Compression Hosiery in Upper Body Lymphoedema

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INTERNATIONAL LYMPHOEDEMA FRAMEWORK

Template Upper body Cover.indd 3 28/9/09 19:26:09 SUPPORTED BY AN EDUCATIONAL GRANT FROM BSN MEDICAL

The views expressed in this MANAGING EDITOR publication are those of the authors Nicola Rusling and do not necessarily reﬂect those of the publishers or BSN medical. SENIOR EDITORIAL ADVISOR THIS DOCUMENT IS ENDORSED BY: Christine Moffatt Honorary Professor, Glasgow University Medical School Australasian Lymphology Association (ALA, Australia) DEPUTY EDITOR British Lymphology Society (BLS, UK) Binkie Mais Lymphoedema Association of Australia (LAA, Australia) EDITORIAL ADVISORS Lymphoedema Support Network Jane Armer (LSN, UK) Professor, Sinclair School of Nursing, Director, Nursing Research, Ellis Fischel Cancer Center, Lymphology Association of Director, American Lymphedema Framework Project, University of Missouri, Columbia North America (LANA) MLD UK Augusta Balzarini National Lymphedema Network MD, Oncological Rehabilitation, Palliative care and Rehabilitation, National Cancer Institute, Milan (NLN, USA) Håkan Brorson Nederlands Lympfoedeem Netwerk Consultant Plastic Surgeon, Department of Clinical Sciences, Lymphoedema Unit, Plastic and Reconstructive (NLN, Netherlands) Surgery, Malmö University Hospital, Malmö, Sweden Norsk Lymfødemforening (NLF Michael Clark Norsk, Norway) Senior Research Fellow, Department of Wound Healing, School of Medicine, Cardiff University, Cardiff, UK Israel Lymphoedema Association (ILA, Israel) Robert Damstra Svensk Förening för Lymfologi Dermatologist, Department of Dermatology, Phlebology and Lymphology, Nij Smellinghe Hospital, Drachten, (SFL, Sweden) The Netherlands STATEMENT OF RECOGNITION: Sarah Davies The International Society of Lymphology Physiotherapist, Peter MacCallum Cancer Centre, Victoria, Australia (ISL) recommends the new Template Etelka Földi for Practice: Compression hosiery in upper body lymphoedema as a valuable, useful Physician-in-Chief, Földi Clinic, special clinic for lymphology, Hinterzarten, Germany and illustrative educational resource for Nicole Stout Gergich general practitioners and the public as Physical Therapist and Lymphedema Specialist, National Naval Medical Center, Breast Care Center, Bethesda, a thoughtful, detailed compendium of established practices within the MD, USA United Kingdom Kaoru Kitamura Vice Director (Department of Breast Surgery), Kyushu Central Hospital, Fukuoka, Japan ©HealthComm UK Ltd, a division of Schoﬁeld Isabelle Querry Healthcare Media Ltd, 2009 Professor of Vascular Medicine, Head of the vascular medicine department, Saint Eloi University Hospital of Montpellier, Montpellier University, France Saskia Thiadens All rights reserved. No reproduction, Founder and Executive Director, National Lymphedema Network, Inc, Oakland, California copy or transmission of this publication may be made without written Anna Towers permission, with the exception of Director, Palliative Care Division, McGill University, Montreal, Canada BSN medical. No paragraph of this publication may be reproduced, copied Horst Weissleder or transmitted save with written Professor of Radiology, Freiburg University, Germany; Honorary President German Society of Lymphology permission or in accordance with the provisions of the Copyright, Designs & Patents Act 1988 or under the terms of any licence permitting limited copying Copies of this document are available from: issued by the Copyright Licensing Agency, 90 Tottenham Court Road, www.wounds-uk.com London W1P 0LP. www.lymphormation.org www.woundsinternational.com TO REFERENCE THIS DOCUMENT CITE THE FOLLOWING: PUBLISHED BY Template for Practice: Compression HealthComm UK Ltd, Suite 3.1, 36 Upperkirkgate, Aberdeen AB10 1BA hosiery in upper body lymphoedema. 2009. HealthComm UK Ltd, PRINTED BY Aberdeen WACE Corporate Print Limited, Swindon, Wiltshire, SN3 4FH, UK TEMPLATE FOR PRACTICE 1

Compression garments in upper body lymphoedema CJ Moffatt

Compression hosiery is at the Lymphoedema is a major, international compression garments to treat oedema of the centre of long-term healthcare problem in both developed and upper body by Johansson shows the paucity of management of developing countries. Although the true size of good quality studies in this area over the last 30 lymphoedema and is one of the problem remains obscure, research across years. All of the existing evidence relates to the the most important aspects the globe is beginning to show the true extent of use of garments on the upper limb, however, it is of care that helps patients to the problem. Millions of people are affected at frequently flawed by poor design, problems of take greater control of their huge personal cost to patients and their families. definition and difficulties of standardising condition. Much of the Professional knowledge and practice is often assessment methods that would allow emphasis in the field of poor and this level of ignorance leads to incorrect comparability between studies. This is an area compression has been on the treatment or no treatment being offered, and that requires considerable research investment. lower limb. This Template for contributes to the lack of reimbursement of The final paper by Doherty and Williams Practice is unique in treatment in many parts of the world. provides in-depth practical advice on how to use attempting to provide an This template follows on from the first compression garments in practice. The international resource that document, Compression hosiery in lymphoedema recommendations are largely drawn from the provides guidance on the (Lymphoedema Framework, 2006a) that International Best Practice Document in appropriate use of recognises the central role that compression Lymphoedema (Lymphoedema Framework, compression garments for garments play in the treatment of lower limb 2006b) that was developed and endorsed by the upper body. lymphoedema. Together they provide a renowned international experts in the field. This comprehensive, yet practical guide for practitioners paper highlights the need for careful and who are managing patients with lymphoedema. continuous assessment of garment efficacy and In the first paper, Krimmel describes the basic also gives an overview of the different construction of compression garments and how presentations of lymphoedema in the upper body. the different types of knitting and use of yarn Despite the lack of empirical evidence there affect the type of garment that is produced. This is a wealth of expert clinical opinion that is a critically important issue as it directly supports the central role that compression influences the choice of compression garment garments play in lymphoedema management. Of that is given to patients with different clinical particular importance is the emerging presentations. Unlike lower limb hosiery where recognition that early treatment and prevention different national hosiery standards exist, there is of lymphoedema are critical if the long-term only one recently introduced standard, the RAL, complications resulting from poor management that underpins the pressures and production are to be avoided. criteria for upper limb garments. By elucidating the rationale for and use of The paper by Carati, Gammon and Piller compression garments in the treatment of provides an in-depth review of the anatomy and lymphoedema of the upper body, this document physiology of the upper body, and outlines how aims to enhance practitioners’ and patients’ use an understanding of arterial, venous and of compression garments and improve the lymphatic flow in the upper body in normal experience of patients with lymphoedema. limbs and those at risk of, or with, CJ Moffatt, CBE, REFERENCES lymphoedema will greatly improve patient Lymphoedema Framework (2006a) Template for practice: Honorary Professor, Glasgow outcomes. The authors highlight the difficulties compression hosiery in lymphoedema. MEP Ltd, London University Medical School, Lymphoedema Framework (2006b) Best Practice for the Director, International of measurement beneath compression. Management of Lymphoedema. International Consensus. Lymphoedema Framework The literature review of the evidence for using London: MEP Ltd 2 TEMPLATE FOR PRACTICE

The construction and classiﬁ cation of compression garments G Krimmel

Flat- and circular-knitting are In patients with lymphoedema of the upper interaction of the physical properties and the two main methods body, compression garments are usually construction of the compression garment, the employed in the construction prescribed for the long-term management of size and shape of limb to which it is applied, of compression garments for lymphoedema following a period of intensive and the activity of the wearer. As a broad patients with lymphoedema. therapy, but they can also be used for principle, the level of compression is directly Both techniques infl uence the prophylaxis or as part of initial treatment in proportional to the tension with which the properties of the fi nished patients with mild lymphoedema. In some compression device is applied and is inversely garment in terms of the level patients, compression garments may be the related to the size of the limb according to of compression it will only form of compression used, or they form Laplace’s Law (Clark and Krimmel, 2006). provide, its thickness, part of a regimen that includes other types of The tension exerted by a compression comfort and cosmetic compression, such as multi-layer lymphoedema garment is related to the type of yarn used in its acceptability. It is important bandaging. For the chosen compression construction and the knitting technique that clinicians understand regimen to be successful, and to aid selected to produce the fabric. how construction infl uences compliance, it must be comfortable and the fi nished garment and how acceptable to the patient (Lymphoedema Yarn garments are classifi ed, so Framework, 2006). The fabric that is used to make compression that they are able to select There are many styles of compression garments is produced by knitting two types of products that deliver garment available for the management of yarn together (Figure 1): effective compression, fi t swelling of the upper body, including gloves, ■ Inlay yarn. This produces the compression correctly, are comfortable gauntlets, armsleeves, vests, and masks for ■ Body yarn. This delivers the thickness and and encourage long-term use. facial swelling. The type of garment selected stiffness of the knitted fabric. and the level of compression prescribed for patients with lymphoedema is dependent on many factors including the site, extent, shape distortion and severity of the swelling, the patient’s ability to manage and tolerate compression, and patient choice (Lymphoedema Framework, 2006). Thus, in order to use compression garments optimally, it is important that clinicians understand the relevance of the technical aspects of garment construction, so that they a. are able to select a garment that is effective and which fi ts accurately and comfortably to encourage patient compliance and long- term use.

CONSTRUCTION OF COMPRESSION GARMENTS b. G Krimmel, General Manager, Compression, deﬁ ned as the pressure applied BSN-Jobst GmbH, Emmerich am to the limb by a garment (Clark and Krimmel, FIGURE 1. The arrangement of inlay and body yarn Rhein, Germany 2006), is dependent upon a complex in ﬂ at-knit (a) and circular-knit fabric (b). TEMPLATE FOR PRACTICE 3

Both types of yarn are produced by The thickness, texture and appearance of the wrapping polyamide or cotton around a knitted fabric can also be changed by adapting stretchable core such as latex or elastane the wrapping of the yarn. Higher levels of (Lycra) (Figure 2). The wrapping can be compression are mainly achieved by increasing adjusted to vary the stretchability and power the thickness of the elastic core of the inlay of the yarn (Figure 2). The stretchability is a yarn, although adjustments may also be made measure of how far the yarn can be elongated, to the body yarn. and the power is a measure of how easily it stretches. High power yarn is less easy to KNITTING TECHNIQUES stretch and is stiffer than its low power There are two main knitting techniques used in counterpart, and thus applies greater the production of compression garments for the compression. treatment of lymphoedema: ■ Flat-knitting ■ Circular-knitting (Table 1). Elastic core, e.g. latex or elastane Flat-knitting As its name suggests, flat-knit technology produces a flat piece of fabric (Figure 3) that is shaped by the addition or removal of needles during the knitting process.The material is then stitched together (resulting in a seam) to Polymide or cotton produce the final garment. wrapping Recently, however, BSN-Jobst have developed a unique flat-knit technique which enables the production of made-to-measure seamless gloves. The unique technology results in a flat-knit material that is softer than the fabric produced using traditional flat-knit technology. Seamless compression gloves are particularly useful for patients with sensitive a. b. skin in whom the presence of a seam may result in skin irritation. They also provide FIGURE 2. The fibres that make up body and inlay uninterrupted or constant pressure and do not yarn. The wrapping of the outer fibre around restrict the movement of the hand (Földi and the stretchable core can be adjusted to vary Greve, 2007) (Figure 4). the stretchability and power of the yarn. Loose wrapping (a) means the yarn has more stretch and less power than a yarn in which the fibres are tightly Circular-knitting wrapped (b). Circular knit garments are produced from material that is continuously knitted on a cylinder resulting in a seamless tube that TABLE 1 . Flat-knit and circular-knit characteristics requires comparatively little finishing to Flat-knit Circular-knit produce the end product (Figure 5). The use of this technique results in a garment which is How is shape controlled? By varying the By varying the tension of the generally thinner and thus more cosmetically number of needles inlay yarn and stitch height; in operation. the number of needles in acceptable than flat-knit alternatives. The elastic inlay operation cannot be changed has no pre-tension resulting in a limited fit CUSTOM-MADE AND when it is put into range READY-TO-WEAR GARMENTS the garment One particular challenge faced when prescribing Number of needles per inch 14–16 (coarse fabric) 24–32 (fine fabric) garments for the management of upper body lymphoedema is that, in most cases, the size and Yarn thickness Coarse, to produce Fine, to produce a more shape of the oedematous area will not match the sufficient stiffness cosmetically acceptable and thickness garment size ranges offered by manufacturers of ready- to-wear garments, prompting the need for 4 TEMPLATE FOR PRACTICE

