Report from Cagliari 2023

It is really interesting the experience that the Sardinian regional section of SIMFER has been carrying on for some years with keen interest from the members. In fact, every year, under the wise direction of the regional secretary Mauro Piria, and with the collegial collaboration of the members, 5 monothematic meetings are organized (alternating in terms of content annually) concerning theoretical-practical aspects of physiatry topics, developed by experts in the field and complemented by interventions of some local colleagues. Moreover, each meeting lasts almost a full day and allows participating members to obtain 10 CME credits.
So that at the end of the 5 annual meetings the individual physiatrist obtains (by participating in each of the events that take place monthly, in the spring period) the full amount of annual credits, combining the two profits: continuous and specific updating in the area and automatic compliance with the obligations related to CME. An example that should probably be followed by other regions and other specialties in the medical and surgical area.
The fourth meeting this year was held in Cagliari, Italy, on April 22, and was devoted entirely to Lymphedema and Lipedema.
Among the speakers, in addition to the writer, were Jeanpaul Belgrado, Andrea Marini (who hosted and operationally organized the day) and a number of physiatrist colleagues and residents.
        The morning session opened with a welcome greeting and an introduction on the day’s topic by Dr. Marini, who subsequently yielded the floor to Belgrade. The latter reported some epidemiological data on primary and secondary lymphedema and some principles of pathophysiology with continuous references to clinic and therapy.
This was followed by the intervention of the writer, who recalled the most salient aspects of the classification of lymphedemas according to their etiology (primary, secondary, syndromic and symptomatic), and staging, emphasizing, in this context, the role of stage zero (provided for in the Consensus Document of the International Society of Lymphology) reserved for primary or secondary sub-clinical forms in which the developmental risk is important and for which primary prevention is essential.             
This was then followed by the second talk by the undersigned, which highlighted the clinical and care aspects of Lipedema, a condition currently the focus of considerable interest by various research groups and still little ‘recognized’ by insiders or confused with Lymphedema. The talk aimed to emphasize precisely the salient aspects of the differential diagnosis between the two pathologies, not neglecting important references to the clinical and therapeutic approach, conservative and/or surgical.
Belgrado then took the floor again, illustrating with suggestive images some advantages brought by the use of video-fluoroscopy, which, however, does not replace the fundamental role of lymphoscintigraphic examination, especially in primary forms of Lymphedema. In some cases, the images themselves can better ‘guide’ the operator’s manual dexterity, allowing for improved therapeutic effects of manual and/or mechanical decongestant maneuvers.
Belgrade then continued with the cornerstones of treatment from which a good elastocompressive bandage cannot be separated, followed by exercise (a concept that will be taken up in the afternoon session somewhat by all the speakers). And on the subject of bandaging, a special role should be reserved for sub-bandage materials, which are essential to achieve a so-called ‘spring’ effect by very strong foam rubber substances that, wrapped around the limb, with a subsequent layer of inelastic or short-elastic material superimposed on top, exert an additional almost ‘spring-like’ compressive action on the underlying tissues, facilitating drainage of the interstitial fluid component.
The presentations were carried out with keen interest by those in the room, and Marini and the other moderators gave rise to more than one interactive, lively and constructive discussion.
It then fell again to the writer to report the guiding principles of the guidelines on the subject. After recalling that because of the few clinical Trials that exist today we rely essentially on the Consensus Documents (first and foremost that of the International Society of Lymphology), it was pointed out that it was precisely from the latter that the ministerial guidelines on Lymphedema and related pathologies were not inspired, which allowed the opening of wards specifically dedicated to the most complex cases of the pathology. Many changes have occurred in recent years from the welfare and social security point of view for these patients. Primary Lymphedema was listed as a rare disease in 2017, with all the protections that come with it. Elastic garments are finally identified with their own specific code in the new Tariff Nomenclator. INPS itself prepared, in 2018, a Document entirely dedicated to Lymphedema emphasizing its disabling nature and the need for the appropriate care of sufferers for concrete control and reduction of costs, both in terms of welfare and social security.
The Third Session (afternoon) was entirely devoted to Lymphedema in Oncology. It opened with two talks by Andrea Marini and Alberto Baio, who emphasized the importance of maintaining the results obtained with intensive treatment by means of definitive elastic garments. For the realization of the latter, it is necessary, for the purposes of the best clinical results and greater patient comfort (which also translates into better compliance with the use of the garment itself), an optimal ‘take-measure’ by the orthopedic technician who will then be the definitive interface between the patient and the health care providers on the one hand and the Company supplying the garments on the other.
The day was closed by the speeches of Roberto Zuncheddu (physiatrics resident), Roberta Nardelli and Elisabetta Pirlo (Andrea Marini’s collaborators) who described interesting experiences in dedicated hospital departments.
A very engaging day, well designed and well attended by the approximately 100 physiatrists (most of them) and physiotherapists who showed keen interest in a topic that is finally beginning to have its proper consideration, and not only in the rehabilitation field. Appointment for the near future to continue with the exchanges of experiences that make the activities of the Sardinian section of SIMFER very attractive and lively.
Dr. Sandro Michelini
Cagliari 22 Aprile 2023