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LYMPHOEDEMA FRAMEWORK
AN INTERNATIONAL PERSPECTIVE
ACKNOWLEDGEMENTS
Supported by an educational SENIOR CONSULTANT EDITOR THIS DOCUMENT HAS BEEN ENDORSED BY:
grant from Sigvaris. Christine Moffatt, Professor of Nursing and American Society of Lymphology (ASL, USA)
Co-director, Centre for Research and British Lymphology Society (BLS, UK)
Implementation of Clinical Practice, Faculty of
Health and Social Sciences, Thames Valley Deutsche Gesellschaft fr Lymphologie (DGL,
University, London, UK Germany)
Fysioterapeuters Faggruppe for Lymfbehandling
CONSULTANT EDITORS (FFL, Denmark)
Debra Doherty, Senior Lecturer and Clinical Nurse Japanese Society of Lymphology (JSL, Japan)
Specialist in Lymphoedema; Lymphedema Association of North America
The views expressed in this Phil Morgan, Post-doctoral Research Fellow; (LANA, USA)
publication are those of the Centre for Research and Implementation of Clinical
Lymphoedema Support Network (LSN, UK)
authors and do not necessarily Practice, Faculty of Health and Social Sciences,
Thames Valley University, London, UK MLDUK
reflect those of Sigvaris.
National Lymphedema Network (NLN, USA)
The images in Figures 2, 16, 18 THE LYMPHOEDEMA FRAMEWORK Nederlands Lymfoedeem Netwerk (NLNet, The
and 23 are courtesy of The Lymphoedema Framework is a UK based Netherlands)
Professor PS Mortimer. research partnership launched in 2002 that aims Norsk Lymfdemforening (NLF Norsk, Norway)
to raise the profile of lymphoedema and improve sterreichische Lymph-Liga (Austria)
standards of care through the involvement of
Professor C Campisi, President of the Italian
specialist practitioners, clinicians, patient groups,
Society of Lymphangiology (SIL) and of the Latin-
healthcare organisations, and the wound care
Mediterranean Chapter of the International
and compression garment industry.
Society of Lymphology (ISL)
Lymphoedema Framework Secretariat Professor N Piller on behalf of the Lymphoedema
Centre for Research and Implementation of Association of Australia (LAA, Australia)
Clinical Practice Schweizerische Gesellschaft fr Lymphologie
Thames Valley University, 32-38 Uxbridge Road, (SGL, Switzerland)
London, UK Sociedad Espaola de Rehabilitacin y Medicina
Tel: +44 (0)20 280 5050. Web: www.lf.cricp.org Fisica (SERMEF, Spain)
Socit Franaise de Lymphologie (SFL, France)
The Lymphoedema Framework would like to Svensk Frening fr Lymfologi (SFL, Sweden)
thank the following for their valuable Svenska dem Frbundet (Sweden)
participation in the consensus process that
formed the basis of this document: The editors of the Lymphoedema Framework
recognise that the standards of lymphoedema
All involved in the Working Groups care advocated are based on the UK model and
British Lymphology Society (BLS) may not be adaptable to the healthcare systems
Centre for Research and Implementation of of all other countries. Some of the organisations
Clinical Practice, Thames Valley University listed above endorse the document as a
MEP LTD, 2006 Industry Consortium* professional resource to advance lymphoedema
Kings Fund diagnosis and treatment.
Lymphoedema Support Network (LSN)
Members of the International Advisory Board STATEMENTS OF RECOGNITION
Participating UK NHS Primary Care Trusts The American Society of Lymphology (ASL, USA)
ISBN 0-9547669-4-6 *List provided in Appendix 1 and its National and International Board
Members support the conclusion of this doc-
Published by Managing Editor Lisa MacGregor ument that standards of education and treatment
Medical Education Partnership Head of Wound Care Suzie Calne must be established for the benefit of patients
(MEP) Ltd Editorial Project Manager Kathy Day with lymphoedema and the physicians charged
53 Hargrave Road Design and layout Jane Walker with overseeing their therapist and medical care.
London N19 5SH, UK Printed by Viking Print Services, UK The International Society of Lymphology (ISL)
Tel: +44 (0)20 7561 5400 recommends the Lymphoedema Framework
Email: info@mepltd.co.uk document as a valuable, useful, and illustrative
All rights reserved. No reproduction, copy or educational resource for general practitioners
transmission of this publication may be made and the public and as a thoughtful, detailed
without written permission. No paragraph of compendium of established practices within the
this publication may be reproduced, copied United Kingdom.
or transmitted save with written permission
or in accordance with the provisions of the The Lymphatic Research Foundation (LRF, USA)
Copyright, Designs & Patents Act 1988 or To reference this document cite the following: endorses the concept of creating a framework
under the terms of any licence permitting for the clinical care of patients with
limited copying issued by the Copyright
Lymphoedema Framework. Best Practice for the
Management of Lymphoedema. International lymphoedema and congratulates this
Licensing Agency, 90 Tottenham Court Road,
London W1P 0LP. consensus. London: MEP Ltd, 2006. extraordinary effort to do so.
THE MANAGEMENT
OF LYMPHOEDEMA
INTERNATIONAL CONSEN SUS
INTRODUCTION 1
IDENTIFYING THE PATIENT AT RISK 3
ASSESSMENT 6
TREATMENT DECISIONS 15
SKIN CARE AND CELLULITIS/ERYSIPELAS 24
LYMPHATIC MASSAGE 29
INTERMITTENT PNEUMATIC COMPRESSION 31
MULTI-LAYER INELASTIC LYMPHOEDEMA BANDAGING 32
COMPRESSION GARMENTS 39
EXERCISE/MOVEMENT AND ELEVATION 47
PSYCHOSOCIAL SUPPORT 48
PALLIATIVE CARE 49
SURGERY 50
OTHER TREATMENTS 50
APPENDICES 52
REFERENCES 53
Introduction
Lymphoedema is a progressive chronic Technology Assessment model for guideline BOX 3 Classification of
condition that affects a significant number development (Box 3)4. recommendations4
of people and can have deleterious effects on This document will be reviewed and
Clear research
patients' physical and psychosocial health.
Even though it may be greatly ameliorated by
updated after five years. Key references
have been included; a complete list of the
A evidence
Limited supporting
appropriate management, many patients
receive inadequate treatment, are unaware
references used in the preparation of the
text can be found at: www.lf.cricp.org.
B research evidence
Experienced common
that treatment is available or do not know
where to seek help. Several recent systematic
C sense judgement
LYMPHATIC FILARIASIS
Lymphatic filariasis is a parasitic infection transmitted by mosquitoes. In endemic areas,
infection usually occurs in childhood. The parasites damage the lymphatic system,
eventually causing lymphoedema. Although lymphatic filariasis is a major cause of
lymphoedema worldwide, detailed information on its management in endemic areas is
outside the scope of this document. For more information on the condition, see:
Dreyer G, Addiss D, Dreyer P, Nores J. Basic Lymphoedema Management. Hollis, USA:
Hollis Publishing Company, 2002.