custom-made products. This is particularly the case for hard to measure areas such as the breast, where breast shape, weight and density of tissue, torso and shoulder proportions will all have an effect on the fit of the garment. There are ready-to-wear support bras with variations in styles and sizes, but custom-made garments are recommended where there are specific anatomical considerations in patients to obtain a better and comfortable fit. Both flat- and circular-knit techniques are used to produce custom-made and ready-to- wear garments. However, custom-made garments are most often made using flat-knit technology since it can accommodate a wide FIGURE 3. Flat-knit garment. range of anatomical distortion. When knitting, the total number of needles can be increased or decreased to produce variations in the width and shape of the fabric used to construct the final garment. When using circular-knit technology, the a. number of needles in use during production of a particular garment is fixed, reducing the range of shape distortion that can be accommodated. However, a small degree of shape variation can be produced during knitting by altering the b. tension of the inlay yarn and varying stitch height. Generally, circular-knit, ready-to-wear garments are only suitable where there is no or minimal limb distortion, as otherwise it may be more difficult to obtain an accurate fit. FIGURE 4. The flat-knit Elvarex® Soft Seamless glove In general, flat-knit fabric is coarser than has: (a) seamless flat edges which are not bulky and circular-knit because it uses thicker yarn and which do not curl; (b) a unique 3D manufacturing consequently fewer needles per inch during technique that facilitates a good fit between the fingers, aiding oedema control in this area. knitting (Table 1). The thicker yarn produces stiffer and thicker material that is better at bridging skin folds and is less likely to cut into the skin or cause a tourniquet effect. The finer finish of circular-knit garments may make them more cosmetically acceptable, but it also makes the garments more likely to roll at the top and cut into the limb, particularly if worn for extended periods.

EUROPEAN STANDARDS FOR COMPRESSION GARMENTS OF THE UPPER BODY National standards cover parameters such as testing methods, yarn speciﬁcation, compression gradient and durability and are of considerable value in ensuring that compression garments can be selected that are known to produce an appropriate level of compression. They are also usually a prerequisite for reimbursement. FIGURE 5. Circular-knit garment. TEMPLATE FOR PRACTICE 5

Unlike lower limb hosiery for which British, washing allows the yarns to realign after being French and German standards exist (Clark and stretched during wear and to maintain the Krimmel, 2006), currently there is only one correct compression. Garments should be dried standard available for upper body garments. away from direct contact with heat, which may The German standard RAL-GZ 387/2 became be harmful to the yarn. effective in January 2008 and applies to The need for replacement garments should be compression armsleeves.The German RAL reviewed every three to six months, or when they standard covers both ready-to-wear and start to loose elasticity. Very active patients may custom-made garments, but in Germany the need replacement garments more frequently. latter are preferentially recommended for the treatment of lymphoedema. CONCLUSION The standard uses the HOSY method during The techniques used in the construction of testing to measure the compression applied to compression garments influence the the upper extremity by the armsleeve and performance characteristics of the final product. focuses upon in vitro measurement of the Understanding this can help the practitioner to pressures applied at various points on the limb. select a compression garment to meet the The level of compression delivered at the wrist needs of the individual patient. is then classified into one of three classes: National standards were developed to guide ■ Class 1: 15–21mmHg manufacturers and to help classify garments ■ Class II: 23–32mmHg according to the compression generated, and ■ Class III: 34–46mmHg. several exist for compression hosiery. Despite the existence of only one standard for the use However, the standard contains little of upper body compression armsleeves, information on the use of compression manufacturers offer a wide range of products garments in the treatment of lymphoedema, so for the upper body, each with their own should be used in conjunction with clinical classification of the compression they produce, guidelines such as the International Consensus: based upon the manufacturer’s testing Best Practice for the Management of methods. Lymphoedema (2006). These differences in class pressure ranges It should also be remembered that there is and testing equipment make comparisons little clinical evidence to indicate the correct between products difficult, and the practitioner pressures for compression garments of the should be aware of this. To assist comparison, it upper body, especially when managing midline would be helpful if garment packaging and oedema. Recommendations are often borrowed studies involving compression garments stated from what we know about hosiery of the lower the pressure ranges and the testing methods body, however, anatomical variations make this used to determine the pressures. practice less than ideal and more research is However, it is important to remember that needed in this area. the classification of compression garments either by standards or manufacturers provides GARMENT CARE only an approximate range of the compression Recommendations for the care of compression delivered. The selection of an appropriate garments are designed to maintain product garment should be based on a thorough and performance and prolong garment life, and holistic assessment of the patient in order to aid derive from the materials and method of compliance and long-term use. construction used. Oil-based skin cream used under REFERENCES AND FURTHER READING Clark M, Krimmel G (2006) Lymphoedema and the compression garments may adversely affect the construction and classification of compression hosiery. In: yarn and thus the garment’s performance. Lymphoedema Framework. Template for Practice: compression hosiery in lymphoedema. London: MEP Ltd Ideally, garments should be hand or machine 2006 washed at the temperature recommended by Földi E, Greve J (2007) Technological quantum leap in lymph therapy Jobst® Elvarex® Soft Seamless: Worldwide first flat the manufacturer every day or every second knit seamless custom-made compression glove. Eur J day. Conditioner should not be used when Lymphol 17(5): 16–7 Lymphoedema Framework (2006) Best Practice for the laundering as this can cause garment Management of Lymphoedema. International consensus. deterioration. As well as cleaning the garment, MEP Ltd, London 6 TEMPLATE FOR PRACTICE

Priniciples of anatomy and physiology in relation to compression of the upper limb and thorax C Carati, B Gannon, N Piller

An understanding of arterial, Little evidence exists to support the use of The superficial system arises from the capillary venous and lymphatic flow in compression garments in the treatment of networks of the skin and subcutaneous tissue, the upper body in normal lymphoedema, particularly in relation to the which drain into two major vessels. The limbs and those at risk of, or upper body and limbs. There is much we do not anterolateral tissue of the upper limb drains into with, lymphoedema will know about the finer details of arterial, venous the cephalic vein. This vein originates from the greatly improve patient and lymphatic flow in normal, at risk and lateral dorsum of the hand and travels via the outcomes. However, there is lymphoedematous limbs, and how this is lateral border of the wrist and forearm, passing much we do not know in this affected by the application of compression. through the lateral aspect of the cubital fossa area, including the effects of However, despite this, the use of compression (where it communicates with the basilic vein compression upon lymphatic garments is a widely accepted and important flow and drainage. Imaging part of treatment (Partsch and Junger, 2006). and measuring capabilities More is known about the possible effects of To subclavian lymphatic trunk are improving in this respect, compression on the pathophysiology of Apical axillary lymph nodes but are often expensive and lymphoedema when used on the lower limbs time-consuming. This, (Partsch and Junger, 2006). While some of Deltopectoral lymph nodes coupled with the unknown these principles can be applied to guide the use Central axillary lymph nodes effects of individual, diurnal of compression on the upper body, it is Pectoralis minor muscle and seasonal variances on important that the practitioner is Humeral (lateral) axillary lymph nodes compression efficacy, means knowledgeable about the anatomy and Pectoral (anterior) axillary lymph nodes that future research should physiology of the upper limb, axilla and thorax, focus upon ways to monitor and of the anatomical and vascular differences Subscapular posterior axillary the pressure delivered by a that exist between the upper and lower limb, so lymph nodes garment, and its effects that the effects of these differences can be Basilic vein upon the fluids we are trying considered when using compression garments. Cephalic vein to control. This paper will describe the vascular Cubital Median cubital vein anatomy of the upper limb and axilla, and will lymph nodes outline current understanding of normal and Cephalic vein abnormal lymph drainage. It will also explain Perforator veins the mechanism of action of compression garments and will detail the effects of Basilic vein compression on fluid movement.

VASCULAR DRAINAGE OF THE UPPER LIMB Superﬁcial palmar It is helpful to have an understanding of the C Carati, Associate Professor; venous arch vascular drainage of the upper limb, since the B Gannon, Associate Professor, Lymphatic plexus of palm Department of Anatomy/ lymphatic drainage follows a similar course Physiology; N Piller, Professor, (Figure 1). The venous system of the upper limb Director Lymphoedema consists of superﬁcial and deep systems, with Digital lymphatic vessels Assessment Clinic, numerous ‘perforating’ veins (so-called because Department of Surgery, School Anterior (palmar) view of Medicine, Flinders University they pierce the deep fascia separating the skin and Medical Centre, Bedford Park, from the muscles and bones) joining the two FIGURE 1. Venous and lymphatic systems of the South Australia systems (Moore and Dailey, 2006). hand and arm. TEMPLATE FOR PRACTICE 7

via the median cubital vein), and ascending the hemiazygous venous system, or anteriorly into arm to pass into the axillary region between the the internal thoracic veins. The posterior wall of deltoid and pectoralis major muscles. The the thorax also drains into the azygous/ basilic vein drains the postero-medial aspect of hemiazygous system, which drains directly into the dorsum of the hand, travels superficially up the superior vena cava. the antero-medial aspect of the forearm, medially through the cubital fossa and about LYMPHATIC DRAINAGE OF THE UPPER LIMB one-third of the way up the arm, before piercing The lymphatic drainage of the upper limb also the deep fascia to then accompany the brachial consists of superficial and deep systems, artery into the axillary region. Both veins which follow similar paths to that of the connect to the axillary vein, and then the vascular system. There are four major subclavian veins en route to the superior vena patterns of lymphatic drainage which are cava. Many perforating veins are evident in the based on early cadaver, lymphography and anterior aspect of the forearm, coalescing into lymphoscintigraphic investigation (Foeldi et the median vein of the forearm, which then al, 2003). joins the basilic and/or the cephalic veins The superficial lymphatic drainage vessels (Figure 1). arise as a plexus within the skin of the upper The lymphatic drainage of the torso does not limb. Vessels drain from the hand mainly along follow the venous drainage of the torso as its palmar surface into larger lymphatic vessels closely as in the arm. However, the venous that converge towards the veins draining the drainage of the torso also enters the axillary, forearm, especially the basilic vein (Moore and subclavian, or branchiocephalic veins en route Dailey, 2006), acquiring new vessels from the to the superior vena cava, and hence may be skin as they travel up the limb (Figure 1). relevant to the venous drainage of the arm. The The lymphatic vessels draining the antero- anterior wall of the torso and the breast drains lateral territory of the arm traverse the upper mainly into the axillary vein, and to a lesser part of the arm and the anterior aspect of the extent the internal thoracic veins. The ribcage is shoulder, draining into the uppermost (apical) drained via intercostal and subcostal veins that lymph nodes of the axillary lymphatic system drain the ribcage posteriorly into the azygous/ (Figure 2). Lymph drainage from the postero-

Supraclavicular lymph nodes Subclavian lymphatic trunk Infraclavicular lymph nodes Internal jugular vein Axillary artery and vein

Apical lymph nodes Deep servical lymph nodes Right lymphatic duct Lateral (humeral) lymph nodes Subclavian vein Central lymph nodes Right brachiocephalic vein and artery

Pectoral (anterior) lymph nodes Subscapular (posterior) lymph nodes Parasternal lymph nodes Interpectoral lymph nodes Pectoralis minor Pectoralis major To contralateral (left) breast

