An additional problem is the lack of appropriate and well-designed studies. What if there is no, or very limited, high-quality evidence upon which to base these clini­cal decisions? Because no trial can answer all possible questions about a treatment, different experts will interpret trial results differently, and it soon becomes clear that the “evidence” is subject to “opinion.”4 The challenge is how to move beyond poor evidence-based data and opinion-based data to treating the patients in the real world. Finally, conflict of interest and expert commercial/promotional bias in the develop­ment of the specific guidelines is an increasingly troublesome problem. Some groups, such as the American College of Physicians, have very clear and detailed rules to avoid conflict and bias,2 but this is lacking in many of the consensus or guideline documents.

Because there are no definitive studies that have been published concerning the best treatment for patients with lymphedema, we are left with an ever-growing collection of studies with lower levels of evidence. These, combined with expert opinions, largely shape the consensus documents that have been produced.

The International Lymphedema Framework published their Best Practice guide­lines in 20067 as the culmination of a multi-year process in the United Kingdom (UK). The document was generated by UK clinicians, therapists, researchers, industry, and patient participants and was reviewed and/or endorsed by a wide international group of experts and Societies. It is written rather as a guideline for care in a clinical setting with added depth because of a diligent research review and is also valuable for policy review in those countries that have health care sys­tems that match the UK model. Its strength is found in the extensive literature review and grading of evidence for treatment modalities, the inclusion of refer­ences culled from a growing volume of literature, and detailed illustrations and flowcharts that may be useful in the clinic for quick reference or for policy makers for quick study. The document confirms the lack of substantial published data for many of the treatment modalities and the great need for more investigations with none of the recommendations reaching their level A (clear research evidence) support and most being noted as limited supporting research (level B) or experi­enced common sense judgment (level C). The framers envision that the document will be updated approximately every 5 years, and such efforts are currently under­way with affiliated groups such as the American Lymphedema Framework. What these changes will bring about is unclear at this point, since each country will have a different focus to bring to the Framework. As an example, the original document described the manual massage and compression as separate treatment modalities while in the United States and many other places around the world (e.g., Germany) the most recommended treatment (as also supported by the ISL Consensus Document) is the combination of the manual massage and compression bandag­ing (i.e., CPT).