Pneumatic Compression

Pneumatic Compression

PEP Topic 
Lymphedema
Description 

A pneumatic compression pump is a basic component of intermittent pneumatic compression (IPC), a widely used technique that involves attaching an electrical air compression pump to an inflatable plastic garment that is placed over the affected limb. The garment is inflated and deflated cyclically for a set period, usually about 30–120 minutes. The pressure produced by the garment can be varied. Garments may be single chambered or contain multiple chambers (usually 3, 5, or 10) that are inflated sequentially to provide a peristaltic massaging effect along the length of the limb.

Effectiveness Not Established

Systematic Review/Meta-Analysis

Chang, C.J., & Cormier, J.N. (2013). Lymphedema interventions: Exercise, surgery, and compression devices. Seminars in Oncology Nursing, 29, 28–40.  

doi: 10.1016/j.soncn.2012.11.005
Print

Purpose:

STUDY PURPOSE: To review the current literature regarding the treatment of lymphedema, providing applications of the evidence to the care of patients with cancer, with or at risk for, lymphedema

TYPE OF STUDY:  General review and semisystematic

Search Strategy:

DATABASES USED: 11 major medical indices from 2004–2010
 
KEYWORDS:  Lymphedema, exercise, surgical treatment, excisional procedures, lymphatic reconstruction, tissue transfer, lymphedema management, intermittent pneumatic compression
 
EXCLUSION CRITERIA:  Predefined, not listed in this article

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: N = 1,303
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: 659 reviewed by clinical lymphedema experts for inclusion in categories of lymphedema, with exercise and/or surgery

Sample Characteristics:

FINAL NUMBER STUDIES INCLUDED =  19 exercise; 20 surgery; 13 IPC
 
TOTAL PATIENTS INCLUDED IN REVIEW:   Approximately 2,554; > 295 exercise, 2,016 surgery, 243 IPC

Phase of Care and Clinical Applications:

PHASE OF CARE:  Mutliple phases of care

Results:

The PAL trial provides the strongest evidence to date that progressive resistive exercises may reduce the risk of, and not exacerbate pre-existing,  BCRL. However, no clear evidence-based recommendation regarding compression garment use during exercise can be made. Surgical treatment is associated with risk, and should not be considered a first line treatment.  IPC devices may play a role in a multi-modality approach.  There are no clear evidence-based guidelines for pressure setting use in lymphedema management.

Conclusions:

CDT remains the standard in LE therapy, but there is some limited evidence supporting consideration of adjunctive therapies, such as exercise, surgery, and IPC. More RCTs looking at exercise and LE in populations other than those with breast cancer are needed, especially studies with LE of other areas of body, and role of compression garments during exercise. Surgical treatments are promising in LE not responsive to standard therapy. IPC in low to moderate pressure ranges appear to be a safe adjunctive treatment option for appropriate, selective patients, in conjunction with CDT.

Limitations:

  • Exercise studies were limited to BCRL. 
  • Surgical studies need larger cohorts. 
  • Longer follow-up was needed. 
  • IPC studies are needed evaluating cost benefit, as well as specific recommendations, for pressure settings and length of treatments.

Nursing Implications:

Patients with LE need education regarding the benefits of exercise in general health and cancer prevention, tailored to their individual needs and comorbidities. Surgery for LE should not be considered a first-line treatment. Microvascular procedures should be treated by experienced surgeons offering ongoing care with support from certified lymphedema providers. IPC is potentially a valuable adjunctive therapy, and should be prescribed only by practitioners trained at a specialist level. With no clear guidelines for use, the authors recommend the current NLN recommendations for pump pressures from 30-60 mmHG. Additional research is essential in these categories to provide evidence based guidelines and safe, effective patient care for patients with lymphedema.

McNeely, M.L., Peddle, C.J., Yurick, J.L., Dayes, I.S., & Mackey, J.R. (2011). Conservative and dietary interventions for cancer-related lymphedema: A systematic review and meta-analysis. Cancer, 117(6), 1136–1148.

doi: 10.1002/cncr.25513
Print

Purpose:

To update evidence from randomized controlled trials (RCTs) regarding benefits of conservative and dietary interventions for all cancer-related lymphedema

Search Strategy:

Databases searched were MEDLINE, EMBASE, CINAHL, PubMed, Dissertation Abstracts, PEDro, and Cochrane Collaboration. Keywords were neoplasm, axillary dissection lymph node excision, lymphedema, conservative treatments (e.g., stockings compression, manual drainage), and publication types of random allocation and clinical trial. Studies were included in the review if they were RCTs with a sample of at least 80% patients with cancer comparing a conservative or dietary intervention to placebo, control, or comparison intervention in secondary lymphedema from cancer. Exclusion criteria were not specified.

Literature Evaluated:

Of the 157 papers that were initially retrieved, a final set of 25 were included. A modified Jadad scoring was used to evaluated the quality of the evidence. Only eight studies met criteria for high quality. Meta-analysis was done for studies examining the effect of manual lymph drainage (MLD)for upper-extremity lymphedema with breast cancer.

Sample Characteristics:

  • The final sample of 25 papers involved 1,018 participants.
  • Study sample sizes ranged from 11–90.
  • Of the 25 papers, 21 were in patients with breast cancer.

Results:

Results were synthesized in terms of effects on lymphedema volume and patient-rated outcomes of pain, heaviness, tenderness and quality of life for nine interventions. Most studies were limited to upper extremities; where lower extremities were included is stated below.

  • Strong evidence from three studies on exercise showed neutral impact on volume and benefit in symptoms and quality of life with upper extremities.
  • There was moderate evidence from one study on compression bandaging for lower- and upper-extremity volume reduction and no evidence related to symptoms
  • Compression Garments
  • Moderate evidence found volume reduction for upper and lower extremities with compression garments. No evidence was found related to symptoms.
  • Three studies had no evidence of benefit of MLD for symptoms; volume of lymphedema was not reported.
  • One study showed moderate benefit related to short-term volume for deep mechanical oscillation with MLD and moderate evidence of benefit for symptoms in the short term but not at follow up.
  • One study showed no evidence of any benefits from mechanically stimulated MLD.
  • One study showed limited short-term benefit in lymphedema volume, but no evidence of benefit for symptoms with dietary modification.
  • Four studies showed limited evidence of benefit in the short and long term for laser therapy ,and three showed limited evidence for benefit related to pain.
  • One study provided no evidence of benefit from electrically-stimulated lymphatic drainage
  • Four studies provided conflicting evidence, with two showing benefit in volume and two showing no benefit from intermittent pneumatic compression.
  • Meta-analysis results found five studies including 198 cases examined the addition of MLD to compression therapy alone or compression therapy along with other interventions. 
  • Analysis showed that the addition of MLD was beneficial (SD = 0.37, 95% CI 0.07–0.67, p = 0.02)

Conclusions:

Meta-analysis demonstrated significant but relatively small benefit from the addition of MLS in patients with breast cancer-related lymphedema. Findings support the growing body of evidence that participation in exercise does not exacerbate lymphedema and can reduce the severity of symptoms. Only two studies were found that examined nutrition and dietary interventions; these reported benefit in terms of volume reduction, but were of relatively low quality. Evidence suggests that compression garments and bandaging are effective in reducing limb volume with various types of cancer.

