Journal of Tissue Viability 1992 Vol. 2 No 4 127
MANAGEMENT OF LYMPHOEDEMA: PUTTING TREATMENT INTO CONTEXT
EUNICE JEFFS Lymphoedema Sister, The Royal Marsden Hospital, London
There has been a growing interest in the management of lymphoedema. It would appear that multi-layer bandaging, with its promise of dramatic results, has most caught people's attention, yet only a relatively small proportion of patients will actually require bandaging.
In 1988, Badger and Twycross prepared written guidelines to assist health professionals in the management of mild-to-moderate uncomplicated lymphoedema1 These principles, applied to the management of complicated, long-standing lymphoedema, are illustrated through two case histories. The aim of this article is to demonstrate the specific role of multi-layer bandaging within the context of a treatment programme for the management of lymphoedema, and to provide a ration-ale for treatment.
CAUSE OF LYMPHOEDEMA The most common cause of lymphoedema in Britain is cancer and its treatment, with available figures suggesting 25-38% risk of developing lymphoedema following breast cancer treat-ments involving surgery or radiotherapy to the axilla2 There are no figures for the incidence of lower limb oedema.
Lymphoedema has been described as a chronic swelling result-ing from the failure of the lymph drainage system, with the consequent accumulation of protein-rich interstitial fluid, af-fecting one or more limbs and, sometimes, the adjacent quad-rant of the trunk1 3 Figures 3 and 7 illustrate the clinical signs and symptoms of lymphoedema, which are described in the case histories; the reader is also referred to Badger\ and Mortimer and Regnard5
MANAGEMENT At present treatment is not curative but aimed at reduction of swelling, control of symptoms and minimisation of complica-tions4. It involves the four comer-stones of medical treatment: external support (comprising multi-layer bandaging and com-pression hosiery), exercise, skin care, and massage 13
The treatment programme is divided into two phases-intensive and maintenance - and careful assessment will provide indica-tors for the appropriate treatment. The vast majority of patients have mild-to-moderate swelling, and therefore, will enter di-rectly into the maintenance phase of the treatment programme. However, the two patients described here required a course of intensive treatment to reduce the volume and improve the shape of their limbs before being fitted into hosiery to control their swelling.
In the intensive phase (see Figure 1 for indications) treatment is performed by the therapist, comprising daily multi-layer bandaging, combined with exercise, skin care and massage for
a period of 2-4 weeks. In the maintenance phase patients continue their own treatment at home with the use of compres-sion hosiery, exercise and skin care. Regular follow-up visits to the clinic are essential for the maintenance of their progress.
* * * *
long-standing or severe lymphoedema awkwardly shaped limb, with deep skin folds damaged or fragile skin lymphorrhoea
Fig 1. Indications for intensive treatment1
EXTERNAL SUPPORT External support, whether in the form of multi-layer bandages (intensive phase) or compression hosiery (maintenance phase), aims to:
1) limit the accumulation of fluid in the subcutaneous tissue (i.e. reduce lymph formation),
2) provide an even pressure gradient (graduated com-pression).to encourage fluid to move to the root of the limb.
3) provide muscles with firm support, thus enhancing the pumping action of the muscles during normal and specific exercises.
The aim of bandaging is to reduce the volume, and improve the shape of the limb so that containment hosiery can be fitted. Thus it can be seen that hosiery is not an alternative, or second rate treatment, but an essential part of the maintenance pro-gramme; it is thought that the first 2-3 months of the mainte-nance phase, following intensive treatment, is critical for con-solidating progress.
EXERCISE Exercise stimulates lymph flow through the 'massaging' effect of muscular contractions on the superficial lymphatics in the overlying tissues3 Maximum benefit is obtained by wearing external support while exercising, and utilising the calf and forearm muscles46
Immobilisation of the limb is not advisable except, for example, in the case of paralysis, where the unsupported limb is at risk of trauma1
SKIN CARE Skin care limits the risk of infection: reduced local immunity (by removal of the lymph nodes) and the presence of static protein-rich lymph in the swollen limb makes the patient prone to infection, which can lead to further fibrosis and scarring of the lymphatics14 Reduction in the limb size lessens the risk of infection by reducing the amount of static lymph.
128 Journal of Tissue Viability 1992 Vol. 2No4
Simple measures are advised to avoid skin trauma and conse-quent infection; patients are encouraged to regular! y moisturise the swollen limb since the heat of the bandages and hosiery cause dry skin (Figure 2).
