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

LYMPHATIC
MASSAGE
An important contraindication to MLD and
SLD is acute cellulitis/erysipelas (Box 20).
In advanced cancer, MLD/SLD can be used
with medical practitioner and patient
consent, but should not be used over the
sites of known primary tumours or
metastases.
Technique
A number of different techniques exist for
MLD. However, there is little evidence to
demonstrate which is the most effective and
for what clinical indications. Essentially,
MLD is a gentle massage technique that
follows the lymphatic pathways. The
different methods have several aspects in
common:
■ performed for up to an hour daily
■ usually performed with the patient in the
lying position, unless for lymphoedema of
the head and neck
■ starts with deep diaphragmatic breathing
■ treats the unaffected lymph nodes and
region of the body first
■ moves proximally to distally to drain the
affected areas
■ movements are slow and rhythmical
■ uses gentle pressure – if the pressure is
too hard it stimulates blood flow, the skin
becomes red, and more fluid is
encouraged to move into the tissues
■ ends with deep diaphragmatic breathing.
MLD may be conducted daily (or sometimes
twice daily) or three times weekly. A course
of therapy may last three or more weeks,
and may be repeated at intervals of three
months to one year 61 . However, the ideal
frequency and length of course for MLD
remains to be defined.
MLD is conducted by practitioners with
training at specialist level.
SIMPLE LYMPHATIC DRAINAGE
Simple lymphatic drainage (SLD) is a
simplified self-administered version of MLD
that patients and carers can learn and apply
themselves 62,63 . Ideally, all patients should
be taught SLD, unless contraindicated (Box
20). While there may be benefits, some
patients find it difficult to learn, memorise
and effectively incorporate this treatment
into a daily regimen. Patients who have MLD
may find it easier to learn SLD.
Technique
In common with MLD, there is little robust
evidence to support the use or effect of SLD.
There is no definitive technique for SLD, but
it is similar to MLD and is conducted for
10-20 minutes daily.
For SLD to be effective, the healthcare
professional must ensure that:
■ the patient/carer is motivated
■ the patient/carer is sufficiently dextrous
to perform SLD
■ time is allocated for initial teaching
■ teaching is progressive and enables the
patient or carer to become skilled
■ written instruction is given and technique
is observed
■ competence in the procedure and the
patient's ability to cope with treatment
are checked regularly.
SLD is conducted and taught by
practitioners with appropriate training.
BOX 20 Contraindications to MLD and SLD
General contraindications
■ Acute cellulitis/erysipelas
■ Renal failure
■ Unstable hypertension
■ Severe cardiac insufficiency
■ Hepatic cirrhosis with abdominal fluid
(ascites)
■ Superior vena cava obstruction
■ Untreated tuberculosis or malaria
Local contraindications*
■ Untreated thyroid dysfunction
■ Primary tumours
■ Metastases
Caution required: cardiac insufficiency.
*MLD and SLD should not be performed at these sites.
30 BEST PRACTICE FOR THE MANAGEMENT OF LYMPHOEDEMA