Tuesday, November 18, 2008
Friday, November 14, 2008
How to Bandage Wrap the Lymphedema Leg
How to Bandage Wrap the Lymphedema Leg
One of the best posts on how to wrap a leg…from one of my online members:
Since you have the swelling in the feet (and toes), it is probably lymphedema, perhaps compounded with lipedema. The traditional bandaging technique is with a stockinet, then some artiflex (cotton padding), and lastly, the bandages. I bandage directly over the skin. The padding is supposed to even out if you should constrict some part of the bandaging, causing the lymph not to flow, but the bandages are really not like rubber bands – properly spaced and overlapped, they will not cause constriction – and the artiflex is a pain. The stockinet is just another thing to wash and dry. I went to a bandage supplier (now out of business) and found that they have new bandages that are thick enough to be used without layering (e.g. the stockinet and padding).
Perhaps this is the way to go, or perhaps you want to bother with stockinets and padding. If you were seeing a therapist, they would also use foam instead of artiflex (just cotton padding). Some pictures of bandaging look absolutely monstrous. My so called therapist used some foam, etc., but I soon discovered that the leg went down more without it. The pad is supposed to “spread” the compression so there is no binding – but what really happens is all the elasticity of the bandages goes to compressing the FOAM – not compressing your leg. A little compression trickles down to the actual leg, but my experience was that the swelling went down better without the extra stuff. However, since this is against tradition, you should at least be aware if any part of your leg feels too tight, and, if so redo the bandages (which is at least an hour for two legs – and bandages that were OK while you were up and around can suddenly become too tight in the middle of the night – which means you have to get up and do it again.) Anyway, with or without stockinet and padding, here is one technique for bandaging:
materials (1 large leg not grossly larger than normal (I am 5'9” and the calf measure is 21” and I have wide, swollen feet - if you are substantially larger, you may need more)
optional: stockinet, artiflex, foam
required:
1 roll 1” professional strength masking tape. 1 ea 3” strip of heavy padding around the ankles 1 ea 1” x 5m medi-rip 2 ea 8 cm. x 5 m short stretch bandages 1 ea 10 cm x 10 m short stretch bandages 1 ea 6 cm x 5 m short stretch bandages.
Double for 2 legs, if you are very much larger than me, add another 1 ea 10 cm. x 5 m short stretch bandage for each leg.
I sit on my bed and have a low table I can rest my foot on, but two chairs will work also (one to sit on and one to put your foot on).
Wrap the 3” strip of heavy padding (or chock pads) around the ankles. The figure 8's you are making around your foot and from the foot onto the leg will tend to bind right at the intersection of the foot and leg (where the 90” turn is made. This is the only place padding is essential.
Secure it with masking tape. Secure all the bandages after they have been wrapped with masking tape. Cut a lot of 5” strips of masking tape and have them ready. Stick them on the edge of the table, or a windowsill, or something.
First hold all the bandages so that you are drawing from the bottom of the bandage cylinder (the bandages rolled up are a cylinder), not the top. A little experimentation will show you that this is much easier.
Start with the 1” medi-rip (it is a self cohesive bandage, but looses some of the self cohesion with laundering). Use this tiny bandage to bandage along the toe line. That is, make the same arc that the joints of the toes to the feet make. Do not bind the toes. If you can, wrap each toe with it, but I find that this binds the toes and hurts, so I leave my toes unwrapped, even though they swell, but if you start with the larger short stretch bandages, there will be a half moon that swells even more (Since if you make a straight circle from just below the little toe to just below the big toe, this will leave some area of foot not bandaged and the lymph will be pushed into this area, and it will be worse than before. The little 1” medirip can be wrapped in a curved path that covers all of the foot. Overlap this 1” medirep by 1/2 and continue winding it around your foot until you get to the end of the arch, then take it up diagonally over the top of the foot, and you will still have enough bandage to wrap again just under the toe line again for a few wraps. The medi wrap has strands of elastic in an otherwise cotton strip, so pull the medirip tight (that is the elastic is extended, but not to the point of discomfort).
When you wrap the bandages, pull a bit at the end of each circle, but do not stretch them too hard, or with constant tension as far as they will stretch. You want them to exert a little spring, but don't strangle your legs. If you get them too tight, it will hurt, and you must undo your wrapping and redo it (a big pain). If you don't stretch them a little, they won't have much compression. Of course, it's always the bottom bandages on the feet that hurt, so you have to unwrap the whole deal to get to them.
Next,step 2 take a 8 cm. x 5 m short stretch bandage, and start at the tip of the foot, but do not bind any toes, and since you already have the medi-rip, allow a little breathing space to make sure you don't bind toes. Then wind around your foot overlapping the bandages by about 1/2 to 2/3 (I probably overlap 2/3) until you have gotten almost to the leg (your foot should be at a 90 degree angle to the leg, and for me this is 2 or 3 wraps), then go around the heel itself, and, as you come off the other side of the heel, take the bandage diagonally up on the top of the foot to just below the top of the first wrap (just under the bottom of the big toe), go around the bottom of the foot, and then bring the bandage back around the ankle just above the heel, then around the ankle, and back up diagonally across the top of the foot just like before, overlapping 1/2 to 2/3 of the previous path. This will make large figure 8s.