Limitations:

Only eight studies in this review were deemed to be of high quality.

Nursing Implications:

Inclusion of MLD provides a relatively small added benefit and may be associated with substantial costs. It is not clear if the benefits outweigh the cost and MLD may be most useful for patients who do not achieve sufficient improvement with other effective approaches. Findings related to dietary interventions are promising, pointing to the value of additional research in this area. Breast cancer continues to be the most frequently studied group. Research in other groups and with lower-limb lymphedema is needed.
 

Moseley, A.L., Carati, C.J., & Piller, N.B. (2007). A systematic review of common conservative therapies for arm lymphoedema secondary to breast cancer treatment. Annals of Oncology, 18(4), 639–646. 

doi: 10.1093/annonc/mdl182
Print

Purpose:

STUDY PURPOSE: To review the common conservative therapies for arm lymphedema secondary to breast cancer treatment

  • Complex physical therapy 
  • Manual lymphatic drainage 
  • Pneumatic pump therapy 
  • Oral pharmaceuticals 
  • Low-level laser 
  • Limb exercise
  • Limb elevations
  • Self-massage 

Search Strategy:

DATABASES USED: Search of English literature using the search engines CINAHL, PubMed, MEDLINE, CancerLit, PEDro, and Cochrane Evidence-Based Medicine Database; proceedings from the International Society of Lymphology and the Australian Lymphoedema Association; and contact with primary authors when publications were difficult to source. 

 

 

Literature Evaluated:

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Data were extracted using EndNote 7® (Thomson Reuters), and a quality scale assessment tool was used. Review included randomized, controlled, parallel, crossover format, and case-controlled and cohort studies. Case reports and anecdotal evidence were not reviewed. Because of treatment and data heterogeneity, authors were not able to perform a meta-analysis.

Results:

Magnitude of reduction in arm volume based on average volume change
 
Recommended for Practice
  • Manual lymphatic drainage and compression: 43%
  • CPT: 28%
  • Compression: 12% (not rated as stand-alone therapy)
 
Likely to Be Effective
  • Low-level laser: 12% therapy 
  • Manual lymphatic drainage alone: 24%
 
Benefits Balanced With Harm
  • Exercise: 5%
 
Effectiveness not Established
  • Pneumatic pump: 27%
  • Self-massage: 3%
 
Not Recommended for Practice
  • Drugs (benzopyrones): 16%
  • Elevation: 3% (not rated as stand-alone therapy)
 

Limitations:

  • Limited sample size in many studies and few randomized, controlled trials

Oremus, M., Dayes, I., Walker, K., & Raina, P. (2012). Systematic review: Conservative treatments for secondary lymphedema. BMC Cancer, 12, 6.

doi: 10.1186/1471-2407-12-6
Print

Purpose:

STUDY PURPOSE: To examine the effectiveness of conservative treatments for lymphedema


TYPE OF STUDY: Systematic review

Search Strategy:

DATABASES USED: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, AMED, and CINAHL 1990–January 2010


KEYWORDS: Search terms provided in online file


INCLUSION CRITERIA: RCT or observational study with comparison group, pediatric and adult patients with secondary lymphedema for any reason except filariasis infection


EXCLUSION CRITERIA: Pharmacologic or surgical treatment for lymphedema

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: 6,814 articles were evaluated.


EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Jadad scale used for RCTs; Newcastle-Ottawa Scale used  for observational studies

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED = 44 (32 with cancer)
  • SAMPLE RANGE ACROSS STUDIES: 21–150
  • KEY SAMPLE CHARACTERISTICS: Cancer evidence was in patients with breast cancer.

Phase of Care and Clinical Applications:

PHASE OF CARE: Not provided

Results:

Six RCTs involving intermittent pneumatic compression (IPC) were used. Two showed IPC had benefit over CDT or self-massage, and three did not show IPC to be any better than massage, skin care, or elastic sleeve; one compared different IPC devices. Six RCTs using massage-based treatments were used, and five showed no benefit. Four studies of low-level laser were used. Three showed low-level laser was superior to exercise, sham laser, or usual care, and one shows that low-level laser was better than sham laser at some time points in the study. Dieting yielded conflicting findings. Equivocal results were seen for ultrasound, modified manual lymph drainage, and compression stockings.

Conclusions:

This review provides limited evidence of effects of conservative treatments for lymphedema, and no conclusions about the most effective conservative approach are possible from this review.

Limitations:

Most studies had “fair” quality. Follow-up time frames in studies varied considerably. The majority of studies were among breast cancer patients only. It is surprising that this review did not include any studies involving CDT.

Nursing Implications:

Findings from this review showed that most interventions reduced limb volume and were not associated with any significant patient harms. Dieting alone does not appear to be particularly effective for limb volume reduction. Patients may benefit from a variety of conservative approaches to manage lymphedema. Ongoing research is needed to determine comparative effects of various approaches.

Rinehart-Ayres, M., Fish, K., Lapp, K., Brown, C.N., & Rucker, B. (2010). Use of compression pumps for treatment of upper extremity lymphedema following treatment for breast cancer: A systematic review. Rehabilitation Oncology, 28(1), 10–18.

Print

Purpose:

To assess if compression pumps decrease lymphedema compared with other treatments and to identify recommended parameters for use of compression pumps

Search Strategy:

Databases searched were MEDLINE, Ovid, PubMed, CINAHL, Scopus through January 2007, and hand searching from article references. Key search words were breast cancer, lymphedema, pneumatic compression, compression pumps, intermittent compression, and sequential compression. Studies were included in the review if they

  • Had participants with upper-extremity lymphedema secondary to breast cancer treatment
  • Had participants who received compression pump therapy
  • Reported pre- and post-treatment lymphedema measurements.

