoulders, chest, waist, abdomen, hips, biceps left, biceps right, forearm left, forearm right, thigh left, thigh right, calf left, and calf right are measured.

The weight and other data analyse the fat percentage. Fat-free mass, fat-free mass index (FFMI), body mass index (BMI), waist-to-hip ratio (WhT) and waist-to-height ratio (WHtR) are calculated and allocated according to age and gender. Electronic documentation enables the values to be compared in follow-up examinations. The analysis levels on the virtual twin, the “avatar”, can be focused on regions of particular interest. The parameters are automatically scaled in a traffic light system according to weight, age, and gender in a standardised scheme. The before and after function enables reproducible measurement sequences, and findings and therapy effects are objectified and documented. This holistic body analysis requires the test person to stand on a rotating platform for 30 seconds.

Final conclusion: In lymphology the documentation of findings has so far focused exclusively on changes in the shape of the extremities. As the increase in tissue massespecially fat in obesityon the body also leads to changes in the extremities, purely extremity-centred measurement systems cannot be used to attribute such influences on the composite. Incorrect interpretations are, therefore, possible.

One example is the coincident obesity in LiDo and its change due to bariatric measures. Adipocytes are decisive for the volumes at the extremities in LiDo without influencing the symptoms. This change in volume, not only in the extremities but in the whole body, is recorded by the 3D scanner and can be monitored in the course of post-bariatric therapy.

The thickening of the cutis, which is typical of lymphoedema in terms of volume, can also be elegantly visualised with the scanner in a side-by-side comparison.

One disadvantage of the system is that the fingers and feet are inaccessible due to this method's vertical measurement.

Number: 40b

Panel discussion: Visualisation, measurement and assessment in lymphology. Which methods are reliable?

The measuring tape

Christine Hemmann-Moll

Master Bandagist, Bad Rappenau, Germany

When assessing lymphedema and taking circumference measurements, we have to ask ourselves: What is our goal? As bandages and compression specialists, our task in treating oedema patients with compression is to conduct a detailed inspection and palpation and document all supply-relevant data.

Different methods can be used to document the pure circumferential measurements or volumes. We all agree that techniques such as Perikit, scanning, or perimeter measurements do not provide any information about the consistency of oedema, mobility, or potential soft tissue shifts in different positions. Increasing obesity and, therefore, resultant oedema presents us with further challenges in daily practice, where the previously mentioned methods reach their limits.

Determining measurements (length and circumference measure, measurements under tension) taken in the decongested oedema state allows us to contact thoroughly with the oedema and the patient. We palpate fibrosis, gain insights into skin texture, assess skin folds, and individually establish measurement points. Joint mobility, muscle activity assessment, possible Achilles tendon adhesions, and changes in the forefoot circumference under load are all crucial indicators when choosing material and the conception of compression stockings.

When applying the measuring tape, we come close to the patients not only physically but also on a personal level. This is an intense interaction, providing a valuable opportunity to understand each unique need and establish contact with the patients' personalities. In this protected setting, we can allay fears and address uncertainties. Preparing the patients and informing them about the new compression supply form the basis for good compliance and adherence.

Our goal is to fit compression garments tailored to each patient's specific needs. The necessary measurements have to be taken individually, considering many criteria, which cannot be satisfactorily implemented technically or digitally so far.

However conservative edema therapy only works if the compression is tolerated and worn by motivated patients. In this context, measuring should not be viewed merely as a technical task. Taking the time and showing personal care have become valuable bridges to enhance patients' willingness and commitment to therapy in today's fast-paced world.

Number: 40c

Panel discussion: Visualisation, measurement and assessment in lymphology. Which methods are reliable?

The PeriKit

Tanja Lenk-Killinger

Wittlinger Therapiezentrum GmbH, Walchsee, Austria

Precise documentation is essential to assess the course of treatment for lymphoedema. This serves both practitioners and patients to monitor the measures carried out (MLD, compression, IPK), as well as cost bearers and referring physicians as proof of the effectiveness of the intervention. This documentation should, therefore, take place as soon as conservative therapy is initiated to define the therapy goals and document the course of treatment.

The most commonly used methods for this are the measuring tape (4cm method according to Kuhnke), water displacement, perometer and scanner. However, some of these methods are very cost-intensive and require space to set up, which is only available in some medical facilities. The intra-intertester reliability also depends on the skills of the user, which in turn can influence the result. Dissatisfied with the methods available at the time for measuring lymphoedema, a Belgian physiotherapist developed the Perikit. It was intended to be easy to use and significantly reduce both the error rate and the time required for measurement. In addition, the financial availability of an accurate measurement method should also be guaranteed for smaller medical facilities, such as physiotherapy practices.

The Perikit is an innovative further development of a classic tape measure. Manual measurement is supported by the use of the Perikit app, in which the graphic representation of the volumes of the measured extremities is displayed and documented. At the same time, the use of a confirmation point (scar, birthmark) ensures that measurement errors are significantly reduced, as measurements can always be taken at the same point. The installation of an isotonic spiral within the measuring tape ensures a continuously constant tension. This development thus offers a reliable, cost-effective, space-saving alternative for measuring lymphoedema compared to the established methods.

Number: 40d

Panel discussion: Visualisation, measurement and assessment in lymphology. Which methods are reliable?

The perometer measurement

Christian Ure

Wolfsberg Lymphology Clinic at the LKH Wolfsberg Rehabilitation, Wolfsberg, Austria

Introduction: Lymphological diagnostics, including follow-up and measuring therapy's success through volume reduction, have so far been a central part of the “proof of performance” of successful lymphological rehabilitation. Therefore, insurance companies, as payers, were interested in a measurement method that was as transparent, reproducible, and independent of the examiner as possible. For example, contactless perometer measurement is a suitable measuring instrument that cannot be falsified in contrast to manual measurements.

However, the value of proven volume reduction as a therapeutic success has changed drastically with the new rehabilitation service demand (RLP Rehab-Leistungs-Portfolio).

Since the beginning of 2024, the new medical service profile (MLP Medizinisches Leistungsprofil) has been applied to all rehabilitation centres throughout Austria. The central therapy goal is now reintegration into professional and social life through individualization of the rehabilitation offerthe so-called “participation-oriented rehabilitation.” Functional goals such as volume reduction are only relevant in relation to achieving the participation goals.

Material/method: The perometer measurement works with parallel-aligned light sources made of light-emitting diodes (LEDs) that illuminate the extremity and record the extinction of the light beam in a scanning unit in the frame as it is pushed over the extremity. Two mutually perpendicular light curtains run in the frame. They record two mutually perpendicular extremity diameters and their position within the frame, with the frame being guided manually over the extremity. This means that the diameter and position are determined at a short distance along the extremity, and two contour images are automatically recorded from two mutually perpendicular sides. A 3-dimensional representation and the extremity volume can be calculated from the recorded contours.

Results: Several studies have proven the reproducibility of the measurement results, with a maximum deviation of 2% stated by the manufacturer. Based on these data, the Perometer measurement is recognized by insurance companies as a valid measurement method and was an important tool for proving the success of therapy until the introduction of the new medical performance profile.

However, for the affected patients and us as doctors and therapists, volume reduction is still of central importance in the sense of proof of the success of the therapeutic measures carried out, with the perometer providing good and time-saving help.