Continue with the figure 8's each layer a little higher around the ankle, until you again are wrapping just in front of the leg (no more space to do another figure 8) and use the rest of the bandages going in straight circles (not figure 8's) around the ankles.
Next,step 3 take the second 8 cm x 5 meter short stretch bandage, and start at the base of the leg (around the ankles), go around once or twice, to anchor the bandage, then on the next turn go down around the bottom of the foot close to the heel, and then around the bottom of the foot and then over and up around the leg, then continue making figure 8's up the leg overlapping by about 2/3.
To make a figure 8 around the leg, on one side of the front of the leg, the bandage is going uphill (or towards your knee), then it goes more or less straight around the back of the leg at the high end of the 8, then goes downhill (or towards the foot), as you come across the front of the leg again, then more or less straight across the back of the leg at the low end of the 8 and then up again for the next figure 8. On me, this bandage is finished just about at the beginning of the calf (a little above the bottom of the muscle – it would be ideal if this bandage ended just before the muscle begins, but it will be a bit different for everyone depending of how much they overlap and how large their leg is.
Next,step 4 do figure 8's with the 10 cm x 10 m bandage. Begin at the bottom of the leg with the beginning of the bandage facing upward, so the first direction is in a downward direction, (the end pointing up) coming around and then going up again. The 10 cm x 10 m bandage should take you up to just below the knee, but if the legs are very large, you may need another 10 cm. bandage. Each course of the figure 8 should overlap a little less or evenly, but not more than the previous course. The more you overlap the greater the compression, and you must always have less compression proximally (towards your heart) than distally (towards your toes).
Finally,step 5 take the last 6 cm. x 5 meter short stretch bandage and start at about mid calf or a little higher, and wind in straight circles until just below and as close as possible to the knee. This last bandage gives compression over the tops of the top 8's where there is not as much overlap, and sort of holds it all up, as the circumference of the leg is actually smaller at the knee than at the mid calf (doesn't slide down because a smaller circle would have to slide over a larger circumference of the leg).
I have been complemented on my ability to wrap, but It is hard to know if a novice can make much sense of my directions – but I tried. You don't see to many photographs of the figure 8's, but they give more compression and stay up better, and bind less. You will get the general idea of winding up the leg, and overlap by looking at the photographs, however. It may seem complicated to follow my directions (I tried to be clear), but the real technique is not very hard at all.
The new thick bandages that do not need padding (padding is included) are : KomprimED. They are located on the bandagesplus web site under bandages, then under two way stretch bandages. I think you should start with these, as the padding may be more important for someone who is just beginning bandages. This is much simpler than all those stupid layers.
*Soft and comfortable directly on patient's skin *Thicker texture avoids application of foam and padding in many cases *Suitable for lymphedema and venous ulcers *Patient-friendly application requires less layers *All bandages are short-stretch/low stretch KomprimED 4cmx5m
Other wise, the standard short stretch bandages are rosidal or comprilan. I use rosidal. The medi-rip is under the section cohesive bandages on page 2 under the more general category bandages.
Suppliers of Bandages, Wrapping materials and Supplies:
Academy of Lymphatic Studies - Academy Store
Drapers Fitness - Lymphedema Bandages
Suppliers of leg compression garments and sleeves:
Self Manual Lymph Drainage for the Lower Extremity
Self Manual Lymph Drainage for the Lower Extremity
Rules for MLD:
The strokes should be made with arcing motions or half circle motions.
Rules for MLD:
The strokes should be made with arcing motions or half circle motions.
Do not slide over your skin, but rather, keep your fingers in contact with your skin and stretch it gently over the underlying tissues.
You should have NO PAIN.
Each stroke should be done 10-15 times SLOWLY, taking about 2 seconds for each stroke.
If redness occurs, you are pressing too hard.
For lymphedema of BOTH legs, perform all moves on both sides.
The best position to be in for this is seated reclined, or lying down and propped up slightly.
Make sure you can make skin-to-skin contact for all of these strokes. They won't work when done over clothing.
1. Neck: Place the flats of your fingers on your opposite shoulder, in the triangular part just above the collarbone and next to your neck. Move your hand in an arcing motion stretching the skin forward and down towards your chest. Repeat this on the other side.
2. Armpit: Raise your arm (on the same side as the leg in which you have lymphedema), bend you elbow, and place the hand behind your head. Place the flat of your opposite hand in your armpit. Stretch the skin in an arcing motion up towards the neck.
3. Above the waist: Place the flat of your opposite hand on the side of your body (on the side on which you have lymphedema) below the breast, but above the waist. Move your hand upwards in an arcing motion in the direction of your armpit, stretching your skin.
4. Below the waist: Place the flat of your opposite hand on the side of your body (on the side on which you have lymphedema) on or just below the waist, but above your hip. Move your hand upwards in an arcing motion in the direction of your armpit, stretching your skin.