* * * * * * * *
protect skin against trauma moisturise skin regularly to avoid dryness or chapping clean cuts and scratches, report signs of infection avoid injections in swollen limb avoid strenuous movements avoid standing for long periods if leg is swollen keep weight within normal limits use swollen limb normally
Fig 2. Caring for a swollen limb6
MASSAGE Manual Lymph Drainage (MLD) is a specific massage tech-nique which is designed to increase the normallymphokinetic activity, and to encourage fluid to drain from the oedematous to non-oedematous areas of the body3 Unfortunately, MLD is not standard treatment in the United Kingdom, and therefore most patients are taught a simplified form, of self-administered massage, based on the principles of MLD.
FOLLOW-UP Regular monitoring encourages motivation and compliance, enabling problems to be detected early and addressed; hosiery may need to be altered to ensure long-term control of the oedema. It also enables patient education to continue, encour-aging and equipping them to take more responsibility for their care. The frequency of appointments is reduced as the patient's condition is stabilised, and as they become more confident in managing their oedema.
CONCLUSION Much can be done to improve the lot of the patient with lymphoedema, even those with gross and long-standing oedema. Careful assessment must be used to guide the choice of treatment, with an appropriate use of multi-layer bandaging and compression hosiery. Increased under-standing, on the part of the nurse and patient, regarding the function and working of the lymphatic system and the effect of treatment measures on lymph drainage, will in-crease the effectiveness of the maintenance phase of treatment.
ACKNOWLEDGEMENTS The author would like to thank her colleagues for their support, and in particular Caroline Badger, Hazel Robertshaw, Sian Thomason and Miriam Wood for their com-ments and suggestions during the preparing of this article.
ADDRESS FOR CORRESPONDENCE Ms E Jeffs, Lymphoedema Sister, The Royal Marsden Hospi-tal, Fulham Road, London SW3 6JJ
REFERENCES 1. Badger C & Twycross R. Management of lymphoedema:
guidelines, Oxford, Sir Michael Sobell House, 1988.
2. Kissen M W, Querci Della Rovere G, Easton D & Westbury G. Risk of lymphoedema following the treatment of breast cancer. Brit J Surg, 1986; 73: 580-4.
3. Foldi E, Foldi M & Weissleder H. Conservative treatment oflymphoedema of the limbs. Angiology, 1985;7: 171-80.
4. Badger C. A problem for nurses - lymphoedema. Surgical Nurse, 1988; 9: 14-19.
5. Mortimer P S & Reginald C. Lymphostatic disorders. BMJ, 1986; 293: 347-8.
6. Regnard C, Badger C & Mortimer P. Lymphoedema: advice on treatment (second edition). Beaconsfield, Beaconsfield Publishers Ltd., 1991.
7. Svensson WE, Al-Murrani B, Badger C & Cosgrove D. Colour Doppler demonstrates the venous abnormality in post-radiotherapy Elephantiasis Chirurgica. ClinRad, 1990; 42:382.
CASE IDSTORY 1. Mary has had progressively worsening oedema of her right arm for fifteen years following treatment for cancer of the breast; this was complicated by a flaccid paralysis of her arm, due to brachial plexus damage. Treatment of her oedematous right arm, using a Flowtron machine and compression hosiery, had been unsuccess-ful in controlling the oedema due to the dependency and weight of the arm as the swelling increased. Emphasis had then been placed on devising an appropriate support since the sheer weight of the arm had resulted in scoliosis and subluxation of the right shoulder joint.
On referral to the lymphoedema clinic in July 1991, examination revealed a grossly swollen and misshapen right hand, and a moderately swollen arm (Figure 3). The circumference of the hand measured 58 centimetres, and it was estimated that there was
Fig 3. Mary before treatment.
approximately 4litres volume in the hand alone. Despite the size of the hand the skin was in remarkably good condition, with only slight breaks in the skin at the base of the fingers.