Subareolar lymphatic plexus

To abdominal (subdiaphragmatic) lymphatics

(A) Anterior view

FIGURE 2. The lymph nodes of the axilla. 8 TEMPLATE FOR PRACTICE

BOX 1 Lymphatic drainage medial aspect of the forearm passes through to the superior vena cava, and hence may be of the axilla nodes in the medial cubital region, proximal to relevant to the venous drainage of the arm. the medial epicondyle of the elbow, and then It is difficult to get optimum pressure, if any, into the axillary/ into lateral (humeral) lymph nodes of the axilla. LYMPHATIC DRAINAGE OF THE THORAX medial proximal upper arm area The deep lymphatic drainage originates from The lymphatic drainage of the torso does not using compression garments. the deeper soft tissue, such as muscles and follow the venous drainage of the torso as This, combined with a likely nerves, joints and the periosteum of the bones. closely as these systems do in the arm. annulus of often inappropriate pressure on the shoulder and Vessels converge and travel close to the deep Superficial lymph drainage from the back of the lateral chest provided by the veins of the upper limb, occasionally passing thorax is mainly via a network of superficial wearer’s bra (in the case of a through a few lymph nodes, before arriving at lymphatics, which converge to the subscapular woman), means that there are the lateral (humeral) axillary lymph nodes (posterior) nodes of the axilla (Figure 2). often very significant issues of fluid accumulation (initially) and (Figure 2) (Moore and Dailey, 2006). However, there is the possibility that the more fibre (later) in this area. The cutaneous venous drainage of the upper medial back drains via perforating lymphatic back (thorax) is via dorsal perforating connections to the posterior intercostal (posterior) cutaneous branches of the posterior lymphatics en route to paravertebral nodes intercostal veins and thence to the azygous/ (Iyer and Libshitz, 1995). hemiazygous system to superior vena cava. Lymph drainage of the skin and dermis of the Venous drainage of the skin and dermis of front of the thorax (chest) anterior to the mid- the chest anterior to the mid-axillary line is axillary line is largely from individually variable largely via the thoraco-epigastric vein network, regions (lymphotomes) to particular axillary to the axillary vein (via the lateral thoracic vein nodes (i.e. the sentinal node for each region; — the superior part of the thoraco-epigastric Suami et al, 2008). The area medial to the venous network). Venous drainage of the nipple in both sexes drains to the parasternal female breast is largely via the lateral thoracic (internal mammary) node chain (Figure 3). vein to the axillary vein, but the more medial Drainage of the well developed lymphatic superficial aspects of the breast drain to the network of the female breast, including the paired internal thoracic venae comitantes, then dense sub-areola network, is largely via to subclavian vein and on to the superior vena laterally or superiorly directed lymphatics, cava. Much of the deepest tissue of the breast which pass to pectoral axillary nodes, or to drains via perforating veins through the deep lateral axillary nodes (Suami et al, 2008) fascia to the anterior intercostal veins, and then (Figure 2). The superficial aspects of the breast to the internal thoracic veins. medial to the areola, drain medially to para- The venous drainage of the skin and dermis mammary and para-sternal nodes (Schuenke of the chest mainly enters the axillary, et al, 2006), then to the right or left lymph subclavian, or branchiocephalic veins en route duct or thoracic duct to the subclavian vein, and on to the superior vena cava. Sentinel node tracing from non-palpable (deep) breast tumours (Tanis et al, 2005) suggests that Supraclavicular lymph much of the deepest tissue of the breast is nodes chain likely to drain via the deep lymphatics, which perforate through the deep fascia to join the Axillary lymph anterior intercostal lymphatics, passing then to nodes chain the internal mammary lymph trunk and chain of nodes. Internal mammary lymph nodes chain LYMPHATIC DRAINAGE TO THE AXILLA The lymphatic drainage of the upper limb is intimately related to that of the anterior and posterior regions of the thorax, especially the breast, all of which drain through the axillary region. The axillary region contains five clusters of nodes, arranged in a pyramid pattern dictated by the shape of the axillary region, FIGURE 3. Drainage into mammary lymph nodes. with three clusters at the base of the axilla, one TEMPLATE FOR PRACTICE 9

BOX 2 Lymphatic drainage at its apex and one in the middle (Figure 2) LYMPHATIC DRAINAGE PATHS paths (Moore and Dailey, 2006). These nodes are Studies have indicated that lymph drainage of embedded in the axillary fat, external to the the upper arm travels into the mammary Studies have indicated that lymph drainage of the upper arm axillary sheath that contains the axillary artery nodes in some individuals with lymphoedema. travels into the mammary nodes and vein. The majority of the lymphatic fl uid Kawase et al (2006) reviewed in some individuals with associated with the antero-lateral lymphatic lymphoscintigraphy results from 1,201 lymphoedema. These drainage territory drains into four to six lateral clinically node-negative patients with invasive patterns also indicate the need to pay attention to the potential (humeral) nodes, while that of the postero- breast cancer who underwent preoperative effect of clothing (particularly medial territory drains into the apical nodes. labial salivary gland (LSG) and axillary sentinel bras) on lymph drainage to the The pectoral and subscapular nodes drain the lymph node (SLN) biopsy. They reported a internal mammary, as well as the anterior and posterior thoracic wall, range of lymphatic drainage patterns, and contralateral axillary nodes. respectively, and along with the humeral almost 25% of patients had drainage to extra- nodes drain through the central, then the axillary lymph nodes, especially the internal apical nodes en route to the subclavian mammary ones (Figure 3). This has also been lymphatic trunk and ultimately the venous confi rmed by Ferrandez et al (1996) who after BOX 3 Lymphatic cutaneous system. The consequence of this arrangement a session of manual lymphatic drainage (MLD) networks is that lymphatic drainage of the upper limb is found Tc-labeled tracers moved to the internal directly affected by both the drainage of the mammary nodes in 8% of patients with There is a greater density of lymphatic vessels in patients upper torso and the state of the central lymphoedema (n=47), as well as to the with lymphoedema compared to lymphatic system. contralateral nodes in 20% (Figure 4). What those with normal healthy limbs. As is the case with the groin area, it is this means for the end results of compression diffi cult to get optimum pressures, or any is that not only must we consider the pressure at all, into the axillary/medial proximal compression level and its gradient in the limb, upper arm area and this, combined with a likely but also the gradient across the truncal area. annulus of often inappropriate pressure on the These drainage patterns also indicate the need shoulder and lateral chest provided by the to pay attention to the potential effect of wearer’s bra (in the case of a woman), means clothing (particularly bras) on lymph drainage that there are often very signifi cant issues of to the internal mammary, as well as the fl uid accumulation (initially) and fi bre (later) in contralateral axillary nodes (Figure 3). this area. LYMPHATIC CUTANEOUS NETWORKS It is known that there is a greater density of Axillary Upper limb lymphatic vessels in patients with lymph nodes lymphoedema compared to those with normal healthy limbs. Mammary gland Mellor et al (2000) used fl uorescence Paramammary microlymphography to examine the dermal lymph nodes lymphatic capillaries of the forearm in 16 Anterior intercostal spaces women with oedema following treatment for breast cancer. They reported that the superfi cial lymphatic density and total length Anterior chest wall Parasternal of capillaries was greater in the swollen limb lymph nodes compared to the control arm. Importantly, the distance travelled by the relatively superfi cial Posterior chest wall lymph contents before draining to the sub- fascial system was longer in the swollen limb Paravertebral compared to the normal limb. Furthermore, Posterior intercostal spaces lymph nodes there was no evidence of lymphatic dilation in the swollen limb. These fi ndings suggest that there is a local re-routing of superfi cial lymph FIGURE 4. Normal drainage pathways of upper and possibly lymphangiogenesis in the limbs limb and thoracic tissues to the lymph nodes. Note drainage from a breast can be to either of patients with lymphoedema. Since the work the ipsilateral nodes (more commonly) or to the of others has shown blood capillary contralateral nodes (less commonly). angiogenesis in swollen limbs, Mellor et al 10 TEMPLATE FOR PRACTICE

BOX 4 Factors affecting (2000) hypothesised that the increased above the deep fascia means that the lymph lymph drainage number (length) of lymphatic capillaries would collectors (which are normally lying above the possibly help to maintain the ratio of drainage deep fascia) are more superfi cial than those There is no resorption of fl uid, and the net fl ux is solely into the capacity to fi ltration capacity. The impact of which are covered with a greater depth of fat, tissue from where it is cleared by external compression on this change is thus generally requiring a lower compression the lymphatics. Thus, fl uid fl uxes possibly minor, but the longer travel distance of pressure. through the lymphatic system the lymph in the superfi cial lymph collectors are likely to be larger than previously thought. may mean that the establishment and PHYSIOLOGICAL FACTORS AFFECTING maintenance of a pressure gradient along the LYMPHATIC DRAINAGE limb is very important. Both normal and abnormal patterns of lymphatic drainage help to demonstrate how TISSUE STRUCTURE OF THE ARM fl uid fl ows through tissues, so it is important to The upper arm contains deep and epifascial fat understand both previous and current theories layers. The deep fat layer found in the posterior of lymph formation and movement. and deltoid region of the arm is thin. In normal In the healthy individual, the vascular system limbs the epifascial fat layer is circumferential, runs into the capillaries, which are small vessels but can hypertrophy in the proximal posterior that are bathed in interstitial fl uid. The one third of the arm. In lymphoedematous capillaries have thin, semi-permeable walls limbs this hypertrophy is marked and not only made up of a single layer of endothelial cells has an infl uence on lymph load, but also on that allow the transfer of oxygen and nutrients lymph drainage, as the additional tissue from the blood into the tissues, and the transfer

pressure of the adiposites on the delicate walls of waste products such as CO2 and urea from of the lymph collectors constrains them from the tissues into the blood. their optimal contraction. Chamosa et al Fluid movement across the capillary wall (2005) found that in normal arms, the anterior behaves according to the principles fi rst and distal third of the upper arm tended to have outlined by Starling (1896), whereby the less thick adipose tissue. Occasionally, a blood‘s hydrostatic pressure forces fl uid from specifi c lipodystrophic zone can be found on the capillaries down a substantial pressure the posterior-external area of the normal arm, gradient into the tissues, while the colloid located between the proximal and medial osmotic pressure of the blood ‘sucks’ fl uid back thirds. Relatively speaking, the skin of the into the capillary ‘up’ a substantial osmotic medial aspect of the normal arm is generally gradient (Figure 5). The balance of these forces thin, devoid of hair follicles, and prone to sag. results in a net fl uid fl ux into the tissue under Overall, the skin is mobile and overlies loose, normal circumstances, which is then drained nonfi brous fat. However, as lymphoedema away by the lymphatic system. Blood fl ow Interstitial fl uid develops, there are a range of signifi cant It is important, however, to be aware that the epifascial tissue changes which occur (mainly current textbook version of this process has to the amount of fat and fi bre, as there is a fl uid being fi ltered from the arterial end of the thickening of the deep fascia and the fascia capillary, and resorbed at the venular end (e.g. Hydrostatic between the lobules of adiposites). These will Marieb et al, 2007), as the hydrostatic pressure pressure have signifi cant effects on the outcome of decreases along the capillary (due to frictional Capillary external compression in terms of its losses or resistance), and the balance of the so- Osmotic pressure transmittance into the tissues and to the called Starling forces shift from favouring vascular and lymphatic systems within it. Of fi ltration to favouring resorption along the particular importance is the increase in the capillary. This view is now being replaced by the Venous end thickness of the deep fascia and its impact on opinion that, at least in most capillaries in the interchange of fl uids between the deep and normal circumstances, there is no resorption of superfi cial lymphatics. We will not go into these fl uid, and the net fl ux is solely into the tissue FIGURE 5. Diagram of the pathophysiological changes here, since they are from where it is cleared by the lymphatics hydrostatic and oncotic well documented and in mainstream literature (Michel, 1997; Levick, 2004; 2009). pressures acting across (Foeldi et al, 2003; Weissleder and During this fl uid movement, most plasma the capillary wall, affecting transendothelial exudation Schuchhardt, 2008). proteins of the blood are retained in the of fl uid from plasma to the Reduced epifascial depth, most often vascular system as they do not cross the interstitium. associated with a lesser amount of fat directly capillary membrane in most tissues. The TEMPLATE FOR PRACTICE 11