Dreyer G, Nores J, Figueredo-Silva J, Piessens WF. Pathogenesis of lymphatic disease in
Bancroftian filariasis: a clinical perspective. Parasitol Today 2000; 16(12): 544-48.
Vaqas B, Ryan TJ. Lymphoedema: pathophysiology and management in resource-poor
settings - relevance for lymphatic filariasis control programmes. Filaria J 2003; 2(1): 4.
Global Alliance to Eliminate Lymphatic Filariasis www.filariasis.org.
Lymphadenitis: inflammation of
the lymph nodes, which become TABLE 1 Classification of causes of secondary lymphoedema, adapted from23
swollen, tender and painful Classification Example(s)
Trauma and tissue damage lymph node excision
radiotherapy
burns
varicose vein surgery/harvesting
large/circumferential wounds
scarring
Infection cellulitis/erysipelas
lymphadenitis
tuberculosis
filariasis
FIGURE 1 Management of
Healthcare professional patients at risk of lymphoedema
awareness of potential risk
factors for lymphoedema
Identification of patients
at risk of lymphoedema
No
BOX 5 Common sense approach to minimising BOX 6 Early signs and symptoms of
the risk of developing lymphoedema lymphoedema
Take good care of skin and nails Clothing or jewellery, eg sleeve, shoe or ring,
Maintain optimal body weight becoming tighter
Eat a balanced diet Feeling of heaviness, tightness, fullness or
Avoid injury to area at risk stiffness
Avoid tight underwear, clothing, watches and Aching
jewellery Observable swelling
Avoid exposure to extreme cold or heat
Use high factor sunscreen and insect BOX 7 Examples of organisations that supply
repellent information for patients
Use mosquito nets in lymphatic filariasis British Lymphology Society
endemic areas www.lymphoedema.org/bls
Wear prophylactic compression garments, if Dutch Lymphoedema Network
prescribed www.lymfoedeem.nl
Undertake exercise/movement and limb Lymph Network (Europe)
elevation www.lymphnetwork.com
Wear comfortable, supportive shoes Lymphoedema Association of Australia
NB While robust evidence is lacking that these actions www.lymphoedema.org.au
reduce the risk of lymphoedema, they reflect a common Lymphoedema Support Network (UK)
sense approach. These actions may also help patients www.lymphoedema.org/lsn
with existing lymphoedema to reduce the risk of
Lymphovenous Canada
deterioration.
www.lymphovenous-canada.ca
National Lymphedema Network (USA)
www.lymphnet.org
Assessment
FIGURE 2 Lymphoscintigraphy
(a) (b) Radiolabelled colloid or protein is
injected into the first web space
of each foot or hand, and is
tracked as it moves along the
lymphatics by a gamma camera.
(a) Normal lower limb images
with fast lymph drainage in left
leg because of associated venous
disease. (b) Normal right leg with
disturbances to lymph drainage
in left leg from past
cellulitis/erysipelas.
micro-lymphangiography using
BOX 11 International Society of Lymphology (ISL) lymphoedema staging6
fluorescein labelled human albumin28
to assess dermal lymph capillaries ISL stage 0
indirect lymphography using water A subclinical state where swelling is not evident despite impaired lymph transport.
soluble contrast media29 to opacify This stage may exist for months or years before oedema becomes evident
initial lymphatics and peripheral lymph ISL stage I
collectors and to differentiate lipoedema This represents early onset of the condition where there is accumulation of tissue
and lymphoedema fluid that subsides with limb elevation. The oedema may be pitting at this stage
CT/MRI scan30 to detect thickening of ISL stage II
the skin and the characteristic Limb elevation alone rarely reduces swelling and pitting is manifest
honeycomb pattern produced by ISL late stage II
lymphoedema, to detect lymphatic There may or may not be pitting as tissue fibrosis is more evident
obstruction by a tumour at the root of a ISL stage III
limb or in the pelvis or abdomen, and to The tissue is hard (fibrotic) and pitting is absent. Skin changes such as thickening,
differentiate lipoedema and hyperpigmentation, increased skin folds, fat deposits and warty overgrowths
lymphoedema develop
bioimpedance31 to detect oedema and
monitor the outcome of treatment
filarial antigen card test to detect repeated periodically throughout treatment. Lymphoedema-distichiasis
infection with Wuchereria bancrofti by The findings of the assessment should be syndrome: a form of primary
lymphoedema with onset at or after
testing for antibodies to the parasite in a recorded systematically (Box 10, page 8) puberty in which the patient has
person who has visited or is living in a and form the baseline from which accessory eyelashes along the
lymphatic filariasis endemic area. management is planned, further referral posterior border of the eyelids. Has
a clear family history
Primary lymphoedema is usually diagnosed made and progress monitored. Specialist
Milroy's disease: a form of primary
after exclusion of secondary lymphoedema. computer programs can assist in lymphoedema that is present at
Genetic screening and counselling may be standardising assessment (eg LymCalc; birth, only affects the lower limbs
required if there is a suspected familial link. details can be found at: and has a clear family history
Hypotrichosis-lymphoedema-
Three gene mutations have been linked with www.colibri.demon.co.uk). telangiectasia syndrome: a form of
primary lymphoedema: Lymphoedema assessment is usually primary lymphoedema associated
FOXC2 lymphoedema-distichiasis carried out by a practitioner who has with sparse or absent hair and
syndrome undergone training at specialist level. telangiectasia (localised collections
of distended blood capillary vessels
VEGFR-3 Milroy's disease
observed in the skin as red spots)
SOX18 hypotrichosis-lymphoedema- Lymphoedema staging
telangiectasia syndrome. Several staging systems for lymphoedema
have been devised, including the
LYMPHOEDEMA ASSESSMENT International Society of Lymphology system
A lymphoedema assessment should be (Box 11). None has achieved international
performed at the time of diagnosis and agreement and each has its limitations.
