Joachim Zuther, Lymphedema Specialist.
Safety of patients suffering with lymphedema and maintenance of the highest standards in the diagnosis, treatment and management of lymphedema must be the utmost priority for all medical institutions, educators and therapists involved in lymphedema care. Why? Because patients deserve nothing less, period!
Lymphedema patients have been misdiagnosed and mistreated for hundreds of years; however, in a more positive light, members of the lymphedema community, including patient advocates, therapists and educators have worked tirelessly over the past decades to improve diagnostic and treatment standards, while establishing meaningful and necessary guidelines for the training of lymphedema therapists in the U.S. and worldwide. As a matter of fact, the current state of training for Certified Lymphedema Therapists (CLT’s) is at the highest proficiency standard in history, whereby it is understood that live hands-on training in schools specialized in the training and certification of CLT’s remains the only effective and responsible system for developing the necessary manual skills to treat a disease as complex as lymphedema. This has been proven for nearly 30 years via live instructor assessment and the honing of skills in a classroom of peers, similar to all other rehabilitation, medical and surgical training programs.
This is why the announcement (1) by the Lymphology Association of North America (LANA®), which intends to allow the entire 135-hour certification course for CLT’s to be taught virtually, without certified instructors being physically present, including the hands-on practical lab work, is so startling and will inevitably prove to move the bar for responsible training for CLT’s to an all-time low if not challenged!
LANA® was created in 1998 to establish certification guidelines for health care professionals diagnosing and/or treating lymphedema and related conditions. Following in March of 2018, some 20 years later, LANA® was granted accreditation by the American National Standards Institute (ANSI), an elite organization, which assesses many quality standards in various industries. LANA’s accreditation was largely granted based upon the measure of quality of its’ CLT-LANA certification exam which measures the knowledge used in the treatment of lymphedema and, most importantly for the current and presently valid LANA® guidelines of a 1/3 theoretical, and 2/3 LIVE practical lesson format spanning a minimum of 135 hours of study.
It should be noted that LANA® would not have sought accreditation for its credential “CLT-LANA”, had it not been for leading training schools demanding and stewarding the accreditation process from start to completion.
The 1/3 theoretical portion is delivered either in the live classroom setting or via home study modules and has proven itself effective in either format since 2009. Home study includes either pre-recorded lessons accessed via various media formats to include online portals or non-electronic traditional formats; the 2/3 practical education requirement is delivered in the live classroom setting among student peers, and with an instructor physically present in the classroom, a format that has also proven itself to be effective and necessary in all instructional programs currently recognized by LANA®.
LANA® recently announced to all school directors that as of January 1, 2022, it will no longer require a live practical education requirement, instead supporting synchronous virtual training, without certified instructors being physically present, contrary to the worldwide acknowledged gold standard live practical skills training models. In our opinion as lymphedema certification trainers with extensive experience, such modifications will inevitably result in inferior training and preparation of CLT’s and subsequent incompetent practice. As inevitably follows, patients affected by lymphedema will pay the price and suffer when encountering the eventual ranks of virtually trained “CLT’s”, an objective many of us have worked for decades to eradicate!
LANA® defends its decision without data to support comparable practical skill and competencies are earned in these two groups of students. As justification LANA® cites that competencies must be examined/tested only in a live setting before students earn a Certificate of Completion, yet the examiners are not extensions of LANA®, but rather the same virtual instructors of a given virtual program. Furthermore, programs having chosen to train the virtual Certified Lymphedema Therapist will not be inclined to offer unbiased examinations for fear of exposing the substandard level of education they provide, which will lead to a new cohort of unqualified CLT’s entering the field.
As founders and directors of lymphedema training schools upholding the current standard, we strongly oppose the position LANA® has adopted and have made clear during focus groups with LANA and the American Cancer Society, that we do not intend to change the processes for the current courses’ delivery regardless of this less strenuous, logistically simpler and less financially demanding model championed by LANA® starting January 2022. The manual techniques used in the treatment of lymphedema are highly specialized and cannot be compared to any other techniques a therapist has learned and practiced in their earlier education and patient interaction. A live practical directive from certified instructors and feedback from student peers on tactile input is essential in building hands-on skills for lymphedema therapists.
In an effort to deflect a corrosion of training standards, the Academy of Lymphatic Studies and the Norton School of Lymphatic Therapy conducted a survey in September of 2020 of their respective CLT graduates. Sample questions of this survey included:
- The live practical instruction provided during my CDT Certification training was essential in building my hands-on skills as a CLT.
- Personalized instructor feedback in the classroom contributed significantly to my manual skills development and theoretical comprehension.
- Daily interaction with student peers in a live classroom was essential in preparing me to treat lymphedema patients
- The current recognized LANA® training program structure of 45 hours of theory curriculum and 90 hours of live practical instruction is of sufficient length, and utilizes an ideal ratio of time allocated between the two components
Possible answers to the above questions were “Completely Agree”, “Somewhat Agree”, “Unsure”, and “Disagree”.