Exclusion criteria were not specified.

Literature Evaluated:

Eighty-five articles were retrieved initially. Studies were categorized using Sackett’s levels of evidence. Additional discussion of study information was done, though specific methods were not described.

Sample Characteristics:

  • A final sample of eight studies was included.
  • The eight studies included a total of 727 breast cancer cases.
  • Study samples ranged from 15–227.

Results:

Among highest level studies, there were no differences between pneumatic compression and no intervention or compression garments or bandages.

Conclusions:

There is no evidence that suggests use of intermittent compression pumps is effective in management of lymphedema or is any better than education about arm care and hygiene. There is no consensus about pressures to be used with compression pumps.
 

Limitations:

  • The majority of studies were of low quality and had multiple methodological issues.
  • Compression pressures used varied greatly as did duration of treatment.

Nursing Implications:

Findings do not support the use of compression pumps for lymphedema management secondary to breast cancer treatment. There is no information to establish appropriate and safe pressure levels for use.
 

Research Evidence Summaries

Fife, C.E., Davey, S., Maus, E.A., Guilliod, R., & Mayrovitz, H.N. (2012). A randomized controlled trial comparing two types of pneumatic compression for breast cancer-related lymphedema treatment in the home. Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer, 20(12), 3279–3286.

doi: 10.1007/s00520-012-1455-2
Print

Study Purpose:

To determine whether an advanced pneumatic compression device provides better results in reducing arm lymphedema than a standard compression device

Intervention Characteristics/Basic Study Process:

Patients with confirmed upper-extremity lymphedema were randomly assigned to home treatments with either the standard or advanced device for 12 weeks. Study measurements were done at baseline and at week 12. The assigned device was used 1 hour per day in addition to routine care, including compression garment wear for 23 hours per day. The standard device was a gradient sequential pneumatic compressor that attaches to an arm garment. The advanced device attaches to three garments that treat the full upper extremity, including the arm and adjacent chest and truncal quadrant. Measures of outcome included local tissue water measurement using the tissue dielectric constant method and arm circumferences measured with a no stretch retractable tape measure calibrated to 4 oz of tension.

Sample Characteristics:

  • The study sample (N = 36) was comprised of femal patients who had breast cancer surgery with node dissection.
  • Mean age was 56.8 years.
  • The majority of patients had adjunctive chemotherapy and radiation therapy.  
  • All patients had at least 5% edema volume of the arm. 
  • All treatment was completed at least three months prior to study entry.

 

Setting:

The study took place across multiple sites in the United States in home settings.
 

Phase of Care and Clinical Applications:

Patients were undergoing the transition stage of care after initial treatment. The study has clinical applicability for late effects and survivorship.
 

Study Design:

The study used a randomized controlled trial design.

Measurement Instruments/Methods:

  • Arm circumference was measured.
  • A tissue water measurement was taken.
     

Results:

Total edema volume was not statistically different between groups at baseline or at 12 weeks; however, there was a group by time difference in repeated measures analysis in favor of the advanced device (p = 0.05).  The advanced device edema mean volume went from 556 ml at baseline to 438 ml at week 12.  Device compliance was 95% in the advanced group and 99% in the standard device group. Adverse events that were considered to be possibly or definitely device related included increased arm swelling, breast inflammation, pain, fibrosis and infection, increased hand swelling, arm pain, finger numbness, increased swelling of torso, pain in axilla and back in the standard device group, and increased swelling of the lymph nodes in the contralateral axilla in the advanced device group. The prevalence of these events is not reported.

Conclusions:

Findings suggest that the use of the advanced pneumatic compression device may provide better outcomes in terms of arm edema. Further research is needed to evaluate adverse events

Limitations:

  • The sample size was small, with less than 100 patients.
  • There were no patient-centered outcome measures to determine if differences in arm volume were associated with less patient discomfort.
  • The follow-up was relatively short.
  • The study has a potential of bias because of no blinding.
     

Nursing Implications:

The use of this advanced type of pneumatic compression may provide better results in terms of arm edema reduction. It is not clear if the differences seen here would continue to be significant long term or if the patients’ experience of arm discomfort and the acceptance of the treatment would also be better.

Forner-Cordero, I., Munoz-Langa, J., Forner-Cordero, A., & DeMiguel-Jimeno, J.M. (2010). Predictive factors of response to decongestive therapy in patients with breast-cancer-related lymphedema. Annals of Surgical Oncology, 17(3), 744–751.

doi: 10.1245/s10434-009-0778-9
Print

Study Purpose:

To identify predictive factors of response to decongestant treatment through univariate and multivariate analysis

Intervention Characteristics/Basic Study Process:

Patients received complex decongestive treatment with manual lymphatic drainage (45 minutes) and pressotherapy with pneumatic multichambered device between 50 and 80 mm Hg (30 minutes). Treatment also included wearing a multilayered bandage until the next day. Sessions were performed consecutive days until a plateau in reduction was reached, which was normally between 10–20 sessions. Compliance with bandages was measured.

Sample Characteristics:

  • The study sample (N = 171) was comprised of patients with breast cancer who had lymphedema.
  • Median age was 60.4 years, with a range of 32–84 years.
  • Patients were included in the study if they were 18 years of age or older, were free from malignant disease, and had no decongestant treatment for your year.

Setting:

The study took place across multiple sites in Spain.

Study Design:

The study used a prospective, multicenter controlled cohort design.

Measurement Instruments/Methods:

  • Factors associated with response were testing in a univariate and multivariate analysis using linear regression.
  • Hypothesis testing was two-tailed with a 5% level of significance.
  • Analyses were made with SPSS version 15.

Results:

Eleven variables were retained after initial screening. Venous insufficiency, treatment in autumn, and compliance were associated with better outcome while higher baseline excess volume and percentage reduction, heaviness, numbness, chemotherapy, axillary radiation, total dose of radiation, and treatment in winter were associated with poorer outcome.

Conclusions:

The most important predictor of response to treatment was compliance. Early intervention is key.

Limitations:

  • The descriptive analysis is only to identify potential risk factors.