Below elbow/knee
(cm)
Lymphoedema Lipoedema*
Signs and symptoms Can involve the legs, arms, trunk, Usually causes symmetrical
genitalia or head and neck bilateral swelling of the lower limbs;
Swelling of limbs affects hands and feet can occur in arms
Affects either sex Swelling stops at ankles and wrists
Stemmer sign may be positive; usually Pain and bruising are prominent
not painful on pinching features
Affects mainly women
In pure lipoedema, Stemmer sign is
negative; often painful on pinching
Aetiology Results from inadequate lymphatic Unknown; results in excessive
drainage subcutaneous fat deposition
May be congenital or result Appears to be oestrogen requiring
from damage to the lymphatic system and starts at time of hormonal
Not usually associated with change eg pregnancy, puberty
hormonal imbalances Family history of lipoedema often
positive
Lymphoscintigraphy Identifies disordered lymphatics Often indicates normal lymphatic
functioning
MRI scan Honeycomb pattern in the subcutis Subcutaneous fat, but no fluid
and thickened skin
Upper limbs
Ask the patient to sit with the arm supported on a table with the hand palm down
On the ulnar aspect of the arm* measure with a ruler and record the distance from the
nail bed of the little finger to 2cm above the ulnar styloid (wrist). Mark this point on
the patient. This determines the starting point
Mark the same point on the contralateral arm
Lie a ruler along the ulnar aspect of the arm and mark the limb at 4cm intervals from
the starting point to 2cm below the axilla
With the limb in a relaxed position, measure the circumference at each mark, placing
the top edge of the tape measure just below the mark
Note measurements above the elbow in the correct section of the paper or electronic
recording form
Repeat the process on the other limb. Ensure there are the same number of
measurements for both arms
Document the position the patient was in when measurements were taken
Lower limbs
Ask the patient to stand or sit with both feet firmly on the ground
On the medial aspect of the leg* measure with a ruler and record the distance from the floor to 2cm above the middle of the medial
malleolus. Mark this point on the patient. This determines the starting point
Mark the same point on the contralateral leg
Seat patient on a chair with bottom as close to the edge as possible, or seat on a couch with the leg straight
Lie a ruler along the medial aspect of the leg and mark the limb at 4cm
intervals from the starting point to 2cm below the popliteal fossa for swelling
below the knee
If swelling extends above the knee, ask the patient to stand or to lie on a couch.
Continue the marks at 4cm intervals above the knee to 2cm below the gluteal
crease
With the limb in a relaxed position, measure the circumference at each mark,
placing the top edge of the tape measure just below the mark
Note measurements above the knee in the correct section of the paper or
electronic recording form
Repeat the process on the other limb. Ensure there are the same number of
measurements for both legs
Document the position the patient was in when measurements were taken
*If only one limb is affected, start with the unaffected side.
If the ulnar styloid or medial malleolus cannot be located, alternative fixed anatomical points can be used to determine the starting point, eg olecranon process or
anterior iliac spine. The distance from the fixed anatomical point to the starting point should be recorded to ensure consistency when measurements are repeated
subsequently.
NB Some limb volume calculation methods or systems may require a different interval between circumferential measurements.
FIGURE 4 Simplified measuring method for patients with palliative care needs
A pretensioned tape measure should be used. No tension should be applied to the tape during measuring.
Psychosocial assessment
BOX 14 Functional assessment of limbs affected by lymphoedema
Arm:
C Patients with lymphoedema should
receive psychological screening to
identify those who require help to
range of joint movement
ability to use fastenings, eg buttons, bra fastenings
ability to put on or remove underwear/compression garments or bandaging
cope with the condition and those who
hand grip and pincer movement (opposition of thumb and index finger)
require specialist psychological
effect of lymphoedema on activities of daily living
intervention.
use of any aids
Leg:
Lymphoedema can result in functional
range of joint movement
impairment, reduced self esteem, distorted
ability to get up from sitting or lying
body image, depression, anxiety, and ability to walk; gait analysis
problems with sexual, family and social ability to lift individual legs
relationships7,10,47. Psychosocial assessment posture when sitting and standing
will highlight areas that require referral for ability to put on and take off footwear/compression garments or bandaging
specialist intervention and factors that may suitability of footwear
have an impact on management and effect of lymphoedema on activities of daily living
concordance with treatment. use of any aids
Psychological evaluation should include
asking the patient how their swelling makes Social factors that should be assessed
them feel about themselves alongside include:
assessment for: accommodation accessibility, general
depression eg low mood, loss of living standards, heating/cooling
interest, low energy, changes in weight, support involvement of carers, effect of
appetite or sleep patterns, poor lymphoedema on personal relationships,
concentration, feelings of guilt or social isolation
worthlessness, suicidal thoughts (Box 13) employment ability to work, effect of
anxiety eg apprehension, panic attacks, work on lymphoedema
irritability, poor sleeping, situation education ability to attend educational
avoidance, poor concentration establishment and study
cognitive impairment may contribute to financial status benefit entitlement,
lack of motivation and inability to be medical insurance
independent recreational activities, exercise, sport.
lack of motivation
ability to cope Mobility and functional assessment
understanding of disease and Assessment of a patient's mobility and
concordance with treatment. functional status (Box 14) will contribute
to the formulation of a management plan
and determine whether referral for further
assessment is necessary. Functional
BOX 13 Screening for depression48 assessment of lymphoedema affecting
NICE recommends that screening for depression the head, neck, trunk or genitalia should
should include the use of at least two questions be undertaken by a lymphoedema
concerning mood and interest, eg: specialist.
During the last month, have you often The World Health Organization has
been bothered by feeling down, depressed produced a standardised, cross-cultural,
or hopeless?
non-disease specific tool for functional
During the last month, have you often
been bothered by having little interest or
assessment the WHO Disability
pleasure in doing things? Assessment Scale, available at:
www.who.int/icidh/whodas.
Patients with functional, joint or mobility
problems should be referred as appropriate
for physiotherapy and/or occupational
therapy assessment.
Treatment decisions
B Patients with lymphoedema should receive a coordinated package of care and information
appropriate to their needs.
B Patients and carers should have early active involvement in the management of lymphoedema.
Wider multidisciplinary
team when psychological,
social or functional factors
complicate management
As appropriate:
Initial lymphoedema leg ulcer/wound service
assessment breast care service
Site, stage, severity Patient requires referral dermatology service
and complexity of to other services vascular service
lymphoedema oncology service
Psychosocial status orthopaedic service
elderly care services
palliative care services
*If problems with garment management are likely to be ongoing, careful consideration should be given to commencing MLLB because
it may be required long-term.
Includes skin care, exercise/movement and elevation. Please see text for practitioner roles.
FIGURE 7 Intensive therapy options for patients with lower limb lymphoedema
Yes No
*Patients with ABPI <0.5 should not receive compression therapy and should be referred to a vascular specialist.
Includes skin care, exercise/movement and elevation.
In the palliative situation, bandages may be used to support the limb and would apply very little compression.