5. Deep (diaphragmatic) breathing: Place both open palms on top of each other below the belly button. Take a slow breath in and feel your belly rise up into your hands as it expands to take in the air. Then breath out and feel your belly sink in as the breath leaves you. As you get better at this you can use your hands to resist your stomach slightly as you breath in, and press in slightly with your hands as you breath out. Don’t get dizzy. Start with only 2 or 3 breaths and work up to 10 as you get stronger.
6. Groin: Place the flat of your hand on the front of your groin, right where your underwear falls. Make a scooping motion in the groin, rolling your hand from the thumb to the little finger. Imagine that your hands are the bottom of a water wheel.
7. Back of knee: Place the flat fingers of both hands behind your knee. Perform a scooping motion up towards the body.
8. Repeat steps 3, 4 and 6 (waist and groin areas)
A very special Thanks to Katy from
LymphedemaTherapists · Lymphedema Therapists
Self Massage Treatment for Leg Lymphedema
Self Massage Treatment for Leg Lymphedema
All the Lymphatic Drainage strokes are based on one principle motion.
Research has found that the initial lymphatics open up and the lymph angions are stimulated by a straight stretch, but even more so with a little lateral motion. After these 2 motions, we need to release completely to allow the initial lymphatics to close and the lymph to be sucked down the channels. In this zero pressure phase don’t completely disconnect from the skin, just return your pressure to nothing. Also don’t pull the skin back with you as you return, let it spring back by itself.
This basic motion may resemble a circle, and is called stationary circles. All motions are based on this principle.
In orienting this motion, we always want to push the lymph towards the correct nodes, so the last, lateral stretch motion should be going towards the nodes.
Think about moving water. Visualize those initial lymphatics just in the skin, stretch, opening them up, then release and wait for the lymph angions to pump the lymph down the vessel. Remember how superficial this is. If you are feeling muscle, or other tissue under the skin, you are pushing too hard.
Here are four points remember when performing Lymphatic Massage-
1. Correct pressure is deep enough so that you do not slide over the skin, but light enough so that you don’t feel anything below the skin. This is about 1-4 ounces. It is very common for massage therapists trained in Swedish or deep tissue to apply too much pressure with lymphatic drainage massage. Sometimes it is hard to believe that something so light could be effective. Always remember- you are working on skin. How much pressure does it take to deform the skin? Almost nothing. Remember- if you push too hard you collapse the initial lymphatic.
2. Direction of your stroke is of great importance, because we always want to push the lymph towards the correct nodes. If you push the lymph the wrong way, your work will not be effective.
3. Rhythm is very important because with the correct rhythm and speed, the initial lymphatics are opened, and then allowed to shut and then there is a little time that is given for that lymph to get sucked down along the vessel. An appropriate rhythm will also stimulate the parasympathetic nervous system, causing the client to relax.
4. Sequence means the order of the strokes. When we want to drain an area, we always start near the node that we are draining to. Always push the lymph toward the node. Then as we work, we move further and further away from the node, but always pushing the fluid back in the direction of the node. In this way we clear a path for the lymph to move, as well as create a suctioning effect that draws the lymph to the node.
RealBodyWork
All the Lymphatic Drainage strokes are based on one principle motion.
Research has found that the initial lymphatics open up and the lymph angions are stimulated by a straight stretch, but even more so with a little lateral motion. After these 2 motions, we need to release completely to allow the initial lymphatics to close and the lymph to be sucked down the channels. In this zero pressure phase don’t completely disconnect from the skin, just return your pressure to nothing. Also don’t pull the skin back with you as you return, let it spring back by itself.
This basic motion may resemble a circle, and is called stationary circles. All motions are based on this principle.
In orienting this motion, we always want to push the lymph towards the correct nodes, so the last, lateral stretch motion should be going towards the nodes.
Think about moving water. Visualize those initial lymphatics just in the skin, stretch, opening them up, then release and wait for the lymph angions to pump the lymph down the vessel. Remember how superficial this is. If you are feeling muscle, or other tissue under the skin, you are pushing too hard.
Here are four points remember when performing Lymphatic Massage-
1. Correct pressure is deep enough so that you do not slide over the skin, but light enough so that you don’t feel anything below the skin. This is about 1-4 ounces. It is very common for massage therapists trained in Swedish or deep tissue to apply too much pressure with lymphatic drainage massage. Sometimes it is hard to believe that something so light could be effective. Always remember- you are working on skin. How much pressure does it take to deform the skin? Almost nothing. Remember- if you push too hard you collapse the initial lymphatic.
2. Direction of your stroke is of great importance, because we always want to push the lymph towards the correct nodes. If you push the lymph the wrong way, your work will not be effective.
3. Rhythm is very important because with the correct rhythm and speed, the initial lymphatics are opened, and then allowed to shut and then there is a little time that is given for that lymph to get sucked down along the vessel. An appropriate rhythm will also stimulate the parasympathetic nervous system, causing the client to relax.
4. Sequence means the order of the strokes. When we want to drain an area, we always start near the node that we are draining to. Always push the lymph toward the node. Then as we work, we move further and further away from the node, but always pushing the fluid back in the direction of the node. In this way we clear a path for the lymph to move, as well as create a suctioning effect that draws the lymph to the node.
