Lymphoedema management: A collaborative approach for patients and clinicians

Lymphoedema is a chronic, progressive condition which can often be debilitating. It is caused by a deficiency or failure of the lymphatic system. Due to its chronic nature, lymphoedema requires ongoing treatment to manage and control the swelling. It is estimated that lymphoedema affects more than 120 million worldwide.¹

Lymphoedema is classified as either primary—a result of an abnormality of the lymphatic system and can present at birth or later in life—or secondary—the result of damage to the lymphatic system. This can occur as a result of surgery eg. cancer surgery, orthopaedic and vascular surgery. It can also occur as a result of injury, inflammation or infection.

Correct diagnosis of lymphoedema requires assessment by a qualified lymphoedema practitioner and in some cases patients may require more specialised investigations including lymphoscintigraphy, magnetic resonance imaging or computed tomography scanning. In most cases lymphoedema can be diagnosed through careful history taking and physical examination but it is essential that the assessment excludes other causes for the swelling and identifies any co – morbidities which could have an impact on the outcome of treatment.

As with other chronic conditions it is essential to encourage the patient to have a say and take part in their management and care pathway, encouraging them to become self- caring where possible; using a patient-centred approach is essential. Addressing the whole person and not just a swollen limb will aid collaboration and concordance from the patient.

To obtain the best outcomes of any lymphoedema management it is essential that the management plan is tailored to a patient’s individual needs and abilities. Honest and open discussions along with a realistic expectation of goals and outcomes will enhance the patient-therapist relationship and improve overall outcomes. It is also important to incorporate prevention strategies and health promotion to optimise outcomes.

The patient journey should begin with assessment by a trained professional who is able to correctly diagnose the condition, and identify and instigate the appropriate care pathway (with or without modifications). In order to support the patient with long-term acceptance and self- management they must receive ongoing education and support.

Managing lymphoedema is multifaceted (Figure 1). Not every component will be appropriate for every patient. Management is very much an individualised approach. There are many issues to consider including the patients ability to undertake specific therapies/self- management techniques and there may be coexisting medical conditions which may restrict the use of certain components of care.

The basic components of care include skin care, exercises and compression therapy. For those patients with more complex lymphoedema, the need for more advanced techniques is required. These include:

• Lymphatic drainage: Whether this be in the form of manual drainage, self -administered drainage, deep oscillation therapy (Hivamatt) or negative pressure therapy (Physiotouch).
• Compression bandaging: Multi- or two-layered specific lymphoedema bandaging to reduce the bulk of the limb and improve shape, prior to the use of compression garments.
• Kinesio taping: Strips of elastic tape are applied to the skin in a specific application technique. Drainage is achieved by the lifting of the skin in an affected area. The tape increases the space in which lymphatic fluid flows, increasing drainage. Some applications can also encourage lymphatic fluid to move towards working lymph nodes.
• Surgery: Liposuction can be used to remove excess fatty tissues formed within the tissues and reduce the bulk of the limb.
• Restoring lymph flow: Eg. lymphovenous anastomoses, lymphatic or venous vessel grafting or lymph node transfer/transplantation.
• Low level laser therapy: This has shown potential, particularly with upper limb lymphoedema where it has reduced limb volume and tissue hardness.³

Collaborative work among healthcare professionals will ultimately improve the chances of successful outcomes. Healthcare workers should all be familiar with the advice that should be given to patients in order to avoid conflicting information and detriment to the patient.

The Lymphoedema Framework (2003)² produced standards of practice for lymphoedema services which were agreed by consensus:

• Standard 1: Identification of people at risk of or with lymphoedema.
• Standard 2: Empowerment of people at risk of with lymphoedema.
• Standard 3: Provision of lymphoedema services that deliver high-quality clinical care that is subject to continuous improvement and integrates community, hospital and hospice based services.
• Standard 4: Provision of high-quality clinical care for patients with cellulitis.
• Standard 5: Provision of compression garments for people with lymphoedema.
• Standard 6: Provision of multi-agency health and social care.

Standards 1, 2 and 6 are essentially where each healthcare professional can meet the needs of the patient.

For those patients with secondary lymphoedema it is essential that they are diagnosed as early as possible. This can only be achieved if clinicians are aware of and able to identify those patients at risk. For surgical patients (eg. vascular, orthopaedic, breast, gynaecology or urology), considering early referral to lymphoedema services if postoperative swelling becomes problematic or is present for up to 6–12 weeks. Providing information to patients on what they need to watch out for in terms of lymphoedema development—not just signs but also symptoms such as heaviness, aching and reduced movement in the at-risk limb—is also important. Those patients undergoing surgery that could pose a risk to the lymphatic system should be questioned as to any family history of lymphoedema.

By working together we can achieve so much more. It is essential that current and concise information is provided to patients and that they are not confused by conflicting information between fields. For example, patients with arterial insufficiency may not be suitable for compression or they may be able to undertake compression therapy with close observation. Vascular and lymphoedema services working together in this area will enhance patient care and outcomes.

Patients with chronic skin problems may require input from the dermatology department and working in conjunction with lymphoedema services could promote improvement in the patients’ quality of life, reduce the risk of repeated episodes of cellulitis and thereby reducing the impact of the skin condition on the patients swelling.

Lymphoedema management requires a multidisciplinary approach that is individualised and holistic. There is no “one plan fits all” approach, as patients are individuals with individual needs and abilities. We must consider this if we are to be successful in obtaining our patients trust and concordance.

References

1. International Lymphoedema Framework (2013) Best Practice for the management of lymphoedema – 2nd edition: Surgical Intervention: A position document on surgery for lymphoedema
2. Lymphoedema Framework. Best practice for the management of lymphoedema: International Consensus. London. MEP (2006)
3. Carati CJ et al (2003) The treatment of post mastectomy lymphoedema with low level laser therapy, a double blind, placebo-controlled trial. Cancer: 98 (6): 1114-22

Tracy Green is a clinical advisor and lymphoedema specialist