Yes No
FIGURE 9 Compression choices in transition management for upper or lower limb lymphoedema
Rapid accumulation of Creeping tissue refill when Larger limbs Lymphoedema with venous
tissue oedema wearing garments Pressure resistant disease
Reduced skin tone Localised tissue thickening Extensive tissue thickening Limited mobility/fixed ankle
Heaviness and discomfort still present Creeping tissue refill with joint with long periods of
difficulty controlling limb limb dependency
volume Soft, pitting oedema
No truncal oedema
Obese patient with difficulty
containing swelling
Yes No Yes No
Skin problems are common in patients with bacteria and irritants. Emollients can be
lymphoedema. Swelling may produce deep bath oils, soap substitutes or moisturisers
skin folds where fungal and bacterial (lotions, creams and ointments). In general,
infections can develop. Chronic ointments, which contain little or no water,
inflammation causes deposition of fibrin and are better skin hydrators than creams, which
FIGURE 11 Intact skin collagen, contributing to skin thickening and are better than lotions.
firm tissue consistency. Reduced tissue The best method of emollient application
compliance may further compromise lymph is unknown. Some practitioners recommend
flow and increase the tendency to infection. applying them using strokes in the direction
Maintenance of skin integrity and careful of hair growth (ie towards the feet when
management of skin problems in patients applying to the legs) to prevent blockage of
with lymphoedema are important to hair follicles and folliculitis. Others
minimise the risk of infection. recommend applying emollients by stroking
The general principles of skin care towards the trunk to encourage lymph
(Box 17) aim to preserve skin barrier drainage.
function through washing and the use of Emollients may damage the elastic
emollients. Ordinary soaps, which usually component of compression garments, and it
contain detergents and no glycerin, should is preferable to avoid application
be avoided because they tend to dry the skin. immediately prior to donning.
FIGURE 12 Rough and scaly dry Natural or pH neutral soap can be used. The
skin
perfumes and preservatives in scented SKIN CARE REGIMENS
products may be irritant or allergenic. In high Following are descriptions of skin care
concentrations, mineral and petrolatum regimens for skin conditions that can occur
based products may exacerbate dry skin in patients with lymphoedema. These
conditions by occluding skin pores and conditions may occur simultaneously and
preventing natural oils from surfacing. require combinations of regimens. The
Emollients re-establish the skin's general principles of skin care apply to all
protective lipid layer, preventing further conditions (Box 17).
water loss and protecting the skin from
Intact skin
Box 17 General principles of skin care The condition of intact skin (Figure 11)
should be optimised by applying emollient
Wash daily, whenever possible, using pH
neutral soap, natural soap or a soap
at night.
substitute, and dry thoroughly
Ensure skin folds, if present, are clean and dry Dry skin
Monitor affected and unaffected skin for Dry skin may vary from slightly dry or flaky
cuts, abrasions or insect bites, paying to rough and scaly (Figure 12). Patients may
particular attention to any areas affected by complain of itching.
sensory neuropathy Emollients should be applied twice daily
Apply emollients (including after washing) to aid rehydration.
Avoid scented products If the heels are deeply cracked, emollients
Particularly in hot climates, vegetable-based and hydrocolloid dressings may help and the
products are preferable to those containing
patient should be referred according to local
petrolatum or mineral oils
dermatology guidelines.
Folliculitis Lymphangiectasia
Folliculitis (Figure 14) is due to inflammation Lymphangiectasia (Figure 16 also known
of the hair follicles. It causes a red rash with as lymphangiomata) are soft fluid-filled
pimples or pustules, and is most commonly projections caused by dilatation of
seen on hairy limbs. The cause is usually lymphatic vessels. Treatment is
Staphylococcus aureus, and it may precede compression with MLLB. If there is no
cellulitis/erysipelas. Swabs should be taken response to initial compression, or the
for culture if there is any exudate or an open lymphangiectasia are very large, contain
wound. chyle or cause lymphorrhoea, the patient
An antiseptic wash/lotion, eg one should be referred immediately to a
containing chlorhexidine and benzalkonium, lymphoedema practitioner with training at
should be used after washing. Emollient specialist level.
should be applied without being rubbed in. If FIGURE 18 Severe papillomatosis
there is no response after one month, the Papillomatosis
patient should be referred according to local Papillomatosis (Figures 17 and 18)
dermatology guidelines. produces firm raised projections on the
skin due to dilatation of lymphatic vessels
Fungal infection and fibrosis, and may be accompanied by
Fungal infection (Figure 15) occurs in skin hyperkeratosis.
creases and on skin surfaces that touch. It The condition may be reversible with
causes moist, whitish scaling and itching, adequate compression. If the condition
and is particularly common between the does not improve after one month, the
toes. It can precede the development of patient should be referred to a
cellulitis/erysipelas. Skin scrapings and, if lymphoedema practitioner with training at
nails are affected, nail clippings should be specialist level.
sent for mycological examination.
FIGURE 19 Lymphorrhoea and FIGURE 20 Ulceration FIGURE 21 Venous eczema FIGURE 22 Contact dermatitis
resulting maceration
TABLE 4 Antibiotics for cellulitis/erysipelas in lymphoedema (developed by the British Lymphology Society and Lymphoedema
Support Network)57
Situation First-line antibiotics* If allergic to penicillin* Second-line antibiotics* Comments*
Home care Amoxicillin 500mg Clindamycin 300mg Clindamycin 300mg Treat for at least 14
Acute cellulitis/ eight hourly +/- six hourly six hourly days or until signs of
erysipelas flucloxacillin 500mg If fails to resolve, convert inflammation have
six hourly to iv regimen as for resolved
hospital admission
Prophylaxis to prevent Phenoxymethylpenicillin Erythromycin 250mg Clindamycin 150mg After one year, halve
recurrent cellulitis/ 500mg once daily (1g once once daily once daily or dose of penicillin to
erysipelas daily if weight >75kg) clarithromycin 250mg 250mg once daily
(two attacks per year) once daily (500mg once daily if
weight >75kg)
History of animal bite Co-amoxiclav 625mg Ciprofloxacin 500mg Consult microbiologist Causes may be
six hourly twelve hourly Pasteurella multocida,
Eikinella corrodens or
Capnocytophaga
canimorsus
Lymphatic massage
Lymphatic massage manual lymphatic research data to conclusively support its BOX 19 Indications for MLD
drainage (MLD) and simple lymphatic use2,58-60. The most appropriate and SLD
drainage (SLD) aims to reduce swelling by techniques, optimal frequency and
Swelling at the root of a
encouraging lymph flow. indications for MLD, as well as the benefits
limb
The efficacy of MLD and SLD remains to be of treatment, all remain to be clarified. Trunk and midline oedema
proven, but there is no doubt that they are MLD remains a specialist skill that needs (eg chest, breast, back,
of immense value in providing regular practice in order to maintain abdomen, genitalia, head
psychological and symptomatic benefits. competence. Deep, heavy-handed and neck)
massage should be avoided because it may Provision of comfort and
MANUAL LYMPHATIC DRAINAGE damage tissues and exacerbate oedema by pain relief when other
increasing capillary filtration. physical therapies are no
longer appropriate
C MLD and compression can reduce and
control lymphoedema of the head, neck
and body.