Nursing Implications:

Patient education and support to promote early intervention and patient compliance with treatment may have a positive effect in response to lymphedema treatment

Gurdal, S.O., Kostanoglu, A., Cavdar, I., Ozbas, A., Cabioglu, N., Ozcinar, B., . . . Ozmen, V. (2012). Comparison of intermittent pneumatic compression with manual lymphatic drainage for treatment of breast cancer–related lymphedema. Lymphatic Research and Biology, 10(3), 129–135.

doi:10.1089/lrb.2012.0002
Print

Study Purpose:

To compare the effects of complete decongestive therapy (CDT) with intermittent pneumatic compression (IPC) and self-lymphatic drainage

Intervention Characteristics/Basic Study Process:

Patients were randomized to receive either CDT, consisting of manual lymphatic drainage and compression bandaging, or self-lymphatic drainage and pneumatic compression. Both groups did the same exercises and wore compression garments at the end of therapy. Treatments were done every other day for six weeks. IPC was applied for 45 minutes in each treatment.   Patients did self drainage at home daily for 15 minutes during the study. Study measurements were done at the beginning and end of the six-week study period.

Sample Characteristics:

  • N  = 30            
  • MEDIAN AGE = 55
  • AGE RANGE = 31–74
  • MALES: 0%, FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: All participants had breast cancer and lymphedema at study entry. All had level 1 or 2 axillary lymph node dissection and had radiotherapy to the regional lymphatics. 
  • OTHER KEY SAMPLE CHARACTERISTICS: Participants had no prior treatment for lymphedema.

Setting:

  • SITE: Single site        
  • SETTING TYPE: Outpatient     
  • LOCATION: Turkey

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Not available

Study Design:

  • Randomized, controlled trial

Measurement Instruments/Methods:

  • Diary of self treatments
  • European Organisation for Research and Treatment of Cancer–Ouality of Life Core 30 (EOTRC QLQ-C30)
  • American Shoulder and Elbow Association Quality of Life questions regarding effective use of the arm during the day
  • Stillwell classification for lymphedema
  • Arm circumference measurement

Results:

Both groups had significant reduction in arm volumes at one, two and six weeks (p < .001). There were no significant differences between the groups in this change. There were no significant differences between groups in other study measures. Quality of life improved significantly across the study in both groups.

Conclusions:

There were no significant differences in lymphedema or associated quality of life between patients receiving CDT or IPC plus self lymphatic drainage. Both approaches were effective in reducing arm lymphedema volumes.

Limitations:

  • Small sample (< 100) 
  • Baseline sample/group differences of import
  • Risk of bias (no blinding)
  • Key sample group differences that could influence results
  • Other limitations/explanation: More patients in the CDT group had total mastectomy. No information is provided as to whether patients were completely finished with adjuvant treatment.

Nursing Implications:

Findings show that both approaches studied were effective in reducing lymphedema and improving QOL over a six-week period. The study is limited by the small sample size and short period of time for follow-up.

Haghighat, S., Lotfi-Tokaldany, M., Yunesian, M., Akbari, M. E., Nazemi, F., & Weiss, J. (2010). Comparing two treatment methods for post mastectomy lymphedema: Complex decongestive therapy alone and in combination with intermittent pneumatic compression. Lymphology, 43(1), 25–33.

Print

Study Purpose:

To compare two treatment methods for postmastectomy lymphedema: complex decongestive therapy (CDT) and modified CDT (MCDT) combined with intermittent pneumatic compression (IPC)

Intervention Characteristics/Basic Study Process:

Patients were randomly assigned to a treatment arm. The CDT group alone served as the control group while the experimental group received MDCT combined with IPC. Edema volume (difference between affected and unaffected arms) was recorded initially, at the final session of phase I, and at the end of the three months follow-up. Treatment was administered five days a week for 10–15 sessions. The experimental group included skin care, 45 minutes of manual lymph drainage (MLD), remedial exercises, and compression applied by multilayered, short-stretch bandages. Lymph drainage was stimulated in the trunk with 10–15 minutes of MLD on the abdomen; chest; and axillary, inguinal, and cervical lymph nodes followed by a four-chamber pneumatic sleeve and intermittent pneumatic compression pump at 40 mm Hg pressure for 30 minutes.

Sample Characteristics:

  • The study sample (N= 112) was comprised of female patients with postmastectomy lymphedema (defined as 10% or greater increase in the volume of affected arm compared to that of the contralateral arm).
  • Mean age was 53.4 years in the control group and 52.7 years in the experimental group.
  • Of 112 patients, two in the control group and one in the experimental group were excluded because of low follow-up compliance.

Setting:

The study took place in the Outpatient Lymphedema Clinic of the Iranian Center for Breast Cancer.

Phase of Care and Clinical Applications:

The study has clinical applicability for patients with breast cancer associated with lymphedema.

Study Design:

The study used a randomized controlled trial design.

Measurement Instruments/Methods:

Volume of edema was measured by water displacement method and performed by a blinded investigator not engaged in treatment.

Results:

CDT alone or in combination reduced edema volume. CDT alone provided better results in both treatment phases. Limb volume measured at three months post-treatment showed 16.9% volume reduction by CDT alone and 7.5% reduction by MCDT plus IPC.

Conclusions:

Further studies are needed to evaluate a multimodal approach to lymphedema. These findings do not support a significant improvement with IPC.

Nursing Implications:

Qualified lymphedema specialists are needed to care for this group of patients and to work with medical device companies to evaluate equipment and techniques. Patient education and support is needed for compliance.

Moattari, M., Jaafari, B., Talei, A., Piroozi, S., Tahmasebi, S., & Zakeri, Z. (2012). The effect of combined decongestive therapy and pneumatic compression pump on lymphedema indicators in patients with breast cancer related lymphedema. Iranian Red Crescent Medical Journal, 14(4), 210–217.

Print

Study Purpose:

To investigate the effect of combined decongestive therapy (CDT) and pneumatic compression pump on upper-limb lymphedema indicators (circumference, volume, and shoulder range of motions) in patients with breast cancer-related lymphedema

Intervention Characteristics/Basic Study Process:

The intervention was completed in two phases. In the first phase, the therapeutic phase, CDT and compression pumping was performed by the one researcher at the clinic. Each session included manual lymphatic drainage for 30–40 minutes. The affected upper limb was then placed in the compression pump for 15 minutes and bandaged with multilayer compression bandages, followed by remedial exercises. Also during the first phase, written and verbal information were given regarding skin and nail care, care of the bandaging and practical training in manual lymphatic drainage, how to bandage the upper limb, and remedial exercises. In the second phase, the maintenance phase, patients performed CDT daily at home. The first phase included three weekly sessions for four weeks; each session lasted 60–90 minutes. The second phase included daily CDT for four weeks. Patients were evaluated at baseline and four and eight weeks after the intervention.