emerging consensus is that the ‘barrier’ to the LYMPHATIC AND VASCULAR CHANGES transcapillary flux of plasma proteins and larger AFTER SURGERY AND RADIOTHERAPY lipophobic solutes lies at the glycocalyx, a The main cause of upper body lymphoedema complex luminal layer of anionic arises from cancer of varying causes, polysaccharides and glycoproteins secreted by, especially breast cancer, which is often and attached to, probably all capillary treated by surgery and radiotherapy. It is clear endothelial cells. The glycocalyx acts as a fine that lymphoedema following surgery and/or fibre filter hindering larger molecule transit by radiotherapy starts with an obstruction of the stearic exclusion in a size-dependent manner drainage in the axillary area, but the exact (Squire et al, 2001; Zhang et al, 2006). The pathophysiology of the following sequelae in physical path for fluid leakage lies beyond the the lymph vessels (and surrounding tissues) glycocalyx, at infrequent short breaks in is not well known (Pain et al, 2005). junctional membrane strands along inter- Furthermore, there are some important endothelial cell junctions, which elsewhere seal haemodynamic aspects of the arm following junctions tight (Adamson et al, 2004; Curry, surgery (+/– radiotherapy) which are poorly 2005). The net result of this arrangement is understood. that fluid resorption at the capillary is unlikely under normal conditions, and requires larger Arterial inflow breaks in endothelial integrity, such as those There is some evidence that arterial inflow is occurring during inflammation. A corollary of increased in lymphoedematous arms following this is that fluid fluxes through the lymphatic treatment for breast cancer (Dennis, 2008). system are likely to be larger than previously Using a variety of techniques, the blood flow thought, since there is no venular resorption of into the lymphoedamatous arm has been fluid under normal physiological conditions. For reported to be increased by 42–68% this reason, improved knowledge of the impact compared to unaffected arms (Jacobsson, of compression on the superficial lymphatic 1967; Svensson et al, 1994a; Martin and Foldi, flow is essential. 1996; Yildrim et al, 2000). Jacobsson (1967) A further corollary is that increasing reported this increase was mainly in the skin interstitial pressure will reduce the pressure and subcutaneous tissues. In contrast, Stanton gradient forcing fluid out of the capillaries, and et al (1998) found that the blood flow was the will thus reduce fluid fluxes into the tissue. same between affected and unaffected arms, Conversely, increased colloid osmotic pressure although the per unit volume of blood flow of the interstitial fluid would increase fluid was actually reduced in affected arms since it fluxes, since the colloid osmotic gradient was of larger volume. The reasons for this withholding fluid in the plasma would be change in blood flow in lymphoedematous reduced in this circumstance (Levick, 2009). arms is not clear, although there clearly are Such a situation may arise if there is structural changes in the affected limb that accumulated interstitial protein due to might cause increased blood flow. On the increased transcapillary protein leakage into the other hand, an increased arterial inflow may tissue, increased interstitial proteolysis (such as serve to increase fluid filtration into the tissue, that occuring during inflammation), or reduced and thus increase the risk of developing drainage of interstitial protein due to poor lymphoedema; such an increase in arterial lymphatic drainage. Each of these factors will flow may result from damage to the autonomic be affected by compression of the limb, and can innervation to the limb due to surgery and/or lead to reduced fluid influx into the tissues. The radiation (Kuhl and Molls, 1995). role of compression on the limb, therefore, may well be to prevent fluid accumulation, rather Venous outflow than to encourage lymphatic drainage, as is Venous outflow may also be compromised in often suggested. lymphoedematous limbs (Dennis, 2008). Blood and lymphatic drainage from the arm Significant venous obstruction was reported in is also influenced by movements and 57% of 81 patients assessed by Svensson et al contractions of skeletal muscle and (1994b) using colour Doppler ultrasound intrathoracic pressure, as well as by positional imaging. Szuba et al (2002) reported a lower changes. but still significant 4.6% prevalence of venous 12 TEMPLATE FOR PRACTICE

obstruction of lymphoedematous upper limbs. ■ Increasing interstitial pressure There are several other lines of evidence that ■ Improving tissue fluid drainage indicate that there is an association between ■ Stimulating lymphatic contractions venous dysfunction and lymphoedema, ■ Breaking down fibrosclerotic tissue. especially in the lower limbs (Dennis, 2008), and this should be considered carefully when Increasing interstitial pressure contemplating compression treatment of the Externally applied pressure is transmitted into upper limb. Any factors that compromise the tissue, although not always in a linear venous outflow will significantly increase fashion. Pressure up to 200mmHg increased capillary hydrostatic pressures and result in interstitial tissue pressure to within 65–75% of increased fluid filtration into the tissues, the externally applied pressure in normal pig leading to larger lymphatic loads. limbs, and up to 100% when the limb was oedematous and less compliant (Reddy et al, Lymph outflow 1981). The pressures generated (and There are few reports on surgery and/or measured) by compression garments are likely radiotherapy for breast cancer and their effects to depend on the measurement technique, the on lymphatic flow through the arm and torso. nature (knit/elasticity) and fit of the garment, Perbeck et al (2006) studied lymph clearance and the compliance of the limb tissue being using 99 Tc-nanocolloid clearance in breast compressed. Pressures of 8–38mmHg have tissues 2.5 years after surgery and/or been measured under garments applied to radiotherapy for breast cancer. They reported a burns patients using standardised protocols 4.0-fold increase in lymph flow after (Mann et al, 1997), but there was wide lumpectomy plus radiotherapy, 2.5-fold variation within and between measurement increase in the contralateral (non-operated) sites; for example, mean pressure over the breast and a 1.5-fold increase in the operated anterior thigh was significantly less (8mmHg) non-irradiated breast, indicating long-term than that over the posterior thigh (15mmHg), changes in basal lymphatic flow of breast presumably due to radial and circumferential tissues. Stanton et al (2008) measured differences (as per the law of Laplace) by the muscle and subcutis lymphatic drainage of the same garment applied at these sites. Custom- arm after axillary surgery for breast cancer in made compression garments increased sub- 36 women, using lymphoscintography. They dermal pressure in burns applications, over a reported that muscle lymph drainage always range of 9–90mmHg, but measurements of exceeded that of subcutis drainage, and the pressures under garments over-estimated subcutis drainage was higher in women who the pressure transmitted into ‘soft’ tissues subsequently went on to develop (e.g. muscle) by up to 50%, and under- lymphoedema. They concluded that women estimated the pressure transmitted into ‘bony’ with higher filtration rates and therefore higher sites by a similar amount (Giele et al, 1997). lymph flows through the axilla, were at greater Thus, measurements taken at the garment- risk of developing lymphoedema after axillary skin interface may not always be surgery, presumably because they had less representative of pressures transmitted into lymphatic reserve to deal with additional fluid the tissues, and should be interpreted loads following surgery. with care. Increased interstitial pressure will affect MECHANISMS OF ACTION OF fluid exchange from the blood into the COMPRESSION GARMENTS interstitium, so as to prevent interstitial fluid In the managment of lymphoedema the term (oedema) accumulation. In addition, ‘compression therapy’ covers a range of interstitial pressures greater than capillary or treatment modalities including multilayer arterial pressures (>40mmHg) are likely to inelastic lymphoedema bandaging and reduce blood flow, further preventing fluid compression garments (Partsch and Junger, accumulation. To our knowledge, the 2006). Compression garments are used for contribution of these factors to compression the prophylaxis, treatment and long-term therapy has never been assessed in large trials, management of lymphoedema and may although the work of Abu-Own et al (1994) is work by: informative and Partsch and Partsch (2005) TEMPLATE FOR PRACTICE 13

give some indications of the impact of position muscles contract, expand and then relax (e.g. on pressures required, although these relate to during exercise), they transiently press against the lower limb. the resisting garment and so the tissue pressure in the limb increases temporarily. Improved tissue fluid drainage This transiently increased interstitial pressure External compression improves tissue fluid compresses the adjacent dermal lymphatics drainage through the lymphatic system up to a and because the collecting and larger point. Clearance of a radioactively labelled lymphatics are valved, these vessels pump colloid in dog hind limbs increased passively so that lymph flows up the arm exponentially (to a maximum of three-fold) without the lymphatics having to contract. The with increasing externally applied pressure up influence of muscle movement and of different to 60mmHg. Above 60mmHg, clearance external pressures (and of their transmittance decreased to almost nothing (Miller and Seale, to underlying tissue) depends on the elastic 1981). Similar results were reported in human property of the garment material and the lower limbs, except that the pressure at which compression pressure applied. There is no maximum clearance occurred varied with evidence to suggest that there is increased posture, being 30mmHg supine compared lymphatic contraction under compression. with 60mmHg sitting (Chant, 1972). In a more clinical setting, below-knee stockings (ankle Breakdown of fibrosclerotic tissue pressure 30mmHg) doubled veno-lymphatic There are two major strategies to break down drainage of intradermally injected sodium- fibrotic tissue, but for both the number and fluorescein solution in both normal limbs and breadth of the studies are limited. One those with venous insufficiency (Lentner and strategy is through frictional massage and the Wienert, 1996). Most convincingly of all, other through the use of low level laser however, is the general observation that therapy. There have been some reasonable compression therapies can acutely reduce studies of the latter, using tonometry as a limb (fluid) volume when appropriately used means of detecting changes in epifascial to treat lymphoedema. fibrosis as measured by the resistance of the The observation that compression tissues to compression. When low level garments enhance tissue fluid clearance is at handheld or scanning laser is used there is a odds with reports that the lymphatic system is slow, although general softening of the a low-pressure system. The lateral pressure in indurated tissues, presumably aiding in the human (and many other) lymphatics reaches passage of extracellular fluid and allowing a 15–40mmHg during movement, but is much stronger contraction of the lymphangions lower under resting conditions (1–12mmHg) since they are less constrained. The softening (Aukland and Reed, 1993). Thus, compression is most often accompanied by limb size garments, which induce interstitial pressures changes and subjective improvement (Piller of, for example, 10–40mmHg on the arm, are and Thelander, 1998; Carati et al, 2003). likely to be collapsing lymphatic vessels under many circumstances. One can only conclude OPTIMISING THE EFFECTS OF that compression therapy is unlikely to simply COMPRESSION GARMENTS increase drainage through the (often In order to achieve optimal effectiveness when compromised) lymphatic system, but is likely using compression to treat patients with to affect tissue fluid exchange through other, lymphoedema, it is claimed that ideally possibly inter-related, mechanisms, such as garments should be custom made and flat- decreasing fluid influx into the limb. knitted; however, large scale trials are required to support these claims. Of the upmost Stimulation of lymphatic contraction importance is accurate measurement of the Lymphatic drainage is dependent upon the garment, accounting for changes in the limb spontaneous contraction of valved lymph volume with position (elevated or in vessels creating a pumping force. The dependent positions), and whether the limb is application of a compression garment results likely to be active or inactive, which depends in constant pressure on the skin when the limb on the patient’s occupational status. However, is at rest (resting pressure). When the little is known regarding the effect of the above 14 TEMPLATE FOR PRACTICE

variables on garment pressure gradients and outcomes of which often necessitate the use on undergarment pressures. In the interim, of a range of limb padding strategies to ensure however, we can extrapolate our knowledge of some modicum of lengthwise pressure (a how lymphoedematous and oedematous legs gradient) over the length of the limb, rather respond (at least in the dependent position), than just across a given cross-section of as this may help to guide research into the the limb. impact of compression on the arm. In addition to these measurement and biological CONCLUSION parameters, information about garment There is much we do not know with respect to characteristics, such as dynamic stiffness accurate details of the arterial flow into and the index, static stiffness index, multi-component lymphatic and venous outflow from normal, at materials, and inelastic bandaging is important risk and lymphoedematous limbs. Specifically, (Partsch et al, 2008; Mosti et al, 2008). There we do not know enough about the effects of are some recent advances in the burns field in compression on venous and lymphatic flow and the design of pressure garments which exert a drainage. In terms of the upper body, the specific and known pressure (Macintyre, contributory impact of variations in intra- 2007), but it is the accuracy of the thoracic pressure on proximal arm clearance, a measurement for the garment that is the patient’s garments and the impact of the prime determinant of an excellent, good or varying circumference of the chest with adverse outcome for the limb. Newer respiratory cycles is relatively unclear and most pressure-sensing materials may help to likely to significantly vary, not only between partially overcome poor measurement, clients, but also in a client from day to day and although these must not be used as an excuse hour to hour depending on their activity, body for inaccuracy. position and the activity level of their limb. Knowing more about the anatomy, ANATOMICAL DIFFERENCES BETWEEN physiology, pathophysiology of the tissues and ARMS AND LEGS structures of the upper body will help us gain When applied to the upper limb the better outcomes for the client at risk of, and compression bandage or garment used is less with, lymphoedema. However, it would seem likely to be completely in a dependent position that the best way forward is to acknowledge in all its parts; the depth of the deep fascia is individuality, diurnal and seasonal variances and often less than a similar position on a leg, the to develop better means to monitor the depth of the often closely adherent lymph pressure effect of the prescribed garment on collectors is less (meaning a more marked the fluids we are trying to control. effect of external pressure application), the Perhaps for the majority of patients this is lymph collectors are often of smaller diameter, an easier, more cost-effective option than (having less strong flow and reduced intra- attempting a range of tests on all patients to lymphatic pressures). Combined, these factors determine the anatomy, physiology and mean that externally applied pressure, such as pathophysiology of the correct function (or from compression bandages or garments or otherwise) of the patient’s blood, tissue and clothing, is likely to have a more profound lymph systems. Knowing the latter will, effect. However, this relative superficiality of however, also help achieve the overall goal of vessels means it must be realised that too high holistic patient care. a pressure may be counterproductive (Modi et REFERENCES al, 2007) and may cause vessels to collapse, Abu-Own A, Shami SK, Chittenden SJ, Farrah J, Scurr JH, Smith which may manifest as swelling in the arm and/ PD (1994) Microangiopathy of the skin and the effect of leg compression in patients with chronic venous insufficiency. J or hand. Vasc Surg 19(6): 1074–83 The shape variation of the arm over its Adamson RH, Lenz JF Zhang X, Adamson GN, Weinbaum S, Curry FE (2004) Oncotic pressure opposing filtration length is often greater than that of a leg, across non-fenestrated rat microvessels. J Physiol 557: 889– meaning the impact of the various radii of the 907 Aukland K, Reed R (1993) Interstitial-lymphatic mechanisms in different parts of the arm result in the the control of extracellular fluid. Physiol Rev 73: 1–78 application of often significantly different Calbet J, Holmberg H, Rosdahl H, van Hall G, Jensen-Urstad M, Saltin B (2005) Why do arms extract less oxygen than legs pressures at each circumferential point. This is during exercise? Am J Physiol Regul Integr Comp Physiol in concordance with the law of Laplace, the 289(5): 1448–58 TEMPLATE FOR PRACTICE 15