Indications Adjunctive treatment to
pain management
MLD may be indicated as part of intensive
therapy, transition management, long-term
Manual lymphatic drainage (MLD) is a management or palliative care (Box 19).
gentle massage technique that is MLD on its own is not sufficient treatment
recognised as a key component of for lymphoedema; it should be combined
decongestive therapy. MLD aims to with compression therapy to support and
encourage fluid away from congested maintain its effects. However, where
areas by increasing activity of normal compression is difficult or is not well
lymphatics and bypassing ineffective or tolerated, eg in lymphoedema of the head,
obliterated lymph vessels. Although there neck, trunk, breast and genitalia, MLD may
is a wealth of clinical opinion advocating be the only realistic option.
the benefits of MLD, there are little
Local contraindications*
Untreated thyroid dysfunction
Primary tumours
Metastases
Intermittent pneumatic
compression
Although there is considerable BOX 21 Contraindications to IPC
international debate over its effectiveness
Untreated nonpitting chronic lymphoedema
in lymphoedema, intermittent pneumatic
Known or suspected deep vein thrombosis
compression (IPC) is widely used. It may
Pulmonary embolism
form part of an intensive therapy regimen Thrombophlebitis
or long-term management in selected Acute inflammation of the skin, eg cellulitis/erysipelas
patients, and may be used with caution in Uncontrolled/severe cardiac failure
the palliative situation. Pulmonary oedema
Ischaemic vascular disease
WHAT IS IPC? Active metastatic disease affecting oedematous region
IPC consists of an electrical air compression Oedema at the root of the affected limb or truncal oedema
pump attached to an inflatable plastic Severe peripheral neuropathy
garment that is placed over the affected Caution required: peripheral neuropathy, pain or numbness in the limb, undiagnosed, untreated or
limb. The garment is inflated and deflated infected wounds, fragile skin, grafts, skin conditions that may be aggravated by IPC, extreme limb
cyclically for a set period, usually about deformity (may impede correct use of IPC).
30-120 minutes. The pressure produced by
the garment can be varied. Garments may
be single chambered, or contain multiple GUIDELINES FOR USE
chambers (usually three, five or 10) that are Consensus on the pressures suitable for
inflated sequentially to provide a peristaltic IPC in lymphoedema is lacking.
massaging effect along the length of the Careful surveillance is required to ensure
limb towards its root. that the correct technique and pressures
The question of whether single or are applied. Pressures should be adjusted
multichambered devices are more effective according to patient tolerance and
remains open. However, multichambered response to treatment. In general:
devices are used most frequently and pressures of 30-60mmHg are advised
randomised controlled trials have shown lower pressures are advised in palliative
them to produce a faster effect64,65. care, eg 20-30mmHg
IPC is thought to reduce oedema by a duration and frequency of 30 minutes
decreasing capillary filtration, and therefore to two hours daily is recommended66-68.
lymph formation, rather than by IPC may exacerbate or cause congestion or
accelerating lymph return. a ring of fibrosis at the noncompressed root
IPC is particularly effective in of a treated limb if the lymphatics in the
nonobstructive oedemas, eg those due to root of the limb have not been cleared. IPC
immobility, venous incompetence, of the lower limbs may precipitate genital
lymphovenous stasis or hypoproteinaemia. oedema69.
In obstructive lymphoedema, ie IPC is not recommended if there is
lymphoedema resulting from lymphatic oedema at the root of the limb or in the
vessel/node damage or lymph node adjacent trunk.
resection, SLD or MLD is recommended IPC should be prescribed and performed
before IPC to stimulate lymphatic flow66. by practitioners who have received
It is important that compression therapy appropriate training at specialist level.
with garments or bandaging is continued
after IPC to prevent rapid rebound swelling.
Contraindications to IPC are listed in Box 21.
Multi-layer inelastic
lymphoedema bandaging
BOX 22 Indications for Multi-layer systems followed by compression garments are more effective than single layer
MLLB B compression garments when used in the initial phase of lymphoedema treatment70.
Lymphoedema with:
fragile, damaged or
Multi-layer lymphoedema bandaging (MLLB) Contraindications to MLLB include severe
ulcerated skin
is a key element of intensive therapy peripheral arterial occlusive disease (Box 23).
distorted limb shape
limb too large to fit
regimens. For some patients it may also form
compression garments part of their transition, long-term or palliative MLLB SYSTEMS
areas of tissue thickening management. The purpose and characteristics of the usual
lymphorrhoea MLLB uses inelastic bandages that have components of MLLB in their order of use are
lymphangiectasia low extensibility and that produce high described in Table 5.
pronounced skin folds working pressures and lower resting MLLB regimens can be adapted to
Cautionary notes: Patients with
pressures (Figure 25), ie they create peak individual patient's needs by varying the:
significant skin sacs/lobes or pressures that produce a massaging effect pressure produced by the bandages
extensive tissue thickening should and stimulate lymph flow. In certain frequency of bandage change
be referred to a lymphoedema
practitioner with training at situations (page 34), elastic bandages may bandage bulk
specialist level. If there is swelling be used instead. Elastic bandages produce type of bandage, eg using elastic
at the root of the limb or adjacent
to the trunk, MLD should be sustained compression with smaller bandages instead of inelastic bandages.
performed in conjunction with variations during movement.
MLLB.
BOX 23 Contraindications to MLLB
USES FOR MLLB Severe arterial insufficiency (ABPI <0.5),
As well as reducing oedema, MLLB: although modified MLLB with reduced
restores shape to the limb/affected area pressures can be used under close
reduces skin changes such as supervision
hyperkeratosis and papillomatosis Uncontrolled heart failure
supports overstretched inelastic skin Severe peripheral neuropathy
eliminates lymphorrhoea
Caution required: cellulitis/erysipelas (MLLB can be
softens subcutaneous tissues. continued, if tolerated, at reduced pressure), diabetes
MLLB is indicated when skin changes are mellitus, paralysis, sensory deficit, controlled congestive
marked or limb distortion and skin folds heart failure (application of MLLB to one limb at a time
may be advisable).
preclude compression garments (Box 22).
Resting pressure the bandage or compression Working pressure when muscles contract and
garment applies a constant pressure to the skin expand (eg during exercise) they press against
when the limb is at rest the resisting bandage and the pressure inside
the limb increases temporarily
Skin Muscle
Veins and
lymphatics
Contracting
muscle
FIGURE 25 Resting and working Fabric
pressures (bandage or
NB In practice, the resting compression Increased
garment) pressure
pressure applied by inelastic
compression bandaging stimulates
diminishes as oedema resolves, lymphatic
pumping and
necessitating bandage
reabsorption
reapplication. Elastic bandages of lymph
Resistance
maintain a more constant resting from fabric
pressure.