RealBodyWork
Wednesday, November 12, 2008
Leg Swelling (Lymphedema) in a Patient With Gynecologic Cancer
Leg Swelling (Lymphedema) in a Patient With Gynecologic Cancer
Lower-Extremity Lymphedema in a Patient With Gynecologic Cancer
Kathleen Appollo, RN, BSN, OCN
Oncology Nursing Forum – Vol 34, No. 5, 2006
Case Study
H.F. is a 56-year-old woman who presented to the gynecologic oncology department at a major comprehensive cancer center after an endometrial biopsy revealed an International Federation of Gynecology and Obstetrics grade III serous carcinoma of the endometri- um. In addition to relevant endometrial cancer statistics, she received information about choices for treatment. The standard surgical treatment at the cancer center consists of a total abdominal hysterectomy with bilateral salpingo-oophorectomy, pelvic lymph node dissection, and para-aortic lymph node sampling. The acute and chronic side effects of surgery were discussed, including develop- ment of lower-extremity lymphedema. H.F. was informed that the lymphedema could occur anytime after surgery and she would need to monitor for lymphedema development for the rest of her life.
After preoperative testing, H.F. had an uneventful surgical procedure and routine postoperative course. The final pathology showed high-grade stage IIIC papillary serous carcinoma deeply invading the endometrium, with spread to a left para-aortic lymph node. As result, her oncologist recommended both radiation and chemotherapy.
H.F. completed all therapy and was scheduled to return every three months for evaluation. She was cautioned to maintain skin integrity by applying moisturizers and sunscreen as needed and to avoid sources of trauma, injury, infection, and constriction to the lower extremities. In addition, she was encouraged to maintain her weight with a healthy diet and she was advised to return to the lymphedema specialist for lymphedema control.
She understands that she must be diligent in her care to maintain control. H.F. knows that she should be joyous that she is free from cancer but often wonders about the sacrifices that she has made in the quality of her per- sonal life. She did not feel the need to seek professional psychiatric help but did join a support group. Although the members of the group all have cancer, none has lymphedema.
Even so, H.F. has found that sharing difficulties with others has helped her to cope, and she feels good when she has helped another deal with a difficult issue. Although she has not returned to her former music activities, she has found that helping others in the support group has given her the same satisfaction that she felt when her music brought happiness to others.
Lymphatic System and Lymphedema
Lymph is extracellular fluid composed of water, fats, proteins, bacteria, and waste products. The lymphatic system is an inter connected network of organs, lymph vessels, and lymph nodes that transports lymph from body tissues to the bloodstream, helping to maintain body fluid balance. It also is a major component of the body’s immune system.
The superficial lymphatic capillaries are made up of endothelial cells that overlap but do not form a continuous connection. Each cell is anchored to surrounding tissue by filaments that pull on the cells in response to changes in tissue pressure. As the cell is pulled by the filament, fluid drains into the vessel. Pressure changes occur during muscle contraction, respiration, and arterial pulsation and when the skin is stretched. Lymph flows into progressively larger deep vessels that have one-way valves to ensure that the fluid moves away from tissues in a slow, steady, low-pressure system. Afferent vessels carry lymph into lymph nodes, where the lymph is filtered of cellular waste products, pathogens, and cancer cells and where lymphocytes are added.
Efferent vessels carry lymph out of the lymph nodes to return to circulation. Lymph drains from the lower limbs into the lumbar lymphatic trunk, joining the intestinal lymphatic trunk and cisterna chyli to form the thoracic duct that empties lymph into the left subclavian vein (Casely-Smith & Casely-Smith, 1997; Mortimer, 1998).
Lymphedema occurs when lymph remains in the tissues because the lymphatic system is unable to transport interstitial filtrate (Foldi, 1998; International Society of Lymphology, 2003). Primary lymphedema is a result of an absence of or abnormalities in lymphatic tissue. Secondary lymphedema, which is the focus of this discussion, results when the flow of lymph is interrupted because of malignancies, surgery, infection, trauma, or postradiation fibrosis and the lymph remains in the tissue.
Incidence and Risk Factors
Although much has been written about upper-extremity lymphedema after breast surgery, information about lower-extremity lymphedema is lacking. The literature varies widely about the number of patients affected. In one study, the incidence of lymphedema in patients after a hysterectomy with lymph node removal was 20% (Ryan, Stainton, Slaytor, et al., 2003). Another study reported a 3.4% incidence rate in patients following endometrial staging surgery, including hysterectomy, bilateral salpingo-oophorectomy, and lymph node dissection (Abu-Rustum et al., 2006). A retrospective series of staging surgery for endometrial cancer followed by radiation therapy reported an incidence of 4.6% (Nunns, Williamson, Swaney, & Davy 2000).
H.F. was at risk to develop lymphedema after her surgery for endometrial cancer because of the disruption of lymphatics and lymph nodes during staging surgery. She was at additional risk because of the postoperative radiation. Other risk factors are believed to include injury, trauma, heat changes, infection to the extremity, and weight gain and decreased mobility (Brewer, Hahn, Rohrbach, Bell, & Baddour, 2000; Mortimer, 1998).