Of the over 800 graduates, who answered and returned the survey 95% answered question 1. with “Completely Agree”, 91% answered question 2. with “Completely Agree”, 78% answered question 3. with “Completely Agree”, and 67% answered question 4. with “Completely Agree”.
These responses could not be any clearer, and to further underline their importance, came from CLT graduates, i.e. therapists who went through the strenuous process of lymphedema training and are thus familiar with the demanding workload of learning and internalizing the techniques necessary to treat lymphedema safely and effectively in the classroom setting.
Summary
COVID-19 forced society to adapt to distance learning models exposing which fields of study are responsible candidates for revising methods of course delivery away from traditional classrooms and into virtual formats. Conversely, COVID clarified programs of study that are poor candidates for virtual delivery, yet LANA has either not researched, or ignored this issue prior to adopting this revised approach. Available literature on the topic of remote learning frequently points out the weaknesses of online instruction, particularly when it comes to hands-on learning subjects, where physical movement and practice, as well as tactile feedback contribute to the achievement of the learning objectives (2, 3, 4) . While remote learning certainly has its strengths, hands-on, practical instruction is most certainly not one of these, as underlined in the literature and the authors’ extensive experience as trainers and educators in the field.
LANA’s lowering of the bar in terms of educational standards represents a disservice to the lymphedema community and is not supported by the authors of this article and other responsible training programs. In the future, patients suffering from lymphedema bear the additional burden of having to make sure that their therapist learned the hands-on treatment techniques in a live classroom setting!
Steve Norton – President, Norton School of Lymphatic Therapy
Joe Zuther – Founder, former Director Academy of Lymphatic Studies
Resources:
- https://clt-lana.org/
- University of Illinois, Springfield
- University of Wisconsin, Madison
- https://crowdmark.com/blog/swot-an-in-depth-look-at-pros-and-cons-of-distance-learning/
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It’s shocking that LANA even considered, much less approved this decision to effectively dismantle its own reputation. It seems to have gone the way of many certification agencies which become all about funding themselves rather than upholding meaningful standards for the profession.
I would have welcomed higher standards, even more hands-on training in our essentially hands-on profession rather than this gutting of basic requirements. Perhaps the responsible training schools will collaborate in creating an alternative to LANA’s now irrelevant credentialing.
I am a CLT, and though not LANA certified, I trained 11 years ago with Klose Training. We already have to deal with massage therapists who claim to do lymphatic massage, and who cause a tremendous amount of damage with postop patients because they are NOT trained in the gold standard but basically just deep tissue clients. I’ve had a few lymphedema patients who didn’t know better and got treated by these “lymphatic massages therapists”; with disastrous results.
Now, LANA approves of 100% virtual training? We all know that it’s impossible to learn how little or how much pressure to apply with the strokes, and that wrong wrapping can cause tremendous damage abd pain.
I’m 100% opposed to virtual classes only to become a CLT.
What can I do to help?
Sincerely,
Ingrid Marsten
Thanks for letting us know about the lowered LANA requirements. I am a CLT-LANA ( Klose and ILWTI certified)I cannot believe that the highest standard of CDT training is being offered online, there is no way the hands on skills can be taught/practiced/online.Im so disappointed.
As a lymphadema patient, i am appalled that new trainees will not have hands on training. Lymphadema is all about touch and just under the skin stimulation for better drainage of lymphatic fluid. It is like teaching some one how to cut hair without actually cutting before you get to do it in your first client or a knee surgeon replacing a knee after watching a video instead of actually learning hands on. What is wrong with the medical field these days. These are patients lives wew are talking about and lymphadema is so very much more than just a little swelling, which becomes so much worse if nothing gets done about it. Heart broken to think lives don’t matter. We patients are already frustrated with the mental aspect of having this issue. Steps were in place to train a very understaffed area dealing with lymphadema, lets not go backwards here.
This is obviously only about money because it clearly is not about any patients and will damage this their graduates work on. LANA should be decertified from any program and cancelled from any partnerships or patient care or research work or funding. Even if they back away from this they have shown they have no interest in lymphedema patients in any way.
How do we raise our voices in effect protest?
So, how do the top schools remove LANA and form a new accreditation body, with a board, and standard testing, similar to any other health profession? We can then take this to our individual state boards for licensing/registration. This will solve the LANA problem, the untrained “lymphatic massages” and allow this new accrediting body to accept fees for registration, insurance and CEs. The Association of Certified Lymphatic (Lymphedema) Therapists. Board members; 2 ACOLS, 2 NORTON, 2 Vodder, 3 CLTs, 1 Oncologist and 1 Lymphologist.
We are heading into a new frontier, time to shed the old and create the new.
I am appalled. As a patient, I would never allow a practitioner with no practical experience to put a hand on me.