1. Skin care To optimise skin health and According to need As a minimum, emollient
treat any skin conditions, eg should be applied to the skin
hyperkeratosis or ulceration before bandaging
2. Finger or toe bandaging To prevent or reduce swelling Conforming bandage Bandaging should not impede
(if indicated) of the fingers function of digits
To reduce swelling of the toes
3. Tubular bandage To provide a protective, A light cotton or cotton-viscose Should be long enough to be
absorbent layer between the bandage applied to the whole area to be folded back over the padding
skin and other bandages bandaged layer at either end to prevent
Does not contribute significantly to fraying or chafing
compression
4. Soft synthetic wool To protect the skin and Soft synthetic wool or polyurethane Extra padding may be required
(sub-compression subcutaneous tissues, to foam is available in different widths and on vulnerable pressure points
wadding bandage') or normalise shape*, to protect thicknesses, and as bandages or sheets such as the Achilles' tendon,
foam roll or sheet bony prominences and to Polyester undercast padding is available dorsum of the foot, tibialis
equalise the distribution of in sheets of various widths anterior tendon, the malleoli,
pressure produced by other Higher densities of foam are used with the popliteal fossa and the
bandage layers greater degrees of shape distortion or elbow
tissue thickening
5. Dense foam Applied locally to soften hard Polyurethane high density foam is Applied over soft synthetic
areas of tissue thickening* or available in sheets or pads of different wool or under foam
areas particularly vulnerable thicknesses that can be cut to shape Edges should be bevelled to
to oedema, eg the malleoli prevent rubbing
6. Inelastic bandages To provide compression Constructed of crimped cotton yarns Several layers are used
Available as nonadhesive, cohesive or Cohesive and adhesive
adhesive bandages can help to prevent
Most types are available in 4cm, 6cm, slippage and are used to
8cm, 10cm and 12cm widths prolong the time the bandage
is worn
*Foam chip bags contain low density foam pieces in a tubular bandage and can be used to bulk out areas such as the palm of the hand or over areas of tissue
thickening.
for the first seven days. This will minimise Self/carer bandaging may be helpful to
bandage slippage and ensure that sub- patients with:
bandage pressure is maintained as swelling pressure resistant lymphoedema
reduces. According to therapy regimen and obesity/larger limbs
wound/skincare requirements, it may then experience of treatment
be possible to reduce the frequency of a desire to be actively engaged in their
change to two to three times per week. management
Continence issues may also influence the refill not controlled by hosiery alone.
frequency of change. Patients may also choose self/carer
Commencement of bandaging and the bandaging to enhance comfort or for use at
timing of bandage change may need to be night when they wear a compression
co-ordinated with any orthotic or podiatric garment during the day.
needs of the patient.
ALLERGY AND MLLB
Use of elastic bandaging Where possible, tubular bandages with high
In some situations, the inelastic bandages cotton content should be used to avoid
used in MLLB may be replaced with a exposing the patient to potential allergens.
multi-layer elastic bandage regimen. The Direct contact between skin and foams
stiffness produced by the combination of should be avoided.
layers and the inclusion of a cohesive
elastic bandage produces high working BANDAGE CARE
pressures. However, the resting pressure is Some components of the MLLB system can
higher than with inelastic systems. be washed and dried according to the
The sustained resting pressure produced manufacturer's instructions and reused. Over
by high stiffness elastic bandage systems time, inelastic bandages will progressively
may be useful when: lose their extensibility, which will increase
the patient is immobile their stiffness. Heavily soiled materials should
the ankle joint is fixed, ie the calf muscle be discarded. Cohesive and adhesive
pump cannot be used bandages should be discarded after use.
the patient has venous ulceration and
lymphatic disease PRINCIPLES OF MLLB
the patient has proven venous disease Practical bandaging skills are important for
large volume loss is expected, ie to the effective use of MLLB (Boxes 25 and
increase time worn. 26).
Practitioners will be appropriately trained.
Modifications for long-term or The use of tailored foam pads requires
palliative use training at specialist level.
MLLB can be modified to apply reduced Clear guidance is given for MLLB of the leg
pressure for long-term, palliative or night in Figures 26-33 and Box 27 (pages 35-37)
time use. In most cases, the bandages are and for MLLB of the arm in Figures 34-38
applied using a spiral technique only. and Box 28 (pages 37-38).
Materials include:
cotton tubular bandage
soft synthetic wool or foam padding BOX 25 Avoiding bandage slippage72
cohesive or adhesive inelastic bandages
Use foam to pad (more likely to stay in place
using fewer layers. than soft wool underpadding)
Place narrow strips of foam between the
Self/carer bandaging inelastic bandage layers at the thigh to act as
For selected patients, self bandaging or a brake
bandaging by a carer may be appropriate. Apply a cohesive or adhesive bandage in
The patient or carer needs good dexterity, one layer, and particularly as the final layer
a clear understanding of the technique Use ordinary noncompressive pantyhose
involved, and to demonstrate proficiency in over the bandage or suspenders attached to
application. The bandaging technique the proximal end of the bandages. This
avoids changing the pressure gradient over
would be modified as described for long-
the leg
term management.
(c) (d)
(a) (b)
FIGURE 28 Application of
underpadding to lower leg
Apply soft synthetic wool padding
to protect and reshape the limb.
Soft foam underpadding can also
be used.
(c) (d)
FIGURE 29 Spiral bandaging of foot and lower leg with inelastic bandage
(a) Anchor an 8cm inelastic bandage with a turn around the base of the toes.
(b) Bandage the foot using spiral technique. Use figure of eight technique around the ankle. Continue up the
leg using spiral technique with any remaining bandage.
(c) Bandage the lower part of the leg using a 10cm inelastic bandage and spiral technique, and continue up
the limb.
(d) The end of the tubular bandage can be folded back and concealed under the next layer of bandage.
FIGURE 31 Padding skin folds FIGURE 32 Forefoot swelling FIGURE 33 Padding for retromalleolar
Deep skin folds can occur on the toes. Foam padding can be applied to the forefoot oedema
Forefoot swelling may also be present. Skin and fastened with a toe bandage to increase Foam padding can aid oedema reduction
folds must be padded. Bevel edged foam local pressure. This care is initiated and around the malleoli.
strips can be used. This is an area of monitored by practitioners with training at
treatment that is initiated and monitored by specialist level, as it requires accurate use of
practitioners with training at specialist level. appropriately cut foam.
(c) (d)
(c) (d)
Compression garments
(a) (b)
Mid-upper arm
Elbow crease
(slightly bent)
*For lower limb garments, the length measurement determines which length of garment is required, and is taken from the heel to just below
the gluteal fold for thigh length garments, and from the heel to just below the knee for below knee garments.