Treatment
Although research is lacking to support many recommendations for the prevention of lymphedema (Ridner, 2002), education regarding measures that are believed to reduce risk include protecting the skin from trauma and infection. Those measures were discussed with H.F. postoperatively and at each office visit. The plan is based on the concept that any action or condition that predisposes a patient to or increases swelling may disrupt the fine balance of drainage after surgery (Mortimer, 1998). In addition, open skin may lead to infection, which can occur more easily in stagnant, protein-rich lymph fluid, a perfect medium for bacteria growth (Brewer et al., 2000). Because deep vein thrombosis and cancer recurrence can cause swelling, they were ruled out before H.F. was referred for complex decongestive therapy. Her treatment began with manual lymphatic drainage, a gentle massage that starts proximally to encourage the flow of lymph from the distal extremity. More lymph is encouraged to move into the normally functioning lymphatics (Cheville et al., 2003; Foldi, 1998; Lerner, 1998).
Massage was followed by padding of the extremity and application of short stretch compression bandages with gradual pressure changes distally to proximally. That type of bandaging helps the flow of lymph to the nodal basins (Cheville et al.; International Society of Lymphology, 2003).
H.F. was taught the techniques so that she could continue maintenance therapy at home. She was encouraged to practice manual lymphatic drainage, use compression bandages at night, wear a fitted compression garment, follow meticulous skin care guidelines, protect the leg from trauma and injury, and perform muscle-building exercises. H.F. also was taught to wear the compression garment especially during air travel because changes in atmospheric pressure may increase the pressure balance in the leg (National Lymphedema Network, 2005).
Quality of Life
Lymphedema may have a profound effect on the lives of cancer survivors (Kwan et al., 2002; Ryan, Stainton, Jaconelli, et al., 2003). H.F. described a heavy, achy feeling in her leg, which has been reported in patients with breast cancer before swelling occurred (Armer, Radina, Porock, & Culbertson, 2003). Pain assessment is crucial in helping patients to cope. An over-the-counter medication may suffice, but some patients may need prescription-strength pain medication, making individual assessment critical.
H.F. stated that her pace was slower in her walks. In patients with breast cancer, fatigue often is a troublesome symptom affecting quality of life (Armer & Porock, 2002). Pacing activities or decreasing distances may help to maintain stamina. Pacing also may deter swelling that is associated with strenuous or long-distance exercise. The need for sleep medication should be evaluated because insomnia caused by leg discomfort or worry may contribute to fatigue.
Changes in wardrobe often are necessary when swelling occurs (Ryan, Stainton, Jaconelli, et al., 2003). Alteration in body image may result in changes to regular social activities and may lead to social isolation (Tobin, Lacey, Meyer, & Mortimer, 1993). Referrals to support groups or individual therapy sessions may be indicated depending on patient preference. H.F. found that she gained much by participating in a support group and thereby moved from one type of social interaction to another. Healthcare professionals must be sensitive to lifestyle changes as well as the financial burden that may result from a forced change in wardrobe.
With increased survival after cancer treatment, the long-term sequelae caused by cancer treatment should be recognized and treated. Patients must be informed about the potential lifelong side effects of treatment. Although H.F. was informed about the possibility of lymphedema development, many patients have reported that they were not informed about this life-alterating condition until they developed symptoms (Beesley, Janda, Eakin, Obermair, & Battistutta, 2007; Ryan, Stainton, Jaconelli, et al., 2003). Continued research is needed to determine the best interventions to decrease the side effects of treatment and maximize quality of life.
Author Contact
Kathleen Appollo, RN, BSN, OCN can be reached at appollok @mskcc.org, with copy to editor at ONF Editor@ons.org.
ONS.metapress
Lower-Extremity Lymphedema in a Patient With Gynecologic Cancer
Kathleen Appollo, RN, BSN, OCN
Oncology Nursing Forum – Vol 34, No. 5, 2006
Case Study
H.F. is a 56-year-old woman who presented to the gynecologic oncology department at a major comprehensive cancer center after an endometrial biopsy revealed an International Federation of Gynecology and Obstetrics grade III serous carcinoma of the endometri- um. In addition to relevant endometrial cancer statistics, she received information about choices for treatment. The standard surgical treatment at the cancer center consists of a total abdominal hysterectomy with bilateral salpingo-oophorectomy, pelvic lymph node dissection, and para-aortic lymph node sampling. The acute and chronic side effects of surgery were discussed, including develop- ment of lower-extremity lymphedema. H.F. was informed that the lymphedema could occur anytime after surgery and she would need to monitor for lymphedema development for the rest of her life.
After preoperative testing, H.F. had an uneventful surgical procedure and routine postoperative course. The final pathology showed high-grade stage IIIC papillary serous carcinoma deeply invading the endometrium, with spread to a left para-aortic lymph node. As result, her oncologist recommended both radiation and chemotherapy.
