best practice for the management of lymphoedema ... - EWMA

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ASSESSMENT BOX 10 Lymphoedema assessment proforma Lymphoedema Assessment Form Assessor: Date: Name: Male/female DOB: Tel: Address: Patient number: Next of kin: Referred by: Primary care physician: Diagnosis Primary/secondary lymphoedema/lipoedema Onset of oedema (age/symptoms): Investigations: Current symptoms: Current/previous cellulitis: Current treatment for lymphoedema: Past treatment for lymphoedema: Current medication Allergies: Past medical history Psychosocial/functional status Emotional state: Social support: Employment: Mobility: Activities of daily living: Current location of swelling √ Swelling Pitting Tissue thickening Dominant side: upper limb R/L; lower limb R/L Skin condition: Tissues in swollen area are predominantly: soft/firm Swelling is predominantly: pitting/nonpitting Sensory changes: Stemmer sign: Hand: R +/- L +/- ABPI/TBPI: R leg Foot: R +/- L+/- L leg Surgery: Radiotherapy: Cancer status: Chemotherapy: Axillary clearance/ Hormonal therapy: sentinel node biopsy: Venous/arterial disease: No. nodes removed: Neurological disease: No. nodes +ve: Family history: Nutritional assessment Weight (kg): Height (m): BMI: Waist circumference (cm): Pain assessment Present? Site/character/pain score: Current treatment: ASSESSMENT Limb circumference measurements Upper limb Lower limb R L R L Hand/foot circumference (cm) Starting point (cm) Above elbow/knee (cm) Below elbow/knee (cm) Total limb volume (ml) Distal volume (ml) Proximal volume (ml) Distal:proximal ratio Excess total limb volume (ml and %) Excess distal limb volume (ml and %) Excess proximal limb volume (ml and %) 8 BEST PRACTICE FOR THE MANAGEMENT OF LYMPHOEDEMA
ASSESSMENT BOX 12 Severity of unilateral limb lymphoedema 6 Mild: 40% excess limb volume Chylous ascites: the accumulation of chyle (fat-bearing lymph) in the abdominal cavity TABLE 2 Differentiating lymphoedema and lipoedema Lymphoedema Lipoedema* Classification of severity One method of establishing the severity of unilateral limb lymphoedema is based on the difference in the limb volume of the affected and unaffected limbs (Box 12). There is currently no formal system for the classification of the severity of bilateral limb swelling or lymphoedema of the head and neck, genitalia or trunk. The severity of lymphoedema can also be based on the physical and psychosocial impact of the condition. Factors to consider include: ■ tissue swelling – mild, moderate or severe; pitting or nonpitting ■ skin condition – thickened, warty, bumpy, blistered, lymphorrhoeic, broken or ulcerated ASSESSMENT 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 *Lipoedema can progress to develop an oedematous component – lipolymphoedema. ■ subcutaneous tissue changes – fatty/rubbery, nonpitting or hard ■ shape change – normal or distorted ■ frequency of cellulitis/erysipelas ■ associated complications of internal organs, eg pleural fluid, chylous ascites ■ movement and function – impairment of limb or general function ■ psychosocial morbidity. A more detailed and comprehensive classification applicable to primary and secondary lymphoedema remains to be formulated. BEST PRACTICE FOR THE MANAGEMENT OF LYMPHOEDEMA 9
Page 1 and 2: INTERNATIONAL CONSENSUS BEST PRACTI
Page 3 and 4: BEST PRACTICE FOR THE MANAGEMENT OF
Page 5 and 6: Introduction Lymphoedema is a progr
Page 7 and 8: Identifying the patient at risk C P
Page 9 and 10: C Patients Healthcare professional
Page 11: ASSESSMENT (a) (b) ■ micro-lympha
Page 15 and 16: ASSESSMENT FIGURE 3 Method for obta
Page 17 and 18: ASSESSMENT FIGURE 5 Stemmer sign In
Page 19 and 20: Treatment decisions B Patients with
Page 21 and 22: LOWER LIMB LYMPHOEDEMA - INITIAL MA
Page 23 and 24: FIGURE 7 Intensive therapy options
Page 25 and 26: FIGURE 8 Transition management - up
Page 27 and 28: MANAGEMENT OF MIDLINE LYMPHOEDEMA T
Page 29 and 30: FIGURE 13 Hyperkeratosis FIGURE 14
Page 31 and 32: Lymphangiosarcoma In the most sever
Page 33 and 34: Antibiotic regimens Antibiotic regi
Page 35 and 36: Intermittent pneumatic compression
Page 37 and 38: TABLE 5 Components of MLLB (in orde
Page 39 and 40: BOX 26 Principles of MLLB MLLB ■
Page 41 and 42: Addressing specific problems FIGURE
Page 43 and 44: Compression garments C Correctly fi
Page 45 and 46: (a) (b) Measurements required for a
Page 47 and 48: Checking fit A trained practitioner
Page 49 and 50: TABLE 7 Compression garment recomme
Page 51 and 52: Exercise/movement and elevation Exe
Page 53 and 54: Palliative care The needs of patien
Page 55 and 56: Oxerutins have been licensed in som
Page 57 and 58: References 1. Badger C, Preston N,

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