Sample Characteristics:

  • The study sample (N = 21) was comprised of 100 femal patients with breast cancer-related upper-limb lymphedema.
  • Mean age ranged from 35–70 years.
  • All patients were at least one year since axillary node dissection and had not received CDT.

 

Setting:

The study took place at the Shahid Mottahari Therapeutic Center in Shiraz, Iran.

Phase of Care and Clinical Applications:

The study has clinical applicability for late effects and survivorship.

Study Design:

The study used a pre-post design.

Measurement Instruments/Methods:

  • Measuring tape was used to measure circumference.
  • Volume was measured using water displacement.
  • Range of shoulder joint motions was measured using a goniometer.

Results:

The mean difference in circumference of the two upper limbs in all areas at different phases of study decreased significantly (p < 0.05). The difference in mean volume between the two upper limbs four and eight weeks after the intervention were smaller than before the intervention (p < 0.001). Mean range of flexion (p < 0.001), extension (p < 0.004), abduction (p < 0.001), and external rotation (p < 0.001) increased four and eight weeks after the intervention.

Conclusions:

Combined CDT and pneumatic compression pump reduce mean volume and mean circumference of the breast cancer-related upper-limb lymphedema and increase shoulder joint range of motion.

Limitations:

  • The sample size was small, with less than 30 participants.
  • The study had a risk of bias because of no control group or random assignment.
  • Unintended interventions or applicable interventions were not described and would influence results.
  • The author did not provide the time (how many minutes) of daily CDT performed by patients in the second phase.
  • No information is provided regarding the compression pump.  

Nursing Implications:

Nurses can play a key role in providing rapid and timely interventions to reduce the severity of lymphedema (e.g., CDT skills and use of compression pump) and patient education regarding self-care and self-management of lymphedema.

Pilch, U., Wozniewski, M., & Szuba, A. (2009). Influence of compression cycle time and number of sleeve chambers on upper extremity lymphedema volume reduction during intermittent pneumatic compression. Lymphology, 42(1), 26–35.

Print

Study Purpose:

To assess the efficacy of different intermittent pneumatic compression (IPC) protocols on edema volume reduction in women with postmastectomy lymphedema

Intervention Characteristics/Basic Study Process:

Study subjects were randomly allocated to four groups with different cycles and sleeves for IPC. All women underwent IPC treatment for five weeks, five times per week for one hour for 25 sessions in total. Arm volume measurements for both arms were performed before and after each session. Group I (n = 17) received one-to-one cycles of compression and interval (90 seconds each), with a single chamber sleeve. Group II (n = 9) received a one-to-one cycle of compression and interval (90 seconds each), with a three-chamber sleeve. Group III (n = 11) received a one-to-one cycle of compression and interval (45 seconds and 15 seconds, respectively), with a single chamber sleeve. Group IV (n = 20) received a one-to-one cycle of compression and interval (45 seconds and 15 seconds, respectively) with a three-chamber sleeve.

Sample Characteristics:

  • The study sample was comprised of female patients with breast cancer-related upper-extremity lymphedema who were post-treatment.
  • Mean age ranged from 39–80 years.

Setting:

The study took place at Wroclaw Medical University, in Wroclaw, Poland.

Study Design:

The study used a randomized trial design.

Measurement Instruments/Methods:

  • Arm volume measurements were performed by water displacement.
  • Distance between the tip of the third finger and bottom of axillary fossa was determined for each extremity; each subsequent measurement was repeated to this distance and mean value was recorded.
  • Degree of lymphedema was represented by a difference in volume between the swollen upper extremity and the health upper extremity and was expressed in percent.

Results:

Significant differences in edema (29%–47%) were observed in all groups post-treatment with the most significant decrease seen in Group IV. The least reduction was observed in Group III, with Groups I and II experiencing similar decreases. Further comparison revealed the 45 second cycles with a three compartmental sleeve proved almost twice as effective as the 45 second cycle with single compartment sleeve.

Conclusions:

IPC can be effective in decreasing lymphedema in upper extremities in patients with breast cancer post-treatment. Further studies are needed to validate the finding of enhanced results with a shorter compression cycle and cyclic sequential massage.

Limitations:

  • The sample size was small, with less than 100 participants.
  • The description of the study population is limited (i.e., length of time post-treatment or extent of surgical intervention).

Nursing Implications:

IPC devices may be efficacious in treatment of lymphedema. More studies are needed to compare pneumatic compression devices and determination of standard equipment for treatment. Nurses need to build awareness for prevention and early detection and early intervention.

Ridner, S.H., Murphy, B., Deng, J., Kidd, N., Galford, E., Bonner, C., … Dietrich, M. S. (2011). A randomized clinical trial comparing advanced pneumatic truncal, chest, and arm treatment to arm treatment only in self-care of arm lymphedema. Breast Cancer Research and Treatment, 131, 147–158.

doi: 10.1007/s10549-011-1795-5
Print

Study Purpose:

To compare advanced pneumatic truncal, chest, and arm treatment to arm only treatment to determine which therapy provides a larger reduction in lymphedema in post-operative patients with breast cancer

Intervention Characteristics/Basic Study Process:

Participants were randomly assigned to receive truncal, chest, and arm compression or arm compression only. The compression was performed for one-hour, once per day for 30 days.

Sample Characteristics:

  • The study reported on 42 patients.
  • The mean age of patients was 56.9 years (SD = 8.1 years) with a range of 38–71.
  • The sample was 100% female.
  • Patients had breast cancer and were diagnosed with lymphedema stage II (2 cm circumference difference or a lymphedema index ratio of 1.163 with dominant arm affected or 1.109 when the nondominant arm was affected).
  • Patients were at least 6 months postsurgery or postradiation treatment.

Setting:

The study was conducted in Nashville, TN. The site and setting were not stated.

Phase of Care and Clinical Applications:

Patients were undergoing active lymphedema treatment.

Study Design:

This was a randomized control trial.