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Plast Reconstruct of tissue fluid balance. J Physiol 557: 704. Surg 121(4): 1231–9 Levick JR (2009) An Introduction to Cardiovascular Physiology. Svensson WE, Mortimer PS, Tohno E, Cosgrove DO (1994a) 5th edn. Hodder Arnold, in press Increased arterial inflow demonstrated by Doppler Macintyre L (2007) Designing pressure garments capable of ultrasound in arm swelling following breast cancer exerting specific pressures on limbs. Burns 33(5): 579–86 treatment. Eur J Cancer 30A(5): 661–4 Mann R, Yeong EK, Moore M, Colescott D, Engrav LH (1997) Svensson WE, Mortimer PS, Tohno E, Cosgrove DO (1994b) Do custom-fitted pressure garments provide adequate Colour Doppler demonstrates venous flow abnormalities in pressure. J Burn Care Rehabil 18: 247–9 breast cancer patients with chronic arm swelling. Eur J Marieb EN, Hoehn K (2007) Human Anatomy and Physiology. Cancer 30A(5): 657–60 7th edn. Pearson Benjamin Cummings, San Francisco Szuba A, Razavi M, Rockson SG (2002) Diagnosis and Martin KP, Foldi I (1996) Are haemodynamic factors important treatment of concomitant venous obstruction in patients in arm lymphoedema after treatment for breast cancer? with secondary lymphedema. J Vasc Interv Radiol 13(8): Lymphology 29(4): 155–7 799–803 Mellor RH, Stanton AW, Azarbod P, Sherman MD, Levick JR, Tanis PJ, van Rijk MC, Nieweg OE (2005) The posterior Mortimer PS (2000) Enhanced cutaneous lymphatic lymphatic network of the breast rediscovered. J Surg Oncol network in the forearms of women with postmastectomy 91: 195–8 oedema. J Vasc Res 37: 501–12 Tschakovsky M, Hughson R (2000) Venous emptying mediates Michel CC (1997) Starling: the formulation of his hypothesis of a transient vasodilation in the human forearm. Am J Physiol microvascular fluid exchange and its significance after 100 Heart Circ Physiol 279(3): 1007–14 years. Exp Physiol 82: 1–30 Weissleder H, Schuchhardt C (eds) (2008) Lymphoedema Miller GE, Seale J (1981) Lymphatic clearance during Diagnosis and Therapy. 4th edn. Viavital Verlag compressive loading. Lymphology 14: 161–6 Willoughby DA, Di Rosa M (1970) A unifying concept for Modi S, Stanton AWB, Svensson WE, et al (2007) Human inflammation. In: Immunopathology in Inflammation. lymphatic pumping measured in healthy and Excerpta Medica Int Cong Series 229: 28–38 lymphoedematous arms by lymphatic congestion Yildirim E, Soydinç P, Yildirim N, Berberoglu U, Yüksel E (2000) lymphoscintigraphy. J Physiol 583(Pt 1): 271–85 Role of increased arterial inflow in arm edema after Mosti G, Mattaliano V, Partsch H (2008) Influence of different modified radical mastectomy. J Exp Clin Cancer Res 19(4): materials in multicomponent bandages on pressure and 427–30 stiffness of the final bandage. Dermatol Surg 34(5): 631–9 Zhang X, Curry FR, Weinbaum S (2006) Mechanism of Moore K, Dailey AF (2006) Clinical Oriented Anatomy. 5th edn. osmotic flow in a periodic fiber array. Am J Physiol 290: Lippincott Williams and Wilkins H844–52 16 TEMPLATE FOR PRACTICE

Evidence for the use of upper body compression garments in patients with lymphoedema K Johansson

Garments are a widely used The importance of wearing compression bandaging, exercise and skin care. Results form of compression in the sleeves in patients with lymphoedema was showed a reduction of the lymphoedema management of upper body demonstrated by Brorson et al (1998) who from 1054 ±633ml to 647± 351ml, using lymphoedema including used custom-made compression sleeves for circumferential measurements to calculate prophylaxis, treatment and the maintenance of arm volume in patients arm volume. After the intensive treatment long-term management. who had undergone liposuction of the period, all the patients were fitted with a Wearing hosiery may lymphoedematous arm, resulting in complete compression sleeve (86% of patients with inﬂuence patients’ feelings of reduction of the oedema. One year after 20–36mmHg and 14% with 15–19mmHg). At comfort, as well as their liposuction, the compression sleeves were 12-month follow-up, 356 patients were psychosocial situation removed for one week in six patients. A mean evaluated and 89% were still wearing their (Johansson et al, 2003). increase in arm volume of 370ml (range 135– compression sleeve, 70% were performing However, there is a paucity of 775ml) was observed, measured by the water regular self-bandaging and 66% were evidence to support this displacement method, but was completely receiving MLD (1–3 times per week). The practice, but what does exist reversed when compression was re- study found that the risk of increased in the literature available to introduced. lymphoedema volume (more than 10% date is reviewed in this paper. Patients with arm lymphoedema were compared to the end of the intensive phase) Randomised controlled compared in two exercise studies by during the follow-up was more than 50% studies are scarce, but some Johansson et al (2005) and Johansson and higher for people not using a compression evidence has been found for Piller (2007). It was observed that sleeve (adjusted relative risk =1.61[95% CI: the management of lymphoedema in the untreated arm increased 1.25–1.82]; P=0.002) and low-stretch lymphoedema in the upper faster in volume than lymphoedema that was bandaging (1.55[95% CI 1.3–1.76]; limb using compression treated by a compression garment. The P<0.0001). By contrast, the risk of increased garments but there is a lack patients in the first study (n=31) were treated lymphoedema volume during the follow-up of evidence for the thorax with a compression sleeve following period was the same for patients using MLD and breast. The ﬁndings and diagnosis, and after 67 ±52 months had an and those who were not. limitations are outlined, and arm volume difference of 17 ±7%. In the All of these studies indicated that it is key points for practice second study, the patients (n=18) did not use beneficial to wear a compression sleeve in highlighted, based on the a compression sleeve. This group had a order to maintain a reduction in limb volume literature. shorter follow-up from diagnosis (54± 49 following liposuction or intensive therapy. No months), but a larger arm volume difference evidence was found to support the use of (25± 6%) compared to the group in the first compression garments in patients with trunk study. In both studies the arm volume was and breast lymphoedema. measured by water displacement method. Vignes et al (2007) found non- PROPHYLAXIS compliance to low-stretch bandages or Casley-Smith (1995) observed that compression sleeves to be a risk factor for secondary arm lymphoedema, if not treated, increased swelling in the long-term progresses faster than other types of K Johansson, Registered management of breast cancer-related lymphoedema, such as secondary leg Physiotherapist (RPT), lymphoedema. Five hundred and thirty-five lymphoedema and primary lymphoedema. Dr Medical Science, Lymphedema Unit, Department of patients were treated with complete Ramos et al (1999) showed in 69 breast Oncology, Lund University Hospital, decongestive physiotherapy, including cancer patients that successful management Lund, Sweden manual lymphatic drainage (MLD), of arm lymphoedema, with a mean reduction TEMPLATE FOR PRACTICE 17

BOX 1 Effectiveness of of oedema volume of 78%, correlated with an whether or not they took precautions, such as compression garments initial oedema volume of 250ml or less (using use of a compression sleeve (17%). It was There is a higher risk of circumferential measurements to calculate arm concluded that domestic flights were of no lymphoedema volume increasing volume). Patients with initial volumes of 250ml risk for patients with arm lymphoedema. in patients with arm or less had a mean reduction of 78% with CDT, However, temporary swelling risk correlated lymphoedema when not wearing whereas those with initial volumes between with overseas flights. compression garments. Early intervention and continual use 250 and 500ml had a mean reduction of 56%. No evidence for the prophylactic role of of the garments are also Delon et al (2008) investigated 133 women compression garments in breast and trunk important factors contributing treated for breast cancer and found that lymphoedema were found. to their efficacy. postoperative swelling after two weeks was the only factor associated with an increase in the TREATMENT incidence of arm lymphoedema. Therefore, Many studies have shown that compression early detection and treatment are essential. therapy in general is an effective treatment BOX 2 Improving treatment This was concluded by Box et al (2002) in a for lymphoedema. In the case of the upper outcomes randomised intervention study (n=65) body, all evidence relates to the treatment of The early diagnosis of arm including a programme for the treatment group arm lymphoedema following breast cancer lymphoedema in conjunction with principles for lymphoedema risk treatment. No evidence exists for the efficacy with a low initial arm volume at minimisation and early management when the of compression garments in the treatment of the start of compression condition was identified. thoracic or breast lymphoedema. intervention improves treatment outcomes. Stout Gergich et al (2008) concluded that The majority of the existing studies used compression garments effectively treat short-stretch bandages for compression, subclinical arm lymphoedema. Arm however, some also reported the sole use of lymphoedema, defined as an increase of more compression garments to be important for than 3% in upper limb volume compared with treatment efficacy. BOX 3 Risks of flying the preoperative volume measured by a The study by Swedborg (1980) observed Domestic flights do not increase perometer, was identified in 43 out of 196 an 11–13% reduction of oedema in 39 breast the risk of developing arm women who participated in a prospective cancer patients with arm lymphoedema after lymphoedema in patients treated for breast cancer, but breast cancer morbidity trial. At diagnosis of various combinations of massage and overseas flights are associated arm lymphoedema, on an average 6.9 months exercise over three treatment episodes, each with temporary swelling. after preoperative measurements, an increase lasting for four weeks, over an overall period in limb volume of 83ml (±119ml) or 6.5% of six months. Patients wore compression (±9.9%) was observed. The daily wearing of a sleeves (40mmHg) daily in the four-week compression garment (20–30mmHg) was interval between treatment periods. During promptly prescribed for an average duration of the intervals when the sleeves were worn, no 4.4 weeks. After the intervention, a volume increase of oedema volume was shown, as reduction of 46ml (±103ml) or 4.1% (±8.8%) measured by water displacement method. was observed. The women were then advised Bertelli et al (1991) reported a 17% to continue wearing the garment only when reduction of oedema, measured by the delta completing strenuous exercise or activity, method, in 37 patients who were randomised during air travel, with symptoms of heaviness, to wear a compression sleeve for six or if visible swelling appeared. The results were consecutive hours per day, for two months. maintained after an average of five months. Results from this group were compared to a In a study of flight-associated group (n=37) who received additional lymphoedema by Graham (2002), 287 treatment with electrically stimulated surveys were completed by relapse-free lymphatic drainage. The second group did not breast cancer survivors. Fifty percent of the demonstrate any further reduction in women had flown after receiving treatment oedema, showing that positive results can be for breast cancer. No difference in rate of obtained through the use of compression clinical lymphoedema was observed between sleeves alone. women who had flown and those who had In a study by Johansson et al (1998) not (11.2% versus 8.3%). Graham found that standard, ready-to-wear compression sleeves there was no difference in the frequency with (23–32mmHg) were applied to 24 patients which the patients with lymphoedema with breast cancer-related arm lymphoedema reported temporary swelling according to who had not received any other treatment. 18 TEMPLATE FOR PRACTICE