H.F. completed all therapy and was scheduled to return every three months for evaluation. She was cautioned to maintain skin integrity by applying moisturizers and sunscreen as needed and to avoid sources of trauma, injury, infection, and constriction to the lower extremities. In addition, she was encouraged to maintain her weight with a healthy diet and she was advised to return to the lymphedema specialist for lymphedema control.
She understands that she must be diligent in her care to maintain control. H.F. knows that she should be joyous that she is free from cancer but often wonders about the sacrifices that she has made in the quality of her per- sonal life. She did not feel the need to seek professional psychiatric help but did join a support group. Although the members of the group all have cancer, none has lymphedema.
Even so, H.F. has found that sharing difficulties with others has helped her to cope, and she feels good when she has helped another deal with a difficult issue. Although she has not returned to her former music activities, she has found that helping others in the support group has given her the same satisfaction that she felt when her music brought happiness to others.
Lymphatic System and Lymphedema
Lymph is extracellular fluid composed of water, fats, proteins, bacteria, and waste products. The lymphatic system is an inter connected network of organs, lymph vessels, and lymph nodes that transports lymph from body tissues to the bloodstream, helping to maintain body fluid balance. It also is a major component of the body’s immune system.
The superficial lymphatic capillaries are made up of endothelial cells that overlap but do not form a continuous connection. Each cell is anchored to surrounding tissue by filaments that pull on the cells in response to changes in tissue pressure. As the cell is pulled by the filament, fluid drains into the vessel. Pressure changes occur during muscle contraction, respiration, and arterial pulsation and when the skin is stretched. Lymph flows into progressively larger deep vessels that have one-way valves to ensure that the fluid moves away from tissues in a slow, steady, low-pressure system. Afferent vessels carry lymph into lymph nodes, where the lymph is filtered of cellular waste products, pathogens, and cancer cells and where lymphocytes are added.
Efferent vessels carry lymph out of the lymph nodes to return to circulation. Lymph drains from the lower limbs into the lumbar lymphatic trunk, joining the intestinal lymphatic trunk and cisterna chyli to form the thoracic duct that empties lymph into the left subclavian vein (Casely-Smith & Casely-Smith, 1997; Mortimer, 1998).
Lymphedema occurs when lymph remains in the tissues because the lymphatic system is unable to transport interstitial filtrate (Foldi, 1998; International Society of Lymphology, 2003). Primary lymphedema is a result of an absence of or abnormalities in lymphatic tissue. Secondary lymphedema, which is the focus of this discussion, results when the flow of lymph is interrupted because of malignancies, surgery, infection, trauma, or postradiation fibrosis and the lymph remains in the tissue.
Incidence and Risk Factors
Although much has been written about upper-extremity lymphedema after breast surgery, information about lower-extremity lymphedema is lacking. The literature varies widely about the number of patients affected. In one study, the incidence of lymphedema in patients after a hysterectomy with lymph node removal was 20% (Ryan, Stainton, Slaytor, et al., 2003). Another study reported a 3.4% incidence rate in patients following endometrial staging surgery, including hysterectomy, bilateral salpingo-oophorectomy, and lymph node dissection (Abu-Rustum et al., 2006). A retrospective series of staging surgery for endometrial cancer followed by radiation therapy reported an incidence of 4.6% (Nunns, Williamson, Swaney, & Davy 2000).
H.F. was at risk to develop lymphedema after her surgery for endometrial cancer because of the disruption of lymphatics and lymph nodes during staging surgery. She was at additional risk because of the postoperative radiation. Other risk factors are believed to include injury, trauma, heat changes, infection to the extremity, and weight gain and decreased mobility (Brewer, Hahn, Rohrbach, Bell, & Baddour, 2000; Mortimer, 1998).
Treatment
Although research is lacking to support many recommendations for the prevention of lymphedema (Ridner, 2002), education regarding measures that are believed to reduce risk include protecting the skin from trauma and infection. Those measures were discussed with H.F. postoperatively and at each office visit. The plan is based on the concept that any action or condition that predisposes a patient to or increases swelling may disrupt the fine balance of drainage after surgery (Mortimer, 1998). In addition, open skin may lead to infection, which can occur more easily in stagnant, protein-rich lymph fluid, a perfect medium for bacteria growth (Brewer et al., 2000). Because deep vein thrombosis and cancer recurrence can cause swelling, they were ruled out before H.F. was referred for complex decongestive therapy. Her treatment began with manual lymphatic drainage, a gentle massage that starts proximally to encourage the flow of lymph from the distal extremity. More lymph is encouraged to move into the normally functioning lymphatics (Cheville et al., 2003; Foldi, 1998; Lerner, 1998).
Massage was followed by padding of the extremity and application of short stretch compression bandages with gradual pressure changes distally to proximally. That type of bandaging helps the flow of lymph to the nodal basins (Cheville et al.; International Society of Lymphology, 2003).