Measurement Instruments/Methods:

Demographic and medical data was collected via nurse interviews. The participants completed a Lymphedema Symptom Intensity and Distress Survey—Arm (LSIDS-A) and a functional assessment screening questionnaire (FASQ).

Results:

A statistically significant reduction was found in the number of symptoms and overall burden from the symptoms in both groups (p < 0.01). However, no statistical significance was found in the number of symptoms between groups (p = 0.145). No statistically significant change was found in functioning from baseline to the end of the study for either group, and no difference was found between the control and intervention group. The physical arm measurements indicated a significant reduction in bioelectrical impedance within both groups at the end of the study compared to baseline (p = 0.004 for arm only and p = 0.023 for truncal, chest, and arm). The combined groups were found to have a significant reduction at p = 0.018.

Conclusions:

Both groups experienced a significant improvement but no difference was found based on treatment of arm alone or of truncal, chest, and arm. Some differences were noted between the intervention and control group that may have led to these conclusions. For example, the participants in the experimental group had more symptoms at baseline than the control group; whether these patients would have benefited equally from the arm-only treatment was not clear. Another variable that may have affected results is that the experimental group developed lymphedema more quickly after surgery and at a younger age. Researchers have hypothesized that opening truncal lymph channels is necessary to promote volume reduction, but this study suggested that the procedure may not play as a big of a role as originally thought. Repeating this study with a larger sample size, while holding these possible confounding variables constant, would be worthwhile.

Limitations:

  • The sample size was small with fewer than 100 patients.
  • Important baseline sample differences exist, such as the fact that the patients in the experimental group developed lymphedema more quickly after surgery and at a younger age.
  • A risk of bias exists because of the lack of blinding and the particular sample characteristics.

Nursing Implications:

This study suggested that truncal, chest, and arm pneumatic compression therapy is not significantly better than arm pneumatic compression alone. Differences between the control group and the experimental group could have contributed to these findings. Repeating the study with more rigorous inclusion and exclusion criteria is needed to ensure that these variables did not affect the results of the study.

Ridner, S.H., Murphy, B., Deng, J., Kidd, N., Galford, E., & Dietrich, M.S. (2010). Advanced pneumatic therapy in self-care of chronic lymphedema of the trunk. Lymphatic Research and Biology, 8(4), 209–215.

doi: 10.1089/lrb.2010.0010
Print

Study Purpose:

To examine potential efficacy of the Flexitouch system (compression garment) for self-care home use in patients with breast cancer who had truncal lymphedema

Intervention Characteristics/Basic Study Process:

The system examined includes compression garments for the trunk, chest, and arm and applies variable dynamic pressure to affected areas, controlled by software programming. It uses multi-chambered inflatable and stretchable fabric garments. Patients were fitted for the garments. Patients completed one-hour daily treatments for 10 days. Patient symptoms and cirumferential measurements were done at baseline, after the fifth treatment, and at the end of the study. Patients were trained in use and, after the initial treatment, were instructed in use for home treatment. Research staff observed the first home treatment, then patients completed the rest on their own at home.

Sample Characteristics:

  • The study sample (N = 12) was comprised of female patients with breast cancer.
  • Mean age was 55.3 years, with a range of 43–79 years.
  • Patients had an average of 5.4 years since diagnosis and an average of 52.6 months duration of lymphedema.
  • Of patients in the study, 75% were married or partnered and 50% were employed full-time.

 

Setting:

The study took place in home settings in the United States.

Phase of Care and Clinical Applications:

The study has clinical applicability for late effects and survivorship.

Study Design:

The study used a quasi-experimental pre-post design.

Measurement Instruments/Methods:

  • Patients took the Lymphedema Symptom Intensity and Distress Survey-Arm and Trunk (LSIDS-AT).
  • Patients took the Functional Assessment Screening Questionnaire.
  • Trunk circumference was measured using Gulick II tape.

Results:

There were significant reductions in symptoms of truncal heaviness (x2 = 15.07, p = 0.0001), swelling (x2=14.73, p = 0.0001), tightness (x2 = 12.63, p = 0.0002) and itchiness (x2= 12.0, p = 0.0002). There were no significant changes in truncal measurements; however, there was a general non-significant trend of reduced circumference in all areas measured. There was also significant reduction in difficulty sleeping (p = 0.008).  All significant changes occurred after the fifth treatment and then remained stable at the end of the study. There was a general trend of increasing reports of skin conditions over the course of the study.

Conclusions:

The system may be an effective device to relieve lymphedema symptoms with home self-care treatment.

Limitations:

  • The sample size was small, with less than 30 participants.
  • The study design had a risk of bias because of no control group, no blinding, no random assignment, and no appropriate attentional control condition. Risk of bias (no control group) 
  • The study duration was short, and it is not clear what the longer-term effects would be, particularly given the trend of increasing skin condition reporting.

Nursing Implications:

The device may be helpful to reduce symptoms of lymphedema with an approach that patients can use at home for self-care. Larger controlled studies are warranted and longer term use should be evaluated.

Szolnoky, G., Lakatos, B., Keskeny, T., Varga, E., Varga, M., Dobozy, A., & Kemény, L. (2009). Intermittent pneumatic compression acts synergistically with manual lymphatic drainage in complex decongestive physiotherapy for breast cancer treatment-related lymphedema. Lymphology, 42, 188–194.

Print

Study Purpose:

To investigate whether the combination of pneumatic pump with manual lymph drainage (MLD) compared to MLD alone in standard complex decongestive physiotherapy (CDP) treatment can improve outcomes in women with stage 2 lymphedema after treatment for breast cancer

Intervention Characteristics/Basic Study Process:

Participants were randomly enrolled into 60-minute MLD or 30-minute MLD plus 30-minute intermittent pneumatic compression (IPC) followed by standardized components of CDP (compression bandaging, physical exercise, and skin care 10 times in a two-week period). Patient assessment was completed at baseline, beginning of therapy, end of therapy, and one and two months after the start of the therapy.

Sample Characteristics:

  • The study sample (N = 27) was comprised of female patients with breast cancer who were assigned to the CDP group (n = 13) or the CDP and IPC group (n = 14).
  • Mean age was 54.83 years in the CDP group and 56.60 years in the CDP and IPC group.
  • Patients were included in the study if they were more than 12 months after surgery or adjuvant treatment.
  • Patients were excluded from the study if they had any sign of local recurrence or distant metastases or if they were within the obligatory treatment-free period of one year.