BOX 4 Wear time of The sleeves were worn for two weeks, in water displacement method. A further mean compression garments order to stabilise the arm volume before relative reduction of 18% was achieved after patients were randomised for intervention treatment with IPC over 10 days. After the Compression garments can be used to effectively treat arm with MLD or intermittent pneumatic IPC treatment the sleeve was worn for six lymphoedema in both the short compression (IPC). A significant reduction of months. During this period no significant and long term, with a volume 7 ±18% (49ml), measured by water increase in arm volume was found; thus, no reduction of up to 60% displacement method, was observed during relapse. depending on frequency and duration of wear-time. the two-week period of treatment in the In a two-month intervention study by compression sleeve group. Bertelli et al (1992), 120 patients with breast Another study of two randomised patient cancer-related arm lymphoedema were groups showed that a three-month treatment randomised into three treatment groups: regimen which included the use of a custom- ■ Compression sleeve worn only for six BOX 5 Compression and volume reduction made compression sleeve (32–40mmHg), consecutive hours per day (n=37) exercises and skin care for one group (n=22) ■ Compression sleeve worn only for six Compression garments can be reduced lymphoedema volume by 60%, consecutive hours per day with the addition used to stabilise and maintain according to circumferential measurements of IPC (n=46) reductions in arm volume up to six months after initial and calculation of arm volume (Andersen et ■ Compression sleeve worn only for six treatment of arm lymphoedema. al, 2000). However, only patients with slight consecutive hours per day with the addition or moderate (<30%) lymphoedema were of electrically-stimulated lymphatic included in this study. drainage for two months (n=37). Compression garments can also be used as The mean delta value (19.7± ±0.7cm) was a long-term treatment of arm lymphoedema. significantly reduced (16.8 ±0.8cm). Patients Brorson et al (1998) introduced a procedure wore the compression sleeve alone for a known as ‘controlled compression therapy’ further four months, and results showed that (CCT), where the garment is continuously the reduction was maintained (17.2 ±0.8). taken in, both by using a sewing machine and Other studies have investigated the effect ﬁtting custom-made compression. In their of wearing compression sleeves in study of patients who had received no combination with other activities. previous conservative treatment for In an intervention study by Szuba et al lymphoedema, 14 patients were selected for (2000), intensive decongestive lymphatic treatment with CCT. After 12 months of therapy including MLD, bandaging and treatment, the lymphoedema volume, as exercise was applied to 43 patients with arm measured by water displacement method, was lymphoedema. Results showed a mean reduced from 1680ml (range 670–3320) to reduction of excess volume of 44 ±62% after 873ml (range 340–2275ml), with a relative a mean duration of therapy of 8±3 days. At reduction of 47% (range -2–80ml). the end of the intensive therapy phase, fitting for a compression garment, most frequently LONG-TERM MANAGEMENT OF UPPER ready-to-wear, was undertaken. After a mean BODY LYMPHOEDEMA follow-up of 38± 52 days, the result was Some studies with longer follow-up periods maintained by self-massage, self-bandaging, have shown that the use of compression exercise and consistent use of compression garments for the management of upper-limb garments. lymphoedema is also effective in the long term. In one study, 249 patients with breast THE USE OF COMPRESSION GARMENTS cancer-related arm lymphoedema were DURING ARM EXERCISE provided with custom-made compression Several studies have shown that patients sleeves that were worn for periods of one undergoing treatment for breast cancer who week to six months prior to treatment with are overweight may be predisposed to intermittent pneumatic compression therapy developing arm lymphoedema (Bertelli et al, (IPC) (Swedborg, 1984). The sleeve was 1992; Segerström et al, 1992; Johansson et al, replaced if it became worn or too large or 2002). In an intervention study by Bertelli et tight. Results revealed a statistically al (1992), superior lymphoedema reduction significant mean relative reduction of 17% in (25%) was observed in those women who the volume of oedema, measured using the had a weight gain of less than 3kg following TEMPLATE FOR PRACTICE 19

treatment for breast carcinoma. It is, months compliance had declined, but not BOX 6 Compression garments and exercise therefore, important for patients with significantly, to a level above three on a lymphoedema not to be overweight, and 1–5 scale. Compression garments should physical exercise is one way to achieve this. Results from a longer follow-up period were be worn immediately after arm exercises, according to usual Boris et al (1997) treated 56 patients with presented by Boris et al (1997). These showed routine. If a patient prefers to breast cancer-related arm lymphoedema with that 56 patients with arm lymphoedema who exercise without their garment complex lymphoedema therapy (CLT), which had received CLT with an average reduction of this will not affect limb volume included skin care, MLD, bandaging and 62.6% and who were non-compliant to if it is replaced immediately post-exercise. exercise for 30 days; CLT resulted in an wearing a compression garment combined average lymphoedema reduction of 62.6%. with exercise twice daily, maintained a Upon completion of CLT, patients were fitted subsequent reduction of 43% of limb volume with compression garments for 24-hour wear, after 36 months’ follow-up. Those with 50% combined with a 15–20-minute exercise compliance had a 60% reduction, and in BOX 7 Patient compliance programme twice daily. After 36 months’ patients who were 100% compliant, Obtaining satisfactory long-term follow-up, the average reduction was lymphoedema reduction increased to 79%. results of arm lymphoedema stabilised at 63.8%. treatment is dependent upon the Using garments during physical activity DISCUSSION patient’s compliance with their and exercise has long been recommended This paper reviews the literature, available to compression garment regimen. (Földi et al, 1985; Casley-Smith and Casley- date for the use of compression garments in Smith, 1992). However, a study by Johansson patients with upper body lymphoedema. et al (2005) investigated the effect of low Considering that the included studies stretch intensive resistance exercise with and out in time for almost 30 years (1980–2009), without compression sleeves in 31 women it is surprising that more high-quality evidence with breast cancer-related arm does not exist. Furthermore, some of the key lymphoedema. Results showed an initial points for practice highlighted in this paper are significant increase of total arm volume derived from single, small scale studies measured by water displacement method, indicating that more research is needed in all but not of oedema volume in both groups, areas, including prophylaxis, treatment and immediately after performing a specifically long-term management of upper body designed programme consisting of five lymphoedema, and on a larger scale. different arm exercises. Within the 24 hours One reason for this lack of evidence may be following the exercise programme, patients associated with the difficulties in assessing wore compression sleeves according to their lymphoedema. Though some instruments are usual routine. At the 24-hour follow-up, the reliable and recommended by the International volume increase had been reversed and both Society of Lymphology (Bernas et al, 1996), groups showed a tendency towards others used need to be developed and tested. lymphoedema volume reduction. In particular, there is a lack of instruments for the measurement of breast and thoracic PATIENT COMPLIANCE lymphoedema, which impacts upon the Compliance with wearing compression sleeves clinician’s ability to robustly evaluate the once treatment has been introduced is good efficacy of treatments in this area. according to the literature. Treatment Another explanation for the lack of compliance was investigated by Bunce et al evidence may be that the definition of (1994) in a multimodal physical therapy lymphoedema, in particular at an early stage, programme which included self-management. has not yet been standardised and therefore Twenty-five women treated with mastectomy this needs to be further investigated and and with lymphoedema were included. At the discussed. end of four weeks of intensive treatment with A limitation of the findings of the studies massage, sequential pneumatic compression, presented in this paper is that the pressure compression bandaging and exercise, the delivered by compression garments is very women were fitted with a compression sleeve rarely documented. This may be due to lack and were educated about its use. Sleeve of standards, although the European wearing showed close to total compliance at Committee for Standardisation (2001) have the one-month follow-up. After six and 12 made recommendations on the range of 20 TEMPLATE FOR PRACTICE

pressure within the four different Box R, Reul H, Bullock S, Furnival C (2002) Physiotherapy after breast cancer surgery: results of a randomised compression classifications. Thus, future controlled study to minimize lymphoedema. Breast research must address issues such as the Cancer Res Treat 75(1): 51–64 Brorson H, Svensson H (1998) Liposuction combined with better monitoring of the pressures delivered controlled compression therapy reduces arm under garments. lymphedema more effectively than controlled compression therapy alone. Plast Reconstr Surg 102: Stout Gergich et al (2008) concluded that 1058–67 compression garments effectively treat Bunce IH, Mirolo BR, Hennessy JM, Ward CW, Luke CJ subclinical arm lymphoedema, even if the (1994) Post-mastectomy lymphoedema treatment and measurement. Med J Aust 161: 125–8 garments are worn only when completing Casley-Smith JR, Casley-Smith JR (1992) Modern strenuous exercise or activity, during air treatment of lymphedema. I. Complex physical therapy: the first 200 Australian limbs. Australas J Dermatol travel, with symptoms of heaviness, or if 33(2): 61–8 visible swelling appeared. The amount of time Casley-Smith JR (1995) Alterations of untreated lymphoedema and its grades over time. Lymphology 28: for which the patient with early diagnosed 174–85 lymphoedema can wear the garment without Collins CD, Mortimer PS, D’Ettorre H, A’Hern RP, Moscovic EC (1995) Computed tomography in the assessment to compromising treatment efficacy could be limb compression in unilateral lymphoedema. Clin Radiol investigated, since reducing daily wear time 50(8): 541–4 Delon M, Evans AW, Cooper S, Walls C, McGillycuddy B, may improve patient compliance. The Martlew B (2008) Early post-op swelling and its comfort and appearance of compression association with lymphoedema. J Lymphoedema 3(1): 26– 30 garments can also impact on compliance with European Committee for Standardisation (CEN/TC therapy, thus garment manufacturers may 205WG2). Medical compression hoisery. European Standard CEN/ENV 12718, 2001. consider undertaking psychosocial research Földi E, Földi M, Weissleder H (1985) Conservative and use the findings to positively influence treatment of lymphoedema of the limbs. Angiology their product development. 36(3): 171–80 Graham PH (2002) Compression prophylaxis may increase the potential for flight-associated lymphoedema after CONCLUSION breast cancer treatment. Breast 11(1): 66–71 Johansson K, Lie E, Ekdahl C, Lindfeldt J (1998) A The literature indicates that the use of randomized study comparing manual lymph drainage compression armsleeves is effective in the with sequential pneumatic compression for treatment of postoperative arm lymphedema. Lymphology 31: 56–64 management of arm lymphoedema, but the Johansson K, Ohlsson K, Albertsson M, Ingvar C, Ekdahl C reported findings need to be confirmed by (2002) Factors associated with the development of arm lymphedema following breast cancer treatment: A match larger scale studies. Research is needed into pair case-control study. Lymphology 35: 59–71 the role of compression garments in the Johansson K, Holmström H, Nilsson I, Albertsson M, Ingvar C, Ekdahl C (2003) Breast cancer patients’ experiences management of breast and thorax of lymphoedema. Scan J Caring Sci 17: 35–42 lymphoedema, but may be difficult to Johansson K, Tibe K, Weibull A, Newton R (2005) Low intensity resistance exercise for breast cancer patients undertake until appropriate measuring tools with arm lymphoedema with or without compression are developed and standardised. Finally, sleeve. Lymphology 38: 167–80 Johansson K, Piller N (2007) High intensity resistance research that results in lower wear-times and exercise for breast cancer with arm lymphedema. J garment design that responds to the patient’s Lymphoedema 2: 15–22 psychosocial needs will help to improve the Ramos SM, O’Donell LS, Knight G (1999) Edema volume, not timing, is the key to success in lymphedema outcomes and quality of life for patients with treatment. Am J Surg 178(4): 311–5 lymphoedema. Segerström K (1992) Factors that influence the incidence of brachial oedema after treatment of breast cancer. Scand J Plast Reconstr Surg Hand Surg 26: 223–7 REFERENCES Stout Gergich NL, Pfalzer LA, McGarvey C, Springer B, Andersen L, Höjris I, Erlandsen M, Andersen J (2000) Gerber LH, Soballe P (2008) Preoperative assessment Treatment of breast-cancer-related lymphedema with or enables the diagnosis and successful treatment of without manual lymph drainage. A randomized study. lymphedema. Cancer 112 (12): 2809–19 Acta Oncol 39(3): 399–405 Swedborg I (1984) Effects of treatment with elastic sleeve Bernas M, Witte M, Witte C, Belch D, Summers P (1996) and intermittent pneumatic compression in post- Limb volume measurements in lymphedema issues and mastectomy patients with lymphoedema of the arm. standards. Lymphology (Suppl) 29: 199–202 Scand J Rehabil Med 16(1): 35–41 Bertelli G, Venturini M, Forno G, Macchiavello F, Dini D Swedborg I (1980) Effectiveness of combined methods of (1991) Conservative treatment of postmastectomy physiotherapy for postmastectomy lymphedema. Scand J lymphedema: a controlled, randomized trial. Ann Oncol :2 Rehabil Med 12: 77–85 575–8 Szuba A, Cooke JP, Yousuf S; Rockson SG (2000) Bertelli G, Venturini M, Forno G, Macchiavello F, Dini D Decongestive lymphatic therapy for patients with (1992) An analysis of prognostic factors in response to cancer-related or primary lymphedema. 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Selecting compression hosiery for hand, arm and midline trunk lymphoedema D Doherty, A Williams

