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

LOWER LIMB LYMPHOEDEMA –
INITIAL MANAGEMENT
Initial management of lower limb
lymphoedema will involve psychosocial
support, education, skin care,
exercise/movement, elevation and
management of any concomitant medical
conditions, pain or discomfort (Figure 6).
The patient's initial management may also
include:
■ compression hosiery
■ modified MLLB
■ intensive therapy.
Compression hosiery
Patients with mild lower limb lymphoedema
(ISL stage I), minor pitting, no significant
tissue changes, no or minimal shape
distortion, or palliative needs may be
suitable for initial management with
compression hosiery. The pressure used
should be guided by the patient's vascular
status and their ability to tolerate
compression and manage the garment
(pages 39-45). Skin care,
exercise/movement, elevation and SLD
should be taught alongside self monitoring
and proper application, removal and care of
hosiery. Patients' application/removal
technique should be assessed and
monitored.
Patients should be reviewed four to six
weeks after initial fitting, and then after
three to six months if response is
satisfactory. The patient should be reviewed
at each garment renewal, ie approximately
every three to six months.
The practitioner will be appropriately
trained.
Modified MLLB
Patients with ISL stage II or late stage II
lower limb lymphoedema may be
candidates for initial treatment with
modified MLLB, outside an intensive therapy
regimen. Modified MLLB may also be useful
in controlling symptoms in patients with
cancer-related lymphoedema and frail
patients who have complex medical
problems (page 34). Management should
include skin care, exercise/movement,
elevation, SLD and psychosocial support.
The practitioner will be appropriately
trained.
Intensive therapy
Intensive therapy reduces swelling by
decongesting impaired lymphatic pathways,
reducing lymphatic load, encouraging the
development of collateral drainage routes,
and stimulating the function of remaining
patent routes.
Intensive therapy is used in patients with
ISL stage II, late stage II and stage III lower
limb lymphoedema. Intensive therapy
regimens use a combination of skin care,
MLLB, exercise/movement and elevation.
The regimen may include MLD or MLD
with IPC.
The frequency of treatment, degree of
compression and type of bandaging used
should be adapted according to the patient's
physical and psychosocial needs, and to the
presence of venous ulceration and arterial or
venous insufficiency (Figure 7, page 19).
Intensive therapy programmes are likely
to be undertaken for a period of two to four
weeks, although a maximal effect may be
achieved more quickly in some patients.
During this time treatment should be
evaluated continuously and appropriate
alterations made according to patient need
and the effectiveness of the selected
regimen. Appropriate training is required for
all practitioners who deliver intensive
therapy programmes 49 .
Standard intensive therapy (>45mmHg)
This involves skin care, exercise/movement,
elevation, MLD, and MLLB with inelastic
bandages (sub-bandage pressure
>45mmHg) undertaken daily.
Patients undergoing standard intensive
therapy must be carefully selected and be
willing and able to commit physically and
emotionally to daily intensive therapy,
including participation in exercise
programmes.
The practitioner will be appropriately
trained at specialist level.
TREATMENT
DECISIONS
INTENSIVE THERAPY
The combination of skin
care, exercise, MLD and
MLLB is often known as
decongestive lymphatic
therapy (DLT) or complete
decongestive therapy
(CDT). The term intensive
therapy has been used in
this document to denote a
holistic approach that
includes education,
psychosocial support and
pain management, and
that may also include SLD
and IPC.
MODIFYING MLLB
Where necessary, MLLB
may be modified and
individualised, according
to patient need and
resources available, by
altering the:
■ compression produced
■ frequency of bandage
change
■ materials used.
BEST PRACTICE FOR THE MANAGEMENT OF LYMPHOEDEMA 17