Some manufacturers prefer shoe size to foot length measurements.
(a) (b)
Waist Waist
Back Front
H
G-H**
Hips Hips
G1 G G 2cm below
G-G1 a-G
gluteal fold
Measurements required for arm sleeve
G
C-G F F Mid-thigh
Mid-upper arm F a-F
B1 B1 Where calf
a-B1 starts to widen
2cm above medial
B B malleolus
a-B
H H Around heel
A a A Base of toes
a
Slant toe: as for open toe plus base of little toe to heel
and base of big toe to heel
* To find C, ask the patient to flex the wrist. Use the level of the second crease from the hand to measure circumference C. C1 is about 3cm
proximal to C.
Measure circumference E at the elbow crease with the elbow slightly bent. Measure again 1-2cm proximal to E. If this circumference is larger
than the E measurement, record this as E.
To measure circumference G, ask the patient to place a piece of paper in the axilla to show where they would like the garment to finish while
putting the arm at their side. Fold the paper around the arm and mark the level of G at the top edge of the paper. When measuring
circumference G do not apply any tension to the tape.
Measure length G-G1 for bias top.
**Measure length G-H for shoulder attachment.
FIGURE 43 Compression garments for lower limb lymphoedema/lymphovenous oedema, adapted from73
Successful outcome
No increase in swelling
No deterioration of skin, tissue density or shape
Improvement in patient/carer involvement and self management skills
*For patients with shape distortion, flat knit hosiery is often preferable.
Including inelastic adjustable compression device.
TABLE 7 Compression garment recommendations for specific problems in lower limb lymphoedema
Problem Recommendations/notes
Swollen toes Where toe caps are difficult to manage, closed toe garments may be helpful
Forefoot swelling No risk of toe swelling use open toe garments; flat knit is preferable
Toe swelling use open toe garment and toe caps, unless toe caps are impractical, when a
closed toe garment may suffice
Lymphoedema of the foot only inelastic adjustable foot wrap may be useful
Forefoot bulge Custom made flat knit garments may be required to produce sufficient pressure
An individually shaped foam pad can apply additional pressure
Inelastic adjustable footwrap may be useful
Check that footwear is well-fitting and supportive
Retromalleolar swelling Foam, crescent shaped stasis pads can be used to focus pressure
Fat/arthritic knees Low classification pantyhose under a calf stocking may be useful for shape distortion of the
knee and thigh
If using circular knit, use an extra wide calf range
Thickened tissue just below patella Below knee garments can exacerbate the problem; ideally use full leg garments
Pressure can be focused by using a crescent shaped ribbed or foam chip stasis pad over
thickened area
If a below knee compression garment is necessary, a stasis pad can be used with an
orthopaedic elasticated knee support
Inverted champagne bottle legs Limb shape should be corrected with MLLB
Flat knit appears to be more effective than circular knit
May need higher pressure levels
May need custom made garments
If using two garment layers, use a combination of flat knit and circular knit
Lymphoedema extends to groin Flat knit custom made garments, eg one- or two-legged closed gusset panty, should be used
A foam chip pad angled into the groin under the compression garment may be used to focus pressure
Close fitting shorts with Lycra (eg cycle shorts) are convenient for some patients
Obesity May need custom made garments; flat knit may be easier to apply
Garments designed to accommodate pregnancy may be useful
Severe distortion of the lower limb or patient preference may restrict treatment to the lower
part of the leg
Using separate overlapping garments for above and below the knee may make application easier
SAFETY ISSUES
Lower limb peripheral arterial occlusive disease
The lower limb peripheral arterial status of patients with lower limb lymphoedema should
be assessed prior to compression. Patients with ABPI <0.5 should not receive compression
and should be referred to a vascular specialist.
Risk reduction
Patients should be advised to wear compression garments when performing high risk,
repetitive activities. Although there is no robust evidence that long sitting while travelling,
eg by aeroplane, increases or precipitates lymphoedema, patients should exercise caution
and wear a compression garment if they are at risk of or have lymphoedema.
Moderate lymphoedema MEDIUM Circular or flat knit Garments can be made that
ISL late stage II-III 20-25mmHg Ready to wear or custom made* incorporate pads to treat areas of
Some shape distortion thickened tissue
Silk inserts can be used at the inner
elbow if irritation and trauma occur
Severe lymphoedema HIGH Circular or flat knit Such high pressure is required only in
ISL stage III 25-30mmHg Custom made* exceptional cases
Major shape distortion
NB The compression applied by knitted armsleeves is graduated. The compression applied at the proximal end of the garment is 50-80% of that applied at the wrist.
*All upper limb styles including gloves and gauntlets and inelastic adjustable compression devices.
Psychosocial support
Patient has:
Poor concordance
Depression Loneliness and isolation Poor coping
with treatment
Palliative care
Problem Intervention
Unable to tolerate full Use modified monitoring and limb volume measurement techniques
assessment procedures
Fragile or dry skin Maintain skin integrity refer to skin management guidance
Discomfort in a swollen limb Reduced compression MLLB with modification to materials used
Low pressure compression garments
Swollen limb due to Good skin care and guidance on limb positioning
dependency or inactivity, or Gentle passive or active exercises
mainly venous oedema of Reduced compression MLLB
lower limbs with no truncal Low pressure compression garment
oedema IPC
Refer to physiotherapist
Swelling of scrotum and/or Close-fitting shorts with Lycra to provide scrotal support
penis Custom made garments and scrotal support for use by ambulant patients
Scrotal bandaging
Teach SLD
Swelling of female genitalia Lycra shorts with 1cm thick anatomically contoured foam pads
Flat knit custom made shorts with foam pads
Compression tights with localised padding
Teach SLD
Surgery
BOX 38 Potential Surgical treatment of lymphoedema can be ation82. Anastomosis of lymph vessels to the
indications for surgery in divided into three main categories: venous system may be attempted in patients
lymphoedema81-84,92-94 surgical reduction with proximal lymphatic obstruction and
procedures that bypass lymphatic patent distal lymphatics, and produces better
Severe deformity or marked
disability due to swelling
obstructions results at earlier stages of lymphostatic
Removal of redundant liposuction. disease83-85. Lymphatic grafting and lymph
tissue after successful Patients for surgery need to be selected node transplantation require microsurgical
conservative therapy carefully (Box 38) and counselled to ensure techniques, and show promising results in
Proximal lymphatic realistic expectations of likely outcome. carefully selected patients86,87.