Setting:

The study took place at an outpatient setting at the Lymphedema Care Unit of the University of Szeged, Hungary.

Study Design:

The study used a randomized controlled trial design.

Measurement Instruments/Methods:

  • Limb volume was measured using tape at every four centimeters.
  • The percentage reduction in total arm volume at each point was calculated with the formula ∆V% = [(pre-treatment arm volume – post-treatment arm volume)/pre-treatment arm volume] × 100.
  • Patients completed subjective symptom questionnaires measuring function, heaviness, tension, and pain as well as their effects on related activities.
  • Percentage improvement in the subjective complains was calculated with the formula ∆S% = [(total sum of pre-treatment scores – total sum of post-treatment scores)]/total sum of pre-treatment scores] × 100.

Results:

Mean reductions in limb volumes for each group at the end of therapy and at one and two months were 7.93% and 3.06%, 9.02% and 2.9%, and 9.62% and 3.6%, respectively (p < 0.05 from baseline for each group and also between groups at each measurement). A significant decrease in the subjective symptom survey was found for both groups compared to baseline, but no significant difference between the groups was found at any time point.

Conclusions:

The application of IPC with MLD provided a synergistic enhancement of the effect of CDP in arm volume reduction.

Limitations:

  • The sample size was small, with less than 30 participants.
  • The study took place at a single site.

Nursing Implications:

More studies involved in multisite settings with large sample sizes are needed to duplicate the findings from this study.

Szuba, A., Achalu, R., & Rockson, S.G. (2002). Decongestive lymphatic therapy for patients with breast carcinoma-associated lymphedema. Cancer, 95(11), 2260–2267.

doi: 10.1002/cncr.10976
Print

Study Purpose:

To provide a prospective evaluation of pneumatic compression therapy in patients with breast cancer-related lymphedema

Intervention Characteristics/Basic Study Process:

During phase I, adjunctive intermittent pneumatic compression (IPC) was assessed for its role as a component of the initial decongestive therapy with previously untreated lymphedema. Phase II was a prospective study to evaluate adjunctive benefit to IPC for maintenance. All patients received standard decongestive lymphatic therapy, which included MLD, compressive wrapping, and decongestive exercises. Each patient received 10 days of daily decongestive lymphatic therapy. The study group had IPC applied to the affected arm daily for 30 minutes, in addition to the treatment as noted previously.

Sample Characteristics:

  • Patients were included in the study if they presented with lymphedema related to breast cancer, defined as greater than 20% in volume compared to the other arm.
  • There was a 12-week interval between cancer treatment and enrollment to study.
  • Patients were excluded from the study if there was evidence of bilateral disease, breast cancer recurrence, active clinical infection, or clinically evident venous occlusion.

Setting:

The study took place at Stanford University in California.

Study Design:

The study used a randomized prospective design.

Measurement Instruments/Methods:

  • Assessments of limb volume, tissue elasticity, and joint mobility were performed at enrollment and on days 10 and 40 of the study.
  • Water displacement volumetry was used.
  • Skin tonometry was used to determine tissue elasticity.
  • Goniometry was used to assess shoulder, elbow, and wrist joints range of motion.
  • Data analysis was done using both paired and unpaired t-tests and analysis of variance.

Results:

In phase I, 23 women were recruited; 12 patients were randomized to group receiving DLT and IPC, while 11 were randomized to the group receiving DLT alone. After two weeks of treatment, reduction in volume of edematous arm was 45.3% for group 1 and 26% for group 2 (p < 0.05). Both groups showed no sign of improvement in skin elasticity study pre- or post-treatment. Also, 48% of patients had objective evidence of impaired range of motion at baseline. After initial therapy, joint mobility improved uniformly (p < 0.011) between both groups. In phase II, 27 patients were recruited. During a month of self-administered treatment, there was a mean increase in volume of the treated limb in group 1 with DLT alone. During the month of therapy, which included self-administered DLT and IPC, there was a mean volume reduction (p < 0.05). Skin elasticity showed no difference between the groups. Data collected poststudy showed that 20 of the 25 patients elected to continue using the IPC. Measurements showed additional reduction of limb volume.

Conclusions:

IPC, when used as an adjunct to the other established elements of DLT, provides an enhancement of the therapeutic response.

Limitations:

Initial cost of pneumatic pumps might limit applicability, but researchers noted that documented improvement of lymphedema may offset the cost of care.

Uzkeser, H., Karatay, S., Erdemci, B., Koc, M., & Senel, K. (2013). Efficacy of manual lymphatic drainage and intermittent pneumatic compression pump use in the treatment of lymphedema after mastectomy: A randomized controlled trial. Breast Cancer. Advance online publication.

doi: 10.1007/s12282-013-0481-3
Print

Study Purpose:

To investigate efficacy and contribution of an intermittent pneumatic compression pump in lymphedema management and evaluation of measurement method correlation

Intervention Characteristics/Basic Study Process:

Patients were randomized into two groups by consecutive alternating allocation by time of admittance. Group 1 received complete decongestive therapy (CDT) treatment (skin care, manual lymphatic drainage, compression bandage, compression garments, and exercise). Group 2 received CDT in combination with the intermittent pneumatic compression pump after manual drainage for 45 minutes at 40mmHg. Both groups were treated five times per week for three weeks for a total of 15 sessions. Measurements were obtained initially, post-therapy in week three, and one month postcompletion.

Sample Characteristics:

  • N = 31 (final sample); 15 in Group 1 and 17 in Group 2
  • MEAN  AGE = 56 years (Group 1), 55 years (Group 2)
  • AGE RANGE = 37–75 years (Group 1), 42–75 years (Group 2) 
  • MALES: 0%, FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: Patients with unilateral upper extremity lymphedema postmastectomy, no history of physical therapy prior to trial, and more than 2 cm circumference difference or more than 10% difference in arm volume between unaffected and affected arm
  • OTHER KEY SAMPLE CHARACTERISTICS: Patients with bilateral lymphedema, metastases, continuing radiation therapy, cellulites, thrombosis, elephantiasis, infection, carcinomatosa, congestive heart disease, and those currently using medication that affects body fluids or electrolye balance were excluded.