H.F. was taught the techniques so that she could continue maintenance therapy at home. She was encouraged to practice manual lymphatic drainage, use compression bandages at night, wear a fitted compression garment, follow meticulous skin care guidelines, protect the leg from trauma and injury, and perform muscle-building exercises. H.F. also was taught to wear the compression garment especially during air travel because changes in atmospheric pressure may increase the pressure balance in the leg (National Lymphedema Network, 2005).
Quality of Life
Lymphedema may have a profound effect on the lives of cancer survivors (Kwan et al., 2002; Ryan, Stainton, Jaconelli, et al., 2003). H.F. described a heavy, achy feeling in her leg, which has been reported in patients with breast cancer before swelling occurred (Armer, Radina, Porock, & Culbertson, 2003). Pain assessment is crucial in helping patients to cope. An over-the-counter medication may suffice, but some patients may need prescription-strength pain medication, making individual assessment critical.
H.F. stated that her pace was slower in her walks. In patients with breast cancer, fatigue often is a troublesome symptom affecting quality of life (Armer & Porock, 2002). Pacing activities or decreasing distances may help to maintain stamina. Pacing also may deter swelling that is associated with strenuous or long-distance exercise. The need for sleep medication should be evaluated because insomnia caused by leg discomfort or worry may contribute to fatigue.
Changes in wardrobe often are necessary when swelling occurs (Ryan, Stainton, Jaconelli, et al., 2003). Alteration in body image may result in changes to regular social activities and may lead to social isolation (Tobin, Lacey, Meyer, & Mortimer, 1993). Referrals to support groups or individual therapy sessions may be indicated depending on patient preference. H.F. found that she gained much by participating in a support group and thereby moved from one type of social interaction to another. Healthcare professionals must be sensitive to lifestyle changes as well as the financial burden that may result from a forced change in wardrobe.
With increased survival after cancer treatment, the long-term sequelae caused by cancer treatment should be recognized and treated. Patients must be informed about the potential lifelong side effects of treatment. Although H.F. was informed about the possibility of lymphedema development, many patients have reported that they were not informed about this life-alterating condition until they developed symptoms (Beesley, Janda, Eakin, Obermair, & Battistutta, 2007; Ryan, Stainton, Jaconelli, et al., 2003). Continued research is needed to determine the best interventions to decrease the side effects of treatment and maximize quality of life.
Author Contact
Kathleen Appollo, RN, BSN, OCN can be reached at appollok @mskcc.org, with copy to editor at ONF Editor@ons.org.
ONS.metapress
Tuesday, November 4, 2008
Preventative Steps for Leg Lymphedema
Preventative Steps for Leg Lymphedema
For the patient who is at risk of developing Lymphedema, and for the patient who has developed Lymphedema.
Who is at risk?
At risk is anyone who has had gynecological, melanoma, prostate or kidney cancer in combination with inguinal node dissection and/or radiation therapy. Lymphedema can occur immediately postoperatively, within a few months, a couple of years, or 20 years or more after cancer therapy. With proper education and care, Lymphedema can be avoided or, if it develops, kept under control. (For information regarding other causes of lower extremity Lymphedema, see What is Lymphedema?) The following instructions should be reviewed carefully pre-operatively and discussed with your physician or therapist.
1. Absolutely do not ignore any slight increase of swelling in the toes, foot, ankle, leg, abdomen, genitals (consult with your doctor immediately).
2. Never allow an injection or a blood drawing in the affected leg(s). Wear a LYMPHEDEMA ALERT Necklace.
3. Keep the edemic or at-risk leg spotlessly clean. Use lotion (Eucerin, Lymphoderm, Curel, whatever works best for you) after bathing. When drying it, be gentle, but thorough. Make sure it is dry in any creases and between the toes.
4. Avoid vigorous, repetitive movements against resistance with the affected legs.
5. Do not wear socks, stockings or undergarments with tight elastic bands.
6. Avoid extreme temperature changes when bathing or sunbathing (no saunas or hottubs). Keep the leg(s) protected from the sun.
7. Try to avoid any type of trauma, such as bruising, cuts, sunburn or other burns, sports injuries, insect bites, cat scratches. (Watch for subsequent signs of infection.)
8. When manicuring your toenails, avoid cutting your cuticles (inform your pedicurist).
9. Exercise is important, but consult with your therapist. Do not overtire a leg at risk; if it starts to ache, lie down and elevate it. Recommended exercises: walking, swimming, light aerobics, bike riding, and yoga.
10. When travelling by air, patients with Lymphedema and those at-risk should wear a well-fitted compression stocking. For those with Lymphedema, additional bandages may be required to maintain compression on a long flight. Increase fluid intake while in the air.
11. Use an electric razor to remove hair from legs. Maintain electric razor, properly replacing heads as needed.
12. Patients who have Lymphedema should wear a well-fitted compression stocking during all waking hours. At least every 4-6 months, see your therapist for follow-up. If the stocking is too loose, most likely the leg circumference has reduced or the stocking is worn.
13. Warning: If you notice a rash, itching, redness, pain, increase of temperature or fever, see your physician immediately. An inflammation or infection in the affected leg could be the beginning or a worsening of Lymphedema.