A wide variety of factors Compression is widely used to control A wide variety of factors must be must be taken into swelling in the upper limb and torso, considered when determining if a patient is consideration when although there is more evidence for the use suitable for compression hosiery: determining if a patient is of compression in lower limb lymphoedema ■ Patient’s lifestyle, mobility, age, suitable for the use of a than upper body swelling. A limited study of psychosocial status and personal compression garment, and interface pressures under compression choice when selecting the most highlighted the difficulties with identifying ■ Dexterity of the patient/carer: they must be appropriate product. effective pressure gradients along the length able to apply and remove the garment Compression level, of armsleeves, and discussed some of the ■ Skin condition and skin sensitivity: the skin construction type and style, clinical implications (Williams and Williams, must be intact and resilient as well as accurate 1999). Despite the widespread use of ■ Condition of underlying tissues and measurement and fit all armsleeves and other compression garments presence of fibrosis or lipoedema influence comfort, such as gloves/gauntlets and bras as first- ■ Arterial status effectiveness and patient line treatment in upper body lymphoedema, ■ Limb size, shape and distribution of swelling concordance. This paper there is a paucity of research to support this ■ Functional status of limb guides the practitioner practice; the evidence that does exist is ■ Status of underlying disease(s) such as through the processes discussed by Johansson on pp. 16–20 of this cancer, congestive cardiac failure or other involved in prescribing upper document. comorbidities body compression garments In the absence of robust evidence, clinical ■ Stage of lymphoedema and its severity for the management practice is guided by consensus and expert ■ Sensory deficit of lymphoedema. opinion, both of which have been utilised to ■ Ability to tolerate compression make the recommendations for practice that ■ The presence of concomitant medical are presented in this paper. conditions such as peripheral neuropathy. In addition, there are some contraindications for the use of compression FACTORS INFLUENCING THE USE OF (Box 1). COMPRESSION GARMENTS Although compression garments can be READY-TO-WEAR OR CUSTOM- used prophylactically or to treat early MADE GARMENTS? lymphoedema, they are mainly used for Following a full assessment by a trained long-term management. Therefore, it is healthcare practitioner, in which the patient’s important that the correct garment is suitability for a compression garment is provided for the patient since fit, style and confirmed, a decision will need to be made on material influence the appearance and the style and type of garment required (i.e. comfort of the garment, and thus patient ready-to-wear or custom-made, flat- or willingness to persevere with treatment circular-knit). D Doherty, Lymphoedema (Doherty et al, 2006). Choosing an Information obtained during assessment Framework Project Director appropriate garment involves working with can be used to select the most appropriate and Clinical Nurse Specialist the patient to explore the variety of product for the individual patient and their in Lymphoedema; A Williams, Cancer Nursing Research Fellow, compression garments available, and circumstances. Edinburgh Napier University, selecting the most appropriate product to Ready-to-wear garments have the Edinburgh, Scotland meet both clinical and lifestyle needs. advantage of being quicker to obtain and fit. 22 TEMPLATE FOR PRACTICE

BOX 1 Contraindications for They can be made of thinner fabrics which are CHOOSING THE APPROPRIATE compression hosiery more cosmetically acceptable to patients than COMPRESSION GARMENT STYLE ■ Arterial insuffi ciency thicker fl at-knit alternatives. However, circular- Garments are available in styles to ■ Venous outfl ow obstruction/ knit products may not fi t perfectly, or provide accommodate different clinical presentations acute deep vein thrombosis enough support; they are more likely to roll of swelling in the upper body. Many arm (DVT) over at the top, especially if the area covered is sleeves have a variety of features which ■ Uncontrolled congestive cardiac failure fl eshy; and can cut into skin folds and include a bias or slant cut style at the axilla, ■ Lymphorrhoea tourniquet. Ready-to-wear circular-knit hosiery shoulder attachments, silicone top bands, ■ Acute untreated cellulitis is suitable for use in patients with mild and separate and combined hand pieces ■ Acute phlebitis oedema where there is little deviation from the (gauntlets/mittens) (Figure 2). Specialist ■ Extreme shape distortion, including very deep skin normal anatomical shape. Ready-to-wear fl at- compression garments are available for folds knit garments can be used to accommodate midline swelling. minimal shape distortion or for rebound Hosiery should cover the entire area of Caution: supraventricular oedema, where circular-knit garments do not oedema to avoid swelling in the adjacent clavicle obstruction, brachial plexus neuropathy, axillary vein contain the swelling. Generally, custom-made quadrant or forcing oedema distally. thrombosis fl at-knit garments are used for patients with more severe and complicated lymphoedema, Hand and finger oedema particularly where limb shape is irregular. They Hand and finger oedema (Figure 3) can occur better accommodate abnormal shape and with or without arm swelling. It can be tissue distribution, allowing for different levels debilitating, making fine finger movement of compression at different anatomical sites difficult and highlighting the condition to within the same garment. They can also be others. The cutaneous affects of docetaxol used when special adaptations are required, chemotherapy, which is given to some such as zips or velcro to ensure exact fi t women with breast cancer, can lead to poorly (Figure 1). They are also recommended in the controlled early lymphoedema of the hand fi rst few months following a period of and fingers and fibrosclerotic/scleroderma- multilayer lymphoedema bandaging to prevent like changes in the dorsum of the hand rebound oedema. (Farrant et al, 2004). Patients may express a preference for a Ready-to-wear gloves and mittens are particular style or thickness of material, available in a variety of sizes, styles and depending on their level of activity and thicknesses, and require careful fitting (Figure garment use. These preferences should be 4). Custom-made flat-knit gloves can be considered when deciding on optimal tailored to meet specific needs, such as hand therapy, while encouraging the most or forearm swelling. Using a separate hand appropriate treatment. Options which may piece allows for removal for handwashing and be preferable include layering of garments, or preserves the integrity of the fabric. However, FIGURE 1. Compression garments varying the stiffness of the material to if separate garments are used, care must be with special adaptations. encourage greater use. taken to avoid too much pressure where the

FIGURE 2. A selection of compression garments for different clinical presentations. TEMPLATE FOR PRACTICE 23

garments overlap at the wrist (Box 2). BOX 2 Tips when selecting gloves and Patients need to understand that wearing a mittens for hand and fi nger oedema sleeve without the glove or mitten can ■ Gloves and gauntlets/mittens are used for increase hand and finger swelling, and so swelling of the hand, fi ngers and forearm. Flat- must adapt their activities and use of knit seamless gloves are now available which garments accordingly. increase freedom of movement of the fi ngers and hand and help to prevent skin damage from pressure at the seams Forearm oedema ■ Gloves and gauntlets/mittens are also required There are a number of garments for the if use of a sleeve causes hand swelling which management of forearm oedema (Box 3). A was not present before FIGURE 3. Hand and fi nger custom-made flat-knit garment may be ■ Before garment application, check for the oedema. presence of interdigital mycosis or excoriation in required to apply sufficient pressure where the web space between the thumb and fi rst fi nger rebound oedema occurs or if tissue ■ Where fi nger swelling is present, custom-made thickening is present in the forearm (Figure fi nger length garments can be adjusted to cover 5). Practitioners measuring for a custom- the area of swelling ■ Softer materials, eg. microfi ne fabric can be made garment can pull the tape tightly to used to allow greater comfort and ease of adjust the measurements at the mid- movement. In some cases there is the fl exibility forearm, and ensure adequate pressure over to cut the fi ngers of the microfi ne fabric to areas in which rebound oedema easily customise the fi t to the patient ■ Tissue thickening on the dorsum of the hand occurs. However, care should be taken to — the use of foam inserts will allow gloves avoid unnecessary tightness at the wrist or to provide additional pressure and friction to elbow. Where fibrosclerosis can occur on the soften thickened tissue lateral aspect of the forearm around the elbow or in the medial forearm, pads can be inserted under the garment in the affected area to apply local pressure and friction to For some patients, custom-made sleeves underlying tissues. that just fit the hand and forearm can also It is important to ensure that the sleeve be useful if the oedema is localised and a does not cause redness or irritation at the full-length sleeve is not indicated (Figure 7). sensitive elbow crease. An advantage of Where night time oedema control is an using a custom-made garment is the shaped issue, bandaging or a garment with lower elbow knitted into the material which can compression used overnight may be eliminate this problem (Figure 6). However, if effective. Additionally, use of an inelastic the garment is a good fit and irritation still compression device may be beneficial. FIGURE 4. Ready-to-wear gloves occurs, a silk inner layer can also be used to and mittens. protect the elbow. Upper arm oedema Swelling in the upper arm may also be accompanied by fat deposition resulting in shape distortion or floppy tissue (Figure 11). In such cases, a compression garment made

FIGURE 5. Forearm oedema. FIGURE 6. Compression sleeve showing shaped FIGURE 7. Custom-made-sleeve to ﬁ t the forearm elbow knitted into the material. and hand. 24 TEMPLATE FOR PRACTICE

BOX 3 Speciﬁc advice for swelling and of a stiffer material is often required and tissue changes limited to the forearm custom-made flat-knit garments can provide and/or hand a good fit. Where swelling occurs at the shoulder (root of the limb), manual ■ A sleeve without a hand piece can be used where no hand oedema is present (Figure 8) lymphatic drainage (MLD) may be required ■ An integrated sleeve and hand piece/mitten (Box 4). can be used with hand swelling. A number of patients need gloves or mittens with an arm Trunk and breast oedema sleeve. The gauntlet variety (i.e. attached to, and part of the sleeve) is preferable as Upper trunk or breast oedema (Figure 12 ) is it reduces the risk of a pressure band at the common after cancer treatment, specifically, overlap (Figure 9) dissection of axillary nodes in breast cancer ■ A separate hand piece and sleeve can be used or malignant melanoma. Areas of the to offer greater versatility (Figure 10). It is advisable to extend the glove 6cm past the adjacent trunk quadrant share lymph wrist to ensure greater overlap with the sleeve, drainage routes with the arm, and drain into as a narrow overlap may create a tourniquet the axillary lymph nodes. Oedema of the ■ Although rare, a custom-made gauntlet that covers the forearm can be used

FIGURE 10. Separate hand piece and sleeve, offering greater FIGURE 9. versatility. Integrated sleeve and hand piece.

FIGURE 8. Sleeve without a hand piece.

BOX 4 Speciﬁc advice for upper axilla, chest wall, breast, back or shoulder arm oedema can therefore occur, with or without ■ Where swelling includes the entire arm or just accompanying arm lymphoedema. the upper arm a full sleeve is required (Figure 8) Pathological changes underlying the ■ A straight or bias slant cut style at the axilla are development of arm lymphoedema and available (the latter sits better anatomically but choice may depend on patient preference) trunk or breast oedema may differ. ■ Arm oedema extending to the shoulder may Radiotherapy to the breast or axilla can lead require a sleeve with shoulder coverage. A to specific inflammatory changes that shoulder cap style of garment with bra or belt damage local lymphatics and cause further attachment is required. Depending on patient preference and if available, a combination of oedema, particularly in a pendulous or MLD and lymphoedema taping can also be used unsupported breast. Scars and adhesions ■ A silicone topband can be useful in ensuring within the axilla, breast or chest wall can armsleeves stay in position but should not lead to discomfort, which is exacerbated by cause undue pressure (which could exacerbate oedema) or damage the skin a poorly-fitting bra or breast prosthesis. Patients are often reluctant to wear a TEMPLATE FOR PRACTICE 25

