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

ASSESSMENT
TESTING FOR
PITTING
Pitting indicates the
presence of excess
interstitial fluid, ie tissue
oedema. Pitting is usually
tested for by pressing
firmly, but without hurting
the patient, on the area to
be examined with a finger
or thumb for a count of at
least 10 seconds. If an
indentation remains when
the examiner ceases
pressing, pitting is present.
The depth of the
indentation reflects the
severity of the oedema.
In a research setting, the
pitting test may be defined
in terms of the pressure
applied and the length of
application, and
measurement of the depth
of any resulting
indentation.
Lymphadenopathy: enlargement of
the lymph nodes
Hyperkeratosis: thickening of the
outer layer of the skin
Elephantiasis: severe
lymphoedema characterised by
severe swelling, hard thickened
tissue, deep skin folds and skin
changes such as hyperkeratosis and
warty growths
Assessment of swelling
The duration, location and extent of the
swelling and any pitting should be recorded,
along with the location of any
lymphadenopathy, the quality of the skin
and subcutaneous tissue, and the degree of
shape distortion. Limb circumference and
volume should be measured.
Limb volume measurement
Limb volume measurement is one of the
methods used to determine the severity of
the lymphoedema, the appropriate
management, and the effectiveness of
treatment. Typically, limb volume is
measured on diagnosis, after two weeks of
intensive therapy with multi-layer
inelastic lymphoedema bandaging
(MLLB), and at follow-up assessment.
In unilateral limb swelling, both the
affected and unaffected limbs are
measured. The difference in limb volume
is expressed in millilitres (ml) or as a
percentage.
Oedema is considered present if the
volume of the swollen limb is more than
10% greater than that of the contralateral
unaffected limb. The dominant limb
should be noted: in unaffected patients,
the dominant limb can have a
circumference up to 2cm greater and a
volume as much as 8-9% higher than the
nondominant limb 32,33 .
In bilateral limb oedema, the volume of
both limbs is measured and used to track
treatment progress.
There is no effective method for
measuring oedema affecting the head
and neck, breast, trunk or genitalia.
Digital photography is recommended as
an appropriate means to subjectively
record and monitor facial and genital
lymphoedema 34 .
Water displacement method
The water displacement method (also
known as water plethysmography) is
considered the 'gold standard' for calculating
limb volume and is the only reliable
method available for the measurement of
oedematous hands and feet 35 . It uses the
principle that an object will displace its
own volume of water. However,
ASSESSMENT
practicalities, such as hygiene issues and
accessing this method, limit its use.
Circumferential limb measurements
Calculation of volume from circumferential
measurements is the most widely used
method. It is easily accessible and its
reliability can be improved if a standard
protocol is followed.
Circumferential measurements of limbs
(Figure 3) are put into a specialist computer
program or calculator for determination of
individual limb volume and excess limb
volume. Some practitioners have set up
standard spreadsheet programs to calculate
volume.
A simplified method for the measurement
of patients with palliative care needs is shown
in Figure 4 (page 12). These measurements
are not used to calculate limb volume, but to
track sequential changes in circumference.
Perometry
Perometry uses infrared light beams to
measure the outline of the limb. From these
measurements, limb volume (but not hand or
foot volume) can be calculated quickly,
accurately and reproducibly 36 . Although the
use of perometry is becoming more
widespread, the cost of the machine limits it
to specialist centres.
Bioimpedance
Bioimpedance measures tissue resistance to
an electrical current to determine
extracellular fluid volume. The technique is
not yet established in routine practice.
However, it may prove useful in
demonstrating early lymphoedema,
identifying lipoedema, and in monitoring the
outcome of treatment 31 . The technique is
currently of limited use in bilateral swelling.
Limitations of excess limb volume
Calculation of excess limb volume is of
limited use in bilateral lymphoedema. In
such cases measurements can be used to
track sequential changes in limb
circumference to indicate treatment
progress. In patients with extensive
hyperkeratosis, elephantiasis or tissue
thickening it should be recognised that a
proportion of the excess volume will be due
to factors other than fluid accumulation.
10 BEST PRACTICE FOR THE MANAGEMENT OF LYMPHOEDEMA