14. Maintain your ideal weight through a well-balanced, low sodium, high-fiber diet. Avoid smoking and alcohol. Lymphedema is a high protein edema, but eating too little protein will not reduce the protein element in the lymph fluid; rather, this may weaken the connective tissue and worsen the condition. The diet should contain easily-digested protein such as chicken, fish or tofu.
15. Always wear closed shoes (high tops or well-fitted boots are highly recommended). No sandals, slippers or going barefoot. Dry feet carefully after swimming.
16. See a podiatrist once a year as prophylaxis (to check for and treat fungi, ingrown toenails, calluses, pressure areas, athelete's foot).
17. Wear clean socks & hosiery at all times.
18. Use talcum powder on feet, especially if you perspire a great deal; talcum will make it easier to pull on compression stockings. Be sure to wear rubber gloves, as well, when pulling on stockings. Powder behind the knee often helps, preventing rubbing and irritation.
Unfortunately, prevention is not a cure. But, as a cancer and/or Lymphedema patient, you are in control of your ongoing cancer checkups and the continued maintenance of your Lymphedema.
Revised © January 2001 National Lymphedema Network. Permission to print out and duplicate this page in its entirety for educational purposes only, not for sale. All other rights reserved. For more information, contact the NLN: 1-800-541-3259.
For the patient who is at risk of developing Lymphedema, and for the patient who has developed Lymphedema.
Who is at risk?
At risk is anyone who has had gynecological, melanoma, prostate or kidney cancer in combination with inguinal node dissection and/or radiation therapy. Lymphedema can occur immediately postoperatively, within a few months, a couple of years, or 20 years or more after cancer therapy. With proper education and care, Lymphedema can be avoided or, if it develops, kept under control. (For information regarding other causes of lower extremity Lymphedema, see What is Lymphedema?) The following instructions should be reviewed carefully pre-operatively and discussed with your physician or therapist.
1. Absolutely do not ignore any slight increase of swelling in the toes, foot, ankle, leg, abdomen, genitals (consult with your doctor immediately).
2. Never allow an injection or a blood drawing in the affected leg(s). Wear a LYMPHEDEMA ALERT Necklace.
3. Keep the edemic or at-risk leg spotlessly clean. Use lotion (Eucerin, Lymphoderm, Curel, whatever works best for you) after bathing. When drying it, be gentle, but thorough. Make sure it is dry in any creases and between the toes.
4. Avoid vigorous, repetitive movements against resistance with the affected legs.
5. Do not wear socks, stockings or undergarments with tight elastic bands.
6. Avoid extreme temperature changes when bathing or sunbathing (no saunas or hottubs). Keep the leg(s) protected from the sun.
7. Try to avoid any type of trauma, such as bruising, cuts, sunburn or other burns, sports injuries, insect bites, cat scratches. (Watch for subsequent signs of infection.)
8. When manicuring your toenails, avoid cutting your cuticles (inform your pedicurist).
9. Exercise is important, but consult with your therapist. Do not overtire a leg at risk; if it starts to ache, lie down and elevate it. Recommended exercises: walking, swimming, light aerobics, bike riding, and yoga.
10. When travelling by air, patients with Lymphedema and those at-risk should wear a well-fitted compression stocking. For those with Lymphedema, additional bandages may be required to maintain compression on a long flight. Increase fluid intake while in the air.
11. Use an electric razor to remove hair from legs. Maintain electric razor, properly replacing heads as needed.
12. Patients who have Lymphedema should wear a well-fitted compression stocking during all waking hours. At least every 4-6 months, see your therapist for follow-up. If the stocking is too loose, most likely the leg circumference has reduced or the stocking is worn.
13. Warning: If you notice a rash, itching, redness, pain, increase of temperature or fever, see your physician immediately. An inflammation or infection in the affected leg could be the beginning or a worsening of Lymphedema.
14. Maintain your ideal weight through a well-balanced, low sodium, high-fiber diet. Avoid smoking and alcohol. Lymphedema is a high protein edema, but eating too little protein will not reduce the protein element in the lymph fluid; rather, this may weaken the connective tissue and worsen the condition. The diet should contain easily-digested protein such as chicken, fish or tofu.
15. Always wear closed shoes (high tops or well-fitted boots are highly recommended). No sandals, slippers or going barefoot. Dry feet carefully after swimming.
16. See a podiatrist once a year as prophylaxis (to check for and treat fungi, ingrown toenails, calluses, pressure areas, athelete's foot).
17. Wear clean socks & hosiery at all times.
18. Use talcum powder on feet, especially if you perspire a great deal; talcum will make it easier to pull on compression stockings. Be sure to wear rubber gloves, as well, when pulling on stockings. Powder behind the knee often helps, preventing rubbing and irritation.
Unfortunately, prevention is not a cure. But, as a cancer and/or Lymphedema patient, you are in control of your ongoing cancer checkups and the continued maintenance of your Lymphedema.
Revised © January 2001 National Lymphedema Network. Permission to print out and duplicate this page in its entirety for educational purposes only, not for sale. All other rights reserved. For more information, contact the NLN: 1-800-541-3259.
Subscribe to:
Posts (Atom)