A careful assessment revealed that this was not simply a case of pure, uncomplicated lymphoedema, but that several factors were responsible for the oedema. The tissues of the arm were soft and pitting, reducing to some extent overnight, indicating that the dependency of the limb (resulting from the paralysis) was a major factor in the development of the gross oedema. The presence of
Fig 4. Skin trauma after one weeks treatment (intensive phase).
collateral veins on the upper arm and trunk, and the mottled appearance of the arm, suggested obstruction to the venous flow. A colour doppler ultrasound of the arm 7 suggested that the venous obstruction was probably caused by a fibrous band narrowing the subclavian vein; it also noted that the arterial input to the right arm was, for some unknown reason, almost three times greater than to her left arm. The resultant increase in formation of interstitial fluid was an added complication since it increased the burden on the lymph drainage system; in pure lymphoedema the load of lymph is normal, but the lymph flow is reduced due to the damaged lymph vessels or nodes4.
The extreme swelling had forced the flaccid fingers into an abnormal position, forming a 'boxing glove', and there was some concern as to whether the fingers were dislocated at the knuckles (Figure3). The physiotherapist provided reassur-ance that the finger joints were intact, which was later confirmed by x-ray of the hand.
Mary was admitted for three weeks intensive treatment compromising daily multi-layer bandaging, passive exer-cises of the fingers, hand and arm, skin care and daily Manual Lymph Drainage3 It was anticipated that multi-layer band-aging would effect a relatively easy reduction in the size of
Fig 5. Mter five weeks treatment (maintenance phase).
Journal of Tissue Viability 1992 Vol. 2 No 4 129
Mary's limb, but four potential problems were identified:
1) The difficulty of ensuring the bandages would stay in place on such a swollen and distorted hand.
2) The risk of trauma to the skin due to anaesthesia of the hand,
3) The possible congestion of the trunk, resulting from the large volume of fluid displaced by the multi -layer bandages on her hand and arm.
4) The difficulty of containing the oedema with hosiery in a dependent and paralysed limb with, in this case, the added problem of obstructed venous outflow and increased arterial inflow.
Great care was taken in the planning and application of the bandages, to ensure that they stayed in place. Normally multi-layerbandagingshouldneverresultin trauma to the skin, however, in the absence of sensation in the limb it was anticipated that it would be more difficult to avoid trauma to the skin. Unfortunately in Mary's case, and
Fig 6. After eight months treatment (maintenance phase).
partly as a result of the difficulty of maintaining good communica-tion between the many nurses involved in her care, a combination of friction and pressure from the bandages led to breakdown of the skin on her hand (Figure 4). Granuflex (Extra Thin) was applied to aid healing of the broken areas and to protect fragile skin.
Mary received daily treatments of MLD from a trained therapist, thus successfully preventing congestion of the trunk. Since paralysis of her muscles meant that propulsion of the lymph was lacking, Mary was taught specific passive exercises to stimulate lymph flow. APolyslingwasprovided, by the physiotherapist, to support the weight of the arm during mobilisation, but at all other times the limb was supported extended on pillows' to avoid pooling of fluid around the elbow joint preventing the hand from draining, which is almost inevitable if the elbow remains flexed.
After 3 weeks intensive treatment the circumference of the hand had reduced from . 58 em to 31.5 em. Mary was discharged with several layers of compression hosiery on the hand, to prevent reaccumulation of the oedema in the slack skin of the hand. Her sister was taught to apply the hosiery and to change the Granufl(}xas necessary until the skin trauma had completely healed. Mary was also placed on prophylactic antibiotics (Penicillin V SOOmg b .d.) to further reduce her risk of infection until the abrasions on her hand had healed.
130 Journal of Tissue Viability 1992 Vol. 2 No 4
Fig 7. Doris before treatment.
Fig 8. After three weeks treatment (intensive phase).
Fig 9. After ten months treatment (maintenance phase).
In the immediate post treatment period weekly follow-up was necessary to monitor the healing of the abrasions on Mary's hand, ensuring that the hand and arm size were maintained. She continued at home with containment hosiery, passive exercises and skin care, and by one month following discharge , her hand had further reduced to 26 em in circumference (Figure 5). The lax tissue of the hand had rapid! y reaccommodated and taken on a leathery appearance (Figure 5), which disappeared as the hand further reduced in size, although the hand remained somewhat discoloured.
Frequent alterations to her compression hosiery were necessary to maintain this progress, and in March 1992 (Figure 6) a further reduction was recorded in the size of the hand, which now measured 20.2 em in circumference, with a minimal difference (2%) between the right and left arms. Her excellent progress (Figures 3 to 6) is largely attributable to the persistence of Mary and her sister in faithfully and consistently applying the hosiery.