obstruction with patent Maintenance of any improvement gained
distal lymphatics requires long-term postsurgical LIPOSUCTION
Lymphocutaneous fistulae compression therapy. In patients with chronic lymphoedema,
and megalymphatics adipocyte proliferation (which may be
Eyelid and external genital SURGICAL REDUCTION related to an inflammatory process) may
lymphoedema
Surgical reduction (sometimes also known mean that conservative treatment or
Lack of response to
compression therapy
as debulking surgery) aims to remove microsurgery do not completely resolve
Recurrent excess subcutaneous tissue and skin, and limb enlargement88.
cellulitis/erysipelas may be useful in the symptomatic treatment Liposuction has been performed on
Intractable pain of severe lymphoedema. However, the patients with long-standing breast cancer
Lymphangiosarcoma postsurgical morbidity of reduction related lymphoedema. It removes excess fat
operations may be considerable80,81. In tissue and is considered only if the limb has
some cases, surgical reduction may be not responded to standard conservative
considered for lymphoedema of the eyelid therapy. Liposuction does not correct
or genitalia. inadequate lymph drainage and is not
Lymphocutaneous fistulae:
abnormal connections between the indicated when pitting is present. Where
lymphatic system and the surface RESTORING LYMPH FLOW concordance with compression garments
of the skin; may leak large Some surgical techniques aim to restore after treatment is high, results have been
quantities of lymph
Megalymphatics: large, dilated
lymphatic function through lymphovenous maintained89,90. Liposuction has also been
incompetent lymph vessels that anastomoses and lymphatic or venous used for primary and secondary leg
allow lymphatic reflux vessel grafting, or lymph node transplant- lymphoedema with promising results91.
Other treatments
A variety of other treatment modalities may Benzopyrones
be used to treat lymphoedema; many Benzopyrones are based on a variety of
require further evaluation (Box 39). National naturally occurring substances. Examples
use of these treatments is variable. include flavonoids, oxerutins, escins,
coumarin, and ruscogen combined with
DRUG TREATMENT hesperidin.
Two main groups of drug have been used in There is little evidence to support the use
the treatment of lymphoedema: of these drugs in lymphoedema1,95. There is
benzopyrones and diuretics. some data, however, that flavonoids may
stabilise swelling by reducing microvascular
filtration96.
Oxerutins have been licensed in some LYMPHOEDEMA TAPING BOX 39 Other treatments
countries, usually for use in chronic venous Lymphoedema taping is an emerging form of
insufficiency, but there are insufficient data treatment for lymphoedema. It involves the Other treatments that have
been used for the treatment
to draw conclusions about their efficacy in application of narrow strips of elastic tape to
of lymphoedema, mainly in
lymphoedema. The same conclusion has the affected area, and can be used in
breast cancer patients, that
been reached about flavonoids. Coumarin combination with compression garments or all require further evaluation,
has been most widely trialled, but the most bandaging. It is thought to improve muscle include:
recent study reported no significant effect95 function and lymph flow98 and may have a cryotherapy
and the drug has been withdrawn in role to play in the treatment of midline and transcutaneous electrical
Australia because of liver toxicity. peripheral swelling. However, evidence is nerve stimulation (TENS)
lacking of its efficacy in lymphoedema. pulsed magnetic fields,
Diuretics vibration and hyperthermia
Diuretics encourage the excretion of salt and HYPERBARIC OXYGEN thermal therapy
ultrasound
water, and by reducing blood volume might Hyperbaric oxygen therapy is known to
complementary medicine
be expected to reduce capillary filtration and promote healing in bone that has become
lymph formation. There is no evidence that ischaemic following radiotherapy. In patients
diuretics encourage lymph drainage. with upper limb lymphoedema following
A diuretic is likely to be prescribed on a radiotherapy, two small studies have
pragmatic basis for anyone with oedema indicated that hyperbaric oxygen may
almost irrespective of cause. However, improve lymph flow and reduce limb volume
higher doses of thiazides or loop diuretics in the short-term99,100. Further research is
(eg furosemide or bumetanide) can reduce required to establish whether benefits can be
body potassium levels with long-term use demonstrated in randomised trials and in the
and may cause muscle weakness, promote long-term.
oedema formation and affect the heart.
Diuretics are not recommended for use in LASER THERAPY
the treatment of lymphoedema. Occasionally, Low level laser therapy has shown potential
short courses may be of benefit in chronic for the treatment of lymphoedema,
oedema of mixed aetiology, and in older particularly of the upper limb, where it has
patients in whom enhanced lymphatic reduced limb volume and tissue hardness101.
drainage as a result of lymphoedema therapy Further research is required to establish the
precipitates cardiac failure. benefits of treatment and the optimal
regimen.
BREATHING EXERCISES
Breathing exercises are recommended by RECOMMENDED READING
some clinicians as a preliminary manoeuvre
Badger C, Preston N, Seers K, Mortimer P. Benzo-pyrones for reducing
that may help to clear the central and controlling lymphoedema of the limbs. Cochrane Database Syst Rev
lymphatics prior to interventions that 2004; 2: CD003140.
promote lymph drainage from the Badger C, Preston N, Seers K, Mortimer P. Physical therapies for
peripheries97. However, other clinicians reducing and controlling lymphoedema of the limbs. Cochrane Database
question the physiological basis of breathing Syst Rev 2004; 4: CD003141.
exercises as there are no experimental data Badger C, Seers K, Preston N, Mortimer P. Antibiotics/anti-
in humans to confirm that variations in inflammatories for reducing acute inflammatory episodes in
lymphoedema of the limbs. Cochrane Database Syst Rev 2004; 2:
intrathoracic pressure due to breathing CD003143.
assist central lymphatic drainage into the
Browse N, Burnand K, Mortimer P. Diseases of the Lymphatics. London:
venous system. Arnold, 2003.
Although a recent human study European Wound Management Association (EWMA). Focus
demonstrated that a combination of exercise Document: Lymphoedema bandaging in practice. London: MEP Ltd, 2005.
and deep breathing significantly reduced the European Wound Management Association (EWMA). Position
volume of lymphoedematous limbs79, Document: Understanding compression therapy. London: MEP Ltd, 2003.
evidence is lacking of the effect of breathing Fldi M, Fldi E, Kubik S (eds). Textbook of Lymphology for Physicians and
exercises in isolation. Nonetheless, breathing Lymphedema Therapists. San Francisco: Urban and Fischer, 2003.
exercises are not harmful, are inexpensive, Lymphoedema Framework. Template for Practice: compression hosiery in
and may be proven beneficial in some groups lymphoedema. London: MEP Ltd, 2006.
of patients with lymphoedema. Olszewski WL. Lymph Stasis: pathophysiology, diagnosis and treatment.
Boca Raton: CRC Press, 1991.
APPENDIX 1
Consensus conference to define issues
Consensus approach
Professionals
Literature review Patients Health service British Lymphology Industry
Lymphoedema Primary care trusts Society consortium
Support Network
Other specialists
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