Thank you both so much for speaking out on this dreadful change. I am vehemently opposed to the approval of 100% virtual training. I firmly believe it will result in the downfall of the medical specialty of lymphatic system disease treatment. I am presently working on authoring a petition to be circulated throughout the CLT community in hopes that we can stop this unfortunate decision from destroying the safety and standards that has been so painstakingly built over the last several decades.
I am vehemently opposed to the approval of virtual training. I am presently working on writing a petition against the LANA changes. Please keep an eye out for it, if you’re interested in signing it!
Please join me in signing this petition to LANA to keep the hands on training component in CLT programs in their list of qualifications to sit for the exam.
https://www.change.org/p/lymphology-association-of-america-keep-the-hands-on-training-requirement-in-certified-lymphedema-therapist-programs?utm_content=cl_sharecopy_31399944_en-US%3A7&recruiter=1236797709&utm_source=share_petition&utm_medium=copylink&utm_campaign=tap_basic_share
As a primary lymphedema patient who has used LANA certified therapists in California and New Mexico I have already experienced large discrepancies in knowledge of the condition, massage technique and recommendations given to me. In fact, initially when my swelling first appeared the LANA certified director of my local clinic told me that I did not have lymphedema (ICG scans proved otherwise).
I know that there are knowledgable dedicated therapists out there but as a patient the lack of consistency in MLD technique and other lymphatic treatment is disconcerting. This field needs rigorous standards supported by clinical research studies.
The fact that the quality of therapists will degrade even further is truly disturbing.
I agree with Kristen above . It’s tough enough for patients to find a knowledgeable therapist. This abandonment of adequate training will further the dilemma for patients who must randomly go to therapists until they find one who actually helps. Most just give up. LANA certification will now be meaningless. So discouraging for those of us in this fight for adequate care!
This news is very disappointing. I am a LANA- CLT and worked very hard for this certification. Now I don’t even want to put these initials after my name. I would have expected LANA to check with its members before making this decision but I was unaware of this until now. I will contact LANA and let them know how I feel about this decision and I hope other members will do the same.
Paula Stuart characterizes the cogent words of Steve Norton and Joe Zuther as “misinformation,” and states LANA is actually, “increasing,” the standards to the eligibility requirements. This is classic double-speak. Steve and Joe are reminding LANA and the lymphedema community of the foundation for all that we do and the benefits that it provides to patients. By allowing squishy criteria about remote learning of manual skills, LANA is in effect lowering the standards for eligibility. The only thing they are increasing is that by lowering the standards, they expand the number of therapists with the LANA certification and expand LANA’s revenue. LANA is misguided and mis-lead and is driving itself toward irrelevancy.
I am a CLT-LANA certified therapist practicing lymphedema treatments for over 18 years. I am appalled that this is where my profession and accrediting body is going. There is no way that you can get experience or understanding of this complex treatment virtually. There is an art to bandaging and so many nuances to lymphedema treatment that need to be considered and learned in person with feedback from instructors. I do not feel this is in the interest of the patients but only of the organization as stated above. LANA should be ashamed of these lowered standards.
I am currently taking an on line course and find your opinions farther from the truth. I work full time, live in a rural area and have a child with special needs. I love my patients and their best interest is my priority. Learning from the best instructors is essential to me. In this time of a pandemic with a grueling scheduling scheduling, it is difficult to get away for up to two weeks. I chose an on line course for multiple reasons. One, because I heard an instructor speak with such authority at a wound care conference on lymphedema and wounds, I thought, “I want to check out her school!”. Secondly, the schedule worked for my busy schedule. I could break it up. Instructors can closely monitor every more I make. Plus, I can actually travel to them for a final assessment. I do believe you are incorrect. Patients will always be first in my world. Welcome to the 21st century where everyone’s lives are chaotic and I am grateful for online learning.
There are far, far too few of us as it stands, in an environment where patient safety must come first. I have noticed many “pop-ups” appearing with claims to provide lymphedema services which are unsubstantiated- they offer illegitimate care and either (1) consider pneumatic pump treatment adequate or (2) cause erythema and bruising by applying excessive force. There is a big difference between working on bilateral LE venous insufficiency lymphedema and BCRL or other oncology-related lymphedema syndromes. Getting feedback in in-person formats allows us to develop our skills safely, out of the arena of patient care so that when we do touch patients we have a solid foundation. The multitude of patients suffering from lymphedema have enough on their plate and whether or not their practitioner is qualified should not be an issue. Our only weapon against decreased quality of care is evidence-based education.
This lowering of standards is a big disappointment and disservice to our patients. I was certified through the Norton School. The hands on portion of CLT certification is paramount to learning proper techniques. Our instructors provided hand over hand assistance and as a group we were practicing until late at night.
This is another example of the watering down of our health care system.
My LANA certification will be up in 2026 and I will not renew it. I have no interest in belonging to an organization who sets a low bar.