CASE lflSTORY 2 Doris had had lymphoedema of her left leg for sixteen years, following treatment for cancer of the cervix. Attempts to treat the lymphoedema with hosiery had proved unsuccessful; the shape of the leg resulted in the compression hosiery accumulating in the ankle creases causing a tourniquet effect, and the size of the leg could not be reduced by compression hosiery.
As a 72 year old widow ,living alone, she hadfounditincreasingly difficult to perform routine daily tasks, since the size and weight of her left leg resulted in a dragging gait and severely reduced her mobility. She also found it extremely difficult to obtain shoes and
clothes that fitted, and had taken to wearing trousers to disguise the size and appearance of her swollen leg.
On referral to the lymphoedema clinic, in September 1990, examination reveal~ gross swelling of the left leg, extending from the toes, and into the adjacent quadrant of the trunk. Herleft leg measured 92% larger than her right leg. The tissues of the lower leg were firm and fibrosed, with the characteristic skin changes ofhyperkeratosis and acquired lymphangiomata over the calf, and deep skin folds around the ankle (Figure 7); an area of lipodermatosclerosis suggested co-existent venous disease.
Three weeks intensive treatment - comprising daily multi-layer bandaging, skin care, exercises and self-administered skin sur-face massage -reduced the size of the left leg from 92% to 52% larger than the right (Figure 8). Using soft foam pads and wadding, to fill out the skin folds, it was possible to create a smooth profile on which to apply several layers of bandage; this ensured an even pressure gradient (graduated compression) and
TISSUE VIABILITY FORUM (WEST OF SCOTLAND)
Venue for all meetings: The Walton Conference Centre, Southern General Hospital, Govan Road,Glasgow
5 November 1992 1930-2130 hrs Use of Hypochlorites Speakers: Mrs M McCowan, Infection Control Sister, Victoria Infirmary. Ms A Mahony, Drug Information Pharmacist.
14 January 1993 1930-2130 hrs Pressure Sores, Varicose Ulcers Speaker to be confmned
4 March 1993 1930-2130 hrs The Nutritional Demands of Long Term Moderate Injury Speaker: Ms S Kindlen, Queen Margaret College, Edinburgh
6 May 1993 1930-2200hrs Occlusive Hydrocolloids and Infected Wounds Speaker: Dr J Hutchinson, Wound Healing Research Institute, Deeside Industrial Park, Dee side Moderator: Dr D Baird, Consultant Microbiologist Monklands Hospital
Further details about the Forum can be obtained from David Kerr, Glasgow College of Nursing 041-445-2466 Ext4372or4381
Journal of Tissue Viability 1992 Vol. 2 No 4 131
avoided any tourniqueteffect1 The shape of the leg improved, the ankle skin folds became much less pronounced, and Doris was discharged home in two layers of Class 3 compression hosiery (Medi 40-50 mmHg; Duomed25-35 mmHg) to maintain hernew leg size and shape.
During the following months Doris continued the maintenance phase of treatment at home - compression hosiery, skin care, exercises and self-administered skin surface massage - resulting in further improvement in size and shape. Doris was encouraged to use her leg normally, but to avoid standing for long periods.
By July 1991, her left leg measured 37% larger than her right (Figure 9), and the condition of the skin on her left calf had improved dramatically, with almost a complete resolution of the skin problems. Her mobility had vastly improved as the leg reduced in size, and for the first time in more than ten years she felt able to wear a skirt in public.
The Multi Disciplinary Approach to the Management
ofF oot Ulceration
Wednesday 11 November 1992 Old ~anor Hospital, Salisbury
Factors Involved in Dressing Selection Mrs R Nicholls, Tissue Viability Nurse Salisbury
The Multi Disciplinary Approach to the Management of Foot Ulceration Dr M Edmunds, Specialist in Diabetic Medicine, King's College, London Mrs A Foster, Chief Chiropodist, Diabetic Foot Care, King's College, London
Four group workshops: Presentations each of twenty minutes by: Britcair (Kaltostat) ConvaTec(Granuflex) Johnson and Johnson (lnadane and Release) Perstorp Pharma (lodosorb)
Fee: 10.00. Half Price for Salisbury Health Authority staff Contact: Miss E Green, Chiropody Dept, Tisbury Surgery Tisbury SP3 6LF Tel : (Y747 871220