Clinical FeaturesOncology

Lymphoedema Treatment and Management

Written by Dr Grainne Sheill, Clinical Specialist in Cancer Rehabilitation and Kelly Coghlan, Senior Physiotherapist, Early Detection Lymphoedema

Cancer related lymphoedema is a chronic, progressive condition resulting from failure of the lymphatic system to drain fluid and proteins from tissue throughout the body and return it to the circulatory system. Lymphoedema usually affects a limb and can cause discomfort, pain, heaviness, limited motion, unsatisfactory appearance and impacts on quality of life. Cancer related lymphoedema is a well know side effect of surgery chemotherapy, radiation therapy and endocrine therapies, impacting up to 1490 new breast, gynaecological, melanoma, prostate and bladder cancers in Ireland annually. Over 15,000 people in Ireland are living with lymphoedema. Lymphoedema is progressive and if not treated, will become more complex with build up of fluid causing skin changes and reduced function which can lead to higher healthcare costs and hospitalization due to cellulitis.

Lymphedema Stages

Stage 0: Subclinical/latent, undetectable by clinical examination.

Stage 1: Clinically visible oedema, spontaneously reversible. Tissues are soft, can have pitting. No pain no skin changes & negative Stemmer’s sign.

Stage 2: Oedema is not spontaneously reversible, can be reversed with complete decongestive therapy. Pitting is difficult as tissues are harder. Positive Stemmer’s sign.

Stage 3: Irreversible, severe oedema with subcutaneous and connective tissue fibrosis, limb disfigurement & skin changes. May include: hyperkeratosis, papillamatosis, pachydermia

In Ireland, 70% of lymphoedema care should be provided in the primary care setting with non specialist services and 30% of care should be in specialist centers (community based) for assessment, complex patients and intensive treatment. The structure of the national lymphoedema model of care is depicted in Figure 1.

Early-Detection Lymphoedema Service

There is ongoing development of early detection services nationally. These services aim to detect subclinical lymphoedema which can be managed conservatively with short term use of compression garments, skin care, exercise and education, and prevent chronic issues which require complex treatment.

An early detection cancer lymphoedema service was established at the physiotherapy department at St James’s Hospital in 2020. The service reviews patients before and after their cancer treatment in order to detect those with sub-clinical changes in limb volume and start lymphoedema education and exercises as early as possible. The service uses a state-of-the-art SOZO Bioimpedance Spectroscopy (BIS) to get pre-operative measurements and detect sub clinical changes in patients’ fluid and tissues after surgery. Patients are provided with information on managing early signs and symptoms of lymphoedema, including skin care advice. They are reviewed postoperative at different time points based on their level of risk, triaged by the Senior Physiotherapist.

The aims of this service are:

  • Prevent lymphoedema in patients at high risk
  • Empower patients to take greater control of their healthcare
  • Move away from the traditional hospital centric model
  • Piece together the fragmented community services
  • Provide proactive planned preventative care
  • Data driven platforms at national level
  • Cemented service based on all stakeholder feedback

Lymphoedema Treatment Service

The lymphoedema service in St James’s Hospital was established in 2003. This service provides assessment and treatment at the earliest point possible in the patient journey and monitors patients lymphoedema, and also lipoedema, in the long term. Although treatment is not a cure it can improve quality of life and prevent complications such as cellulitis which reduces unnecessary hospital admissions. The management involves education, lymphatic drainage, the provision of garments and prescription of exercise.

4 cornerstones of lymphoedema management:

  • Skin Care: moisturising vital to avoid cracks and reduce risk of infection
  • Exercise: important for muscle pump, weight control, mental health
  • Compression: bandaging in intensive phase, garments long term. Correct garment helps maintain/slow progression of condition
  • MLD: by a trained therapist, helps to reduce size of limb & improve skin condition. Also SLD which is a modified form of MLD which patients perform themselves.

Once the symptoms are controlled long term maintenance treatment will begin with regular reviews, measurement for new compression garments at least every 6 months. Our service works with patients to ensure they can self-manage their lymphoedema which can often be a life-long diagnosis.

References available on request

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