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A guide to treating lymphoedema

VOL: 96, ISSUE: 38, PAGE NO: 42

Martine Huit, BSc, RGN, is lymphoedema nurse specialist, Guy’s and St Thomas’s Hospital NHS Trust, London.

The lymphatic system has an immunological function that helps to maintain homeostasis. It returns fluid that contains water, protein and waste products of metabolism from the interstitial spaces back to the blood circulation. When this function is impaired, protein accumulates in the tissues and osmotic forces attract water, which results in swelling. This is referred to as lymphoedema (Mortimer, 1990).

 

The lymphatic system has an immunological function that helps to maintain homeostasis. It returns fluid that contains water, protein and waste products of metabolism from the interstitial spaces back to the blood circulation. When this function is impaired, protein accumulates in the tissues and osmotic forces attract water, which results in swelling. This is referred to as lymphoedema (Mortimer, 1990).

 

 

The presence of lymphoedema represents ‘end-stage failure of lymph drainage’ (Mortimer, 1990); it is a condition that cannot be cured. But action can be taken to help control the amount of swelling, reduce the risk of acute inflammatory episodes, improve mobility and range of movement, and enhance the person’s overall quality of life (Jeffs, 1992). Early diagnosis, treatment and advice are important if long-term complications, including psychological distress, are to be reduced (Woods et al, 1995).

 

 

The majority of people treated at the lymphoedema clinic, St Thomas’ Hospital, London, have lymphoedema that results from obstruction of the lymphatic system by a tumour or following cancer treatment, including both surgery and radiotherapy.

 

 

A protein-rich environment, such as that associated with lymphoedema, provides an ideal medium for bacterial growth and fungal infections, increasing the risk of acute inflammatory episodes and chronic inflammation (Veitch, 1993). In turn, inflammation may cause further damage to the lymphatic system with subsequent increased swelling (Harty Getz, 1985). Over a period of time, changes may occur in the interstitial tissues and overlying skin, for example, thickening, deepened skin folds and fibrosis (Mortimer, 1990).

 

 

It is important to note that not all swellings are lymphoedema and therefore an accurate diagnosis must be confirmed before planning and implementing any treatment. Collecting accurate, relevant information is necessary if an appropriate plan of care is to be implemented (Badger, 1996a; Williams, 1997).

 

 

Case study
Edina Wrinn (not her real name) was referred to the lymphoedema clinic with lymphoedema of the left arm that had developed secondary to treatment for breast cancer (removal of lymph nodes followed by radiotherapy). A comprehensive assessment of Ms Wrinn’s physical and psychosocial needs indicated that her affected left arm was 108% larger (2445ml volume) than the right arm (1178ml).

 

 

Her skin was dry, the shape of the arm was distorted and fibrosis was present in the subcutaneous tissues from her wrist to the shoulder. Subcutaneous tissues of the arm were gently palpated to assess any change in consistency, for example, thickening of skin due to interstitial change or further fibrosis.

 

 

These clinical findings indicated that a course of intensive treatment would be necessary. However, there were contraindications to commencing treatment. Ms Wrinn was experiencing constant pain in the left axilla of unknown origin and restriction in her range of movement and function due to a frozen shoulder. In addition, the limb was warm to touch with diffuse erythema and Ms Wrinn also described experiencing ‘flu-like’ symptoms - all clinical signs of an acute inflammatory episode (Mortimer, 1990).

 

 

Liaison with other members of the multidisciplinary team (see box) for reassessment was necessary before commencing treatment. Ms Wrinn’s GP prescribed a course of antibiotics to treat her acute inflammatory episode. Prompt antibiotic treatment is very important in such episodes to prevent further compromise of the lymph system through infection.

 

 

Treatment
Once further contraindications to treatment had been excluded, and the acute inflammatory episode had been resolved, Ms Wrinn attended the lymphoedema clinic daily on an outpatient basis for two weeks, which was decided as appropriate for her needs. Complex decongestive therapy was planned according to the four cornerstones of care in the management of lymphoedema defined by Regnard et al (1991) and Todd (1996):

 

 

- Skin care;

 

 

- Lymphatic drainage;

 

 

- Compression hosiery;

 

 

- Exercise.

 

 

Skin care

 

 

Careful cleansing and drying of skin is vital in those with lymphoedema in order to keep the skin moist, supple and hydrated. This is necessary to prevent any cracks or breaks in the skin which could provide access for bacteria and further compromise the lymph system. A simple, non-perfumed emollient, in this instance aqueous cream, was applied daily. It is best to avoid the use of products containing perfume and lanolin as reactions to these products can develop and further irritate the skin.

 

 

Manual and simple lymphatic drainage

 

 

The aim of applying manual lymphatic drainage (a specialised technique that should only be carried out by a qualified therapist) is to stimulate lymph drainage through collateral pathways and remove protein from the interstitial spaces (Foldi, 1985; Casely-Smith and Casely-Smith, 1997). Used in conjunction with skin care, manual lymphatic drainage and a modified version known as simple lymphatic drainage, can help minimise acute inflammatory episodes (Badger, 1996b).

 

 

Ms Wrinn was taught how to stimulate the lymph nodes and enhance flow of lymph in the neck region before manually clearing the lymph vessels in the axilla on the unaffected side. Then, by working back towards the affected limb, the lymphatic pathway was cleared ahead of the swelling to allow forward movement of lymph (Foldi, 1985). It is important that these methods of manual lymph drainage are performed carefully and precisely in order to have the desired effect and not cause any harm.

 

 

Multi-layered bandaging and exercise

 

 

Skilled application of bandages is required to provide sustained, evenly graduated compression (Badger, 1996b). A cotton sleeve dressing and padding were used to protect the skin, bony prominences, underlying nerves and blood vessels. A cylindrical shape was created with a latex bandage and padding before applying short stretch bandages.

 

 

The use of a latex bandage was assessed as appropriate in Ms Wrinn’s case in an attempt to soften fibrous tissue as quickly as possible. As muscles contract, short stretch bandages act as a counterforce that brings about changes in the surrounding tissue (Stemmer et al, 1980). This helps to stimulate flow of lymph towards the root of the limb (Mortimer, 1995). Therefore, Ms Wrinn was encouraged to use the limb as normally as possible and to carry out gentle stretching and strengthening movements at home to improve the range of movement to her arm. Exercise also helps to maintain muscle tone and improve joint mobility and function (Miller, 1998).

 

 

Combining the four cornerstones of care in the management of lymphoedema in this way can help to control and reduce oedema. Particular attention to skin care has the potential to reduce the incidence of acute inflammatory episodes (Badger, 1996a; Todd, 1998).

 

 

Outcomes
The aim of treatment was to soften areas of fibrosis, improve the shape of the limb and reduce swelling. After two weeks of treatment, a degree of improvement was achieved in all of these areas. There was sufficient improvement in the shape of Ms Wrinn’s limb to enable it to be fitted into a compression sleeve. However, because of the size of the limb and extent of fibrosis in the subcutaneous tissues, further intensive treatment was necessary before Ms Wrinn could progress to the maintenance phase, when she could care for her swollen arm independently at home and maintain the swelling at an acceptable level. Follow-up after treatment of this kind depends on the person’s health and their ability to manage their condition.

 

 

Conclusion
Lymphoedema is a chronic condition that cannot be cured. So until Ms Wrinn can independently manage her swollen arm, her progress will need to be reviewed and re-evaluated by a lymphoedema therapist. In addition, as her health needs change, she will require planned and integrated care from the multiprofessional team if she is to receive appropriate treatment, consistent advice, education and emotional support.

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