Setting:

  • SITE: Single site 
  • SETTING TYPE: Outpatient 
  • LOCATION: Physical Medicine and Rehabilitation Department, Atatürk University Faculty of Medicine

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Late effects and survivorship
  • APPLICATIONS: Elder care, palliative care

Study Design:

  • Randomized, controlled trial

Measurement Instruments/Methods:

  • Affected and unaffected upper limbs were measured with tape at four sites: metacarpophalangeal joint, wrists, and 10 cm below and above the lateral epicondyles.
  • Dermal thickness was measured with ultrasonography at the affected and unaffected limbs.
  • Circumferences, dermal thickness, and the volume of affected and unaffected limbs were calculated, and the difference between them was recorded as delta.
  • Pain was measured by a visual analog scale of 0–10.
  • All measurements were taken by the same physician who was blind to the treatment groups.

Results:

Significant correlation (p = 0.001) between dermal thickness with ultrasound and circumference of forearm measurement and water immersion measure method on forearm. Pre- and post-treatment measurements with both groups were significantly reduced, but no statistically significant difference between groups after therapy and one month later were noted.

Conclusions:

CDT remains the standard treatment for lymphedema. The addition of the pneumatic pump to CDT yielded no significant improvement in lymphedema. Limitations included small sample size and no long-term follow-up. More prospective randomized studies are needed to evaluate potential efficacy of pneumatic pump and to correlate ultrasound measurement of dermal thickness with water immersion method on forearms.

Limitations:

  • Small sample (< 30)
  • Measurement/methods not well described

 

Nursing Implications:

Nurses should continue to focus on education for prevention and early intervention for lymphedema.

Guideline/Expert Opinion

Lymphoedema Framework. (2006). International consensus: Best practice for the management of lymphoedema. London, UK: Medical Education Partnership. Retrieved from http://www.woundsinternational.com/pdf/content_175.pdf

Print

Purpose & Patient Population:

TYPES OF PATIENTS ADDRESSED: Sample not described

Type of Resource/Evidence-Based Process:

PROCESS OF DEVELOPMENT: Study utilized previous Cochrane Systematic reviews along with current references to a United Kingdom national consensus on standards of practice for people at-risk for, or who have, lymphedema (LE)

Evidence weighed using the following classification:
  • A = Clear research evidence
  • B = Limited supporting research evidence
  • C = Experienced common sense judgment.

Guidelines & Recommendations:

Recommended for Practice
 
Complete decongestive therapy
  • Patients with LE should receive a coordinated package of care appropriate to their needs (B).
Compression bandaging
  • Multilayer inelastic lymphedema bandaging (B)
  • Compression garments (C)
Management of infection: Cellulitis/erysipelas
  • Criteria for hospitalization
    • Signs of septicemia (e.g., high fever, hypotension, tachycardia, confusion, vomiting).
    • Continuing or deteriorating systemic signs with or without deteriorating local signs after 48 hours of antibiotic therapy.
    • Unresolved or deteriorating local signs with or without systemic signs after first- and second-line oral antibiotics.
    • Close medical follow-up
Exclude other causes of systemic infection, DVT, or dermatologic conditions such as eczema and contact dermatitis.
  • Before starting antibiotics
    • Swab any exudates, if present
    • Mark extent of rash and date edge
    • Note any painful or swollen regional lymph nodes
    • Obtain labs for ESR, CRP, WBC, and blood cultures.
Begin antibiotics as soon as possible (recommended for practice).
 
During bed rest, elevate limb, administer appropriate analgesia, and increase fluid intake.
 
Avoid simple lymphatic drainage (SLD) and manual lymphatic drainage (MLD). If tolerated, continue compression at a reduced level or switch from compression garments to MLLB.
 
Avoid long periods without compression.
 
Likely to be Effective
 
Manual lymphatic drainage (C) 
 
Prevention of infection: skin care 
  • Good skin care regimens should be implemented by patients and caregivers in the management of LE (B).
  • Use neutral pH soaps to avoid drying.
  • Apply emollients. 
  • Keep skin folds clean and dry.
  • Inspect skin for cuts, scrapes, abrasions, and insect bites.
  • Avoid scented products.
Benefits Balanced With Harm                                      

Exercise

  • Exercise/movement/elevation (C)
  • Breathing exercises (C) 

Prophylactic antibiotics: prevention of infection 

  • Patients are advised to travel with a two-week supply of antibiotics if they have a history of lymphedema. 
Effectiveness not Established

Intermittent pneumatic compression (C)

Simple lymphatic drainage (SLD)

Surgery (limited evidence, carefully selected patients may benefit, more research needed)

  • Surgical reduction
  • Bypass of lymphatic obstruction
  • Liposuction/lipectomy
Expert Opinion

Patient education 

  • People at risk of lymphedema should be identified early during routine assessment, monitored, and taught self-care (C). 
  • Patients and caregivers should be offered information about LE and its management.
  • Take good care of skin and nails.
  • Maintain optimal body weight (B).
  • Eat a balanced diet.
  • Avoid tight clothing, watches, and jewelry.
  • Avoid extremes in temperature.
  • Use sunscreen and insect repellent.
  • Wear compression garments if prescribed.
  • Undertake exercise and diaphragmatic breathing exercises.
  • Wear comfortable, supportive shoes.
  • Risk factors for upper extremity lymphedema 
  • Surgery of breast with axillary node dissection
  • Scar formation, radiodermatitis from postoperative radiotherapy
  • Radiotherapy to breast
  • Drainage or wound complications
  • Cording or seroma formation
  • Obesity
  • Congenital predisposition
  • Trauma to affected extremity (venipuncture, injection, BP)
  • Taxane chemotherapy
  • Insertion of a pacemaker
  • AV fistula for dialysis
  • Living in or visiting a lymphatic filariasis endemic area
  • Risk factors for lower extremity lymphedema
  • Inguinal node dissection
  • Postoperative pelvic radiotherapy
  • Recurrent soft-tissue infection
  • Obesity
  • Vein stripping or vein harvesting
  • Genetic predisposition
  • Intrapelvic or intra-abdominal tumor
  • Thrombophlebitis
  • Poor nutritional status
  • Chronic skin disorders or inflammation
  • Any unresolved asymmetric edema
  • Concurrent illness
  • Immobilization or prolonged limb dependency
  • Living in or visiting a lymphatic filariasis endemic area
Measurement 
  • Accurate assessment including staging (C)
    • Measurement  of LE
    • Assessment of skin
    • Assessment of vascular integrity
  • Patients with LE should receive psychological screening to identify those who require help to cope with the condition and those who require specialist intervention (C).
 

 


Menu