compression bra or light compression BOX 5 Advice for those with swelling of garment, even though the area is likely to the trunk or breast oedema benefit from having adequate support and ■ Keep the area clean and moisturised (check compression. with radiotherapy department for advice on Swelling of the breast or upper trunk, emollients if appropriate) axilla and shoulder area creates particular ■ Consult doctor if the area is hot and tender and anxieties for the patient, as it is often if infection is suspected ■ Wear a well-ﬁtting bra or garment to support associated with pain, discomfort and the swollen areas and provide gentle numbness (Bosompra et al, 2002), leading compression to the tissues, where comfortable to fears of cancer recurrence. It can be ■ Get advice on exercises that will help to difficult for the patient and the practitioner decongest the area ■ Consider the use of self-massage or MLD to differentiate between oedema, seroma ■ Find out from a lymphoedema practitioner if (post-operative accumulation of fluid) and lymphoedema taping would be helpful other problems such as post-operative ■ Go back for a follow-up check with the neuropathic pain, radiotherapy reaction or lymphoedema practitioner as new or different garments may be required FIGURE 11. Upper arm oedema. cellulitis (Stevenson et al, 2005). Therefore, ■ Remember that breast and trunk swelling will careful assessment of the problem and a reduce and sometimes resolve completely, multidisciplinary approach is required. It will although this can take several months and up to be important to differentiate between a two years; the changed sensations, e.g. numbness, can remain seroma and trunk oedema, as both may exist simultaneously. However, needle aspiration of seroma, or biopsy of fibrotic areas (used to exclude the possibility of cancer recurrence) have the potential to exacerbate eventually resolve, particularly if effective local oedema. treatment and compression can be Compression garments such as specialist instigated early. FIGURE 12. Breast oedema. bras or body products can be useful for some people with lymphoedema, alongside Bra and garment fitting other treatments such as MLD and In women with trunk or breast oedema, a lymphoedema-taping. Patients need support good-fitting bra is essential. A variety are with self-care including self-massage and available through companies specialising in exercises which will help to decongest the breast and lymphoedema care. Sensitivity in affected areas, as well as the choice of a measuring and fitting a garment is required, well-fitting and supportive bra or garment. It particularly if a woman is in discomfort and is possible that techniques such as tissue is reticent to have compression over the release and mobilisation of the fascia can area. It is useful to emphasise that good help to restore healthy lymph drainage support is vital to encourage lymph drainage pathways, although this aspect of treatment from the breast. If a woman has had breast requires further research (Mondry et al, conservation surgery, her breasts may now 2002). be different sizes and shapes, and the oedematous one is likely to be heavier and Assessment often pendulous and uncomfortable. Those Assessment of trunk and breast oedema by with a bra cup size of more than C may be at a specialist practitioner is recommended. greater risk of oedema (Pezner et al, 1985), Complications such as recurrent or primary and may also benefit from wearing a softer malignancy, cellulitis requiring antibiotic garment or bra at night. therapy, and presence of an abscess in the Care is required to achieve a good fit and underlying breast tissue, for example, should symmetry, sometimes with the use of all be excluded before compression is prosthetics, or surgical reduction of the considered. Patients need well-timed and untreated breast. Those who have breast appropriate information to understand the reconstruction are also at risk of oedema underlying changes and learn what they (Parbhoo, 2006), although the surgeon can do to help reduce the oedema. In many should be consulted before MLD is used. instances, trunk and breast oedema will Some companies provide specific 26 TEMPLATE FOR PRACTICE

garments for trunk and breast oedema, oedema, or lymphorrhoea, even if the arm or mainly compression vests, or bras (Figure trunk remains relatively swollen. Those with 13) that are made of stiff (but soft) materials brachial plexus neuropathy leading to a and have wide straps. Vests can be used to dependent arm may be more comfortable provide support across the back, using long-term support bandaging but can incorporating the posterior axillary area and also be fitted with a garment, provided that the breast/chest wall. They are available they can find ways to apply the garment, from some companies in white, black and either independently or with assistance. beige and are useful in the early postoperative months. They should be MEASURING FOR HOSIERY measured for and fitted by an appropriately Measurement for compression garments trained practitioner. should take place when any intensive therapy is completed and the limb is in the FIGURE 13. Specialist bra. Inserts best possible condition.Thus, the Inserts made of materials such as foam can oedematous area should be as free from be used inside the bra to provide friction swelling as possible, pitting oedema should over fibrotic areas. They can be obtained as be minimal or absent and shape distortion ready-made sheets or can be cut and minimised (Lymphoedema Framework, assembled using hypoallergenic foam and 2006). In most patients, decongestive adhesive materials. therapy with manual lymphatic drainage (MLD) and bandaging may be required to Oedema of the upper trunk and arm achieve this. Subtle swelling, including skin in advanced disease and tissue changes in the limb and trunk Oedema can be a significant problem and should also be identified, since limb swelling difficult to control if locally invasive disease may be less well controlled if the trunk area or distant cancer metastases are present. remains congested. Skin and tissue changes This may be complicated by an open wound such as blisters, lymphorrhoea or due to a fungating tumour around the chest subcutaneous thickening may also require wall, or systemic changes leading to fluid alternative management, such as bandaging, imbalance due to hypoalbumaemia, or use of before compression garments can be used. medications such as dexamethasone. Many For patients already wearing a women with advanced breast cancer compression garment, measurement should undergo palliative chemotherapy that can be carried out: exacerbate swelling. However, the direct ■ Before garment renewal to confirm correct action of chemotherapeutic drugs in size is being prescribed reducing tumour size can lead to significant ■ If the patient is switching from ready- improvement in oedema. to-wear to custom-made garments or Fitting compression garments in those vice versa with advanced disease requires skill and an ■ If a different style of garment is required awareness of the wider issues around the ■ If adaptions to the garment are needed, or treatment and palliation of symptoms. if a different pressure is required Patients may have reduced mobility and be (Lymphoedema Framework, 2006). in pain, and thus less likely to tolerate high Accurate measurement is essential for compression levels. They may find it difficult correct garment fit and optimal patient to apply a garment and, therefore, some comfort. Badly fitting hosiery may not creativity and appreciation of individual contain the lymphoedema, cause tissue need and ability is often required from the damage, be uncomfortable and poorly practitioner. Both circular- and flat-knit tolerated, and dissuade the patient from garments, usually at low compression, can wearing hosiery long term. be used in this patient group depending on A guide to the measurement of different individual need. compression garments for use on patients Support bandaging may be useful before with upper body lymphoedema is given in using a compression garment and can be Boxes 6–11. However, it should be noted that used specifically to reduce finger and hand these are just a guide and careful attention TEMPLATE FOR PRACTICE 27

BOX 6 Measuring for ready-to-wear compression hosiery

For forearm or upper arm oedema H ■ Begin by relaxing the arm and resting it on a table, bending it slightly to create a small bend in the elbow ■ The arm should not be completely straight, or fully bent ■ Hold measuring tape around the wrist, going over the little bone (ulnar styloid process) on the outside ■ Pull tape to the point of gentle tension; there 2cm below axilla G should be no slack, but do not pull so hard that the tape creates an indentation ■ Write down this measurement Mid-upper arm F ■ Next, move the measuring tape up the arm so that it goes around the area of the forearm that is directly between the wrist and the elbow crease (mid-forearm, D) Elbow crease (slightly bent) E ■ Use the same amount of gentle tension and record the measurement ■ Take measurement at elbow crease ■ Finally, bring the measuring tape to the upper part Mid-forearm D of the arm, halfway between the elbow and the armpit (mid-upper arm, F) ■ If there is extra skin here, gather it together as

much as possible and hold the tape a bit tighter so arm sleeve for required Measurements that all the skin is encircled evenly ■ Take fi nal circumferential measurement 2 fi nger Wrist C widths (2cm) below the axilla ■ The length measurement is taken along the inside of the arm from the wrist to 2cm (2 fi nger widths) below the axilla (G) to determine whether a short, standar d or longer length garment is required. Measure from G to outside of bra strap, point H, B for shoulder cap option A ■ For an integrated hand piece without fi ngers, measure the hand at points A and B

BOX 7 Measuring for ready-to-wear mitten/gauntlet

■ Measurements to be taken with the hand relaxed, palm upwards ■ Let the fi ngers relax, and bring the measuring tape so it is just under the knuckles. Pull gently so the tape has no slack ■ Measure on hand at point A ■ Measure widest part of the hand, stay slightly A away from the web space at point B ■ Ask the patient to fl ex the hand upwards at the wrist and mark this point. Measure at this wrist B fl exure point C ■ Record the measurement

should be paid to the manufacturer’s RECOMMENDATIONS FOR COMPRESSION measuring instructions and measuring GARMENTS IN UPPER LIMB LYMPHOEDEMA should be performed by a qualified The optimal therapeutic pressures and practitioner. stiffness of materials for compression in 28 TEMPLATE FOR PRACTICE

BOX 8 Measuring for ready-to-wear glove

■ Measurements to be taken with the hand relaxed, 3 palm upwards 4 ■ Let the fi ngers relax, and bring the measuring tape 2 so it is just under the knuckles. Pull gently so the 5 tape has no slack ■ Measure on hand at point A ■ Measure widest part of the hand, stay slightly C1 A away from the web space at point B 1 A-B ■ Ask the patient to fl ex the hand upwards at the wrist and mark this point. Measure at this wrist B fl exure point C A-C ■ Record the measurement ■ Take measurement at C1, approximately 3cm proximal to C C ■ For hand length take measurements from A– B, A– A-C1 C, A–C1 to determine size of hand piece ■ Take circumferential measurements of the fi ngers and thumb at the tip and base

BOX 9 Measuring for custom-made armsleeves

For forearm or upper arm oedema ■ Begin by relaxing the arm and resting it on a table, H bending it slightly to create a small bend in the elbow ■ The arm should not be completely straight, or fully bent ■ To ﬁ nd C, ask the patient to ﬂ ex the wrist. Use the level of the second crease from the hand to measure circumference C. C1 is about 5–7cm proximal to C G-G1 ■ Pull tape to the point of gentle tension; there should G be no slack, but do not pull so hard that the tape creates an indentation ■ Write down this measurement ■ Next, move the measuring tape up the arm so that it Mid-upper arm F goes around the area of the forearm that is directly C-G between the wrist and the elbow crease (D, mid- forearm). Measure circumference at D pulling the tape to the point that there is tension against the resistant Elbow crease C-F oedema (slightly bent) E ■ Measure circumference E at the elbow crease with the elbow slightly bent, without any tension applied C-E to the tape. Measure again 1–2cm proximal to E. If Mid-forearm D this circumference is larger than the E measurement, record this as E ■ Bring the measuring tape to the mid-upper part of

the arm (F), halfway between the elbow and the arm sleeve for required Measurements armpit. If there is extra skin here, gather it together C-D as much as possible and hold the tape a bit tighter C1 so that all the skin is encircled evenly. Measure the C circumference at F pulling the tape to the point that C there is gentle tension against the resistant oedema ■ Measure G 2cm below the axilla. When measuring circumference G do not apply any tension to the tape ■ Measure length G–G1 for bias top ■ Measure length from G to outside of the bra strap (H) for shoulder attachment. Also measure width of the bra strap for bra attachment ■ The length measurement is taken along the inside of the arm following the entire contour of the arm TEMPLATE FOR PRACTICE 29

BOX 10 Measuring for custom-made glove/gauntlet

■ Measurements to be taken with the hand relaxed, 3 palm downwards, pressing gently on the table 4 ■ 2 Let the fi ngers relax, and bring the measuring tape Z so it is just under the knuckles. Pull gently so the 5 tape has very little slack. Avoid any constriction X-Z ■ Measure on hand at point A, applying gentle tension to the tape A X ■ Measure widest part of the hand, stay slightly 1 A-B away from the web space at point B Z ■ Ask the patient to fl ex the hand upwards at the B X-Z wrist and mark this point. Measure at the wrist A-C fl exure point C, pulling the tape gently to make X skin contact ■ Record the measurement C ■ A-C1 Take measurement at C1, approximately 5–7cm C1 proximal to C ■ For hand length, take measurements with hand D relaxed, palm upwards from A–B, A-E E A–C, A–C1 to determine size of hand piece ■ Take circumferential measurements of the fi ngers ■ Take a circumferential measurement at the and thumb at the tip and base point on the forearm where the glove should ■ Measure the length of the fi ngers and thumb from fi nish web space. This can be a short or long length as ■ Take a length measurement from point A to required. For fi nger length, use the fl exi card and point D and/or E (contoured measure) read the shorter side for the fi nger length

lymphoedema of the upper limb have not of this document. Patients with lymphoedema been precisely defined. Usually arm sleeves, may report a wide variety of complaints such compression gloves and truncal garments as heaviness or fullness related to the weight correspond to mild to moderate compression of the limb, a tight sensation of the skin, or levels, which are lower than those for the decreased fl exibility of the affected joint. With equivalent leg garments. This is mainly due to upper extremity involvement, there may be lower blood pressure and gravity force in the diffi culty fi tting the affected area into clothing arms and hands plus other anatomical and or wearing previously well-fi tting rings, physiological differences. Moderate watches, or bracelets. Low compression is compression levels are usually effective and frequently used as part of a preventative better tolerated in the torso (Lymphoedema programme for those at risk of secondary Framework, 2006). lymphoedema following treatment for cancer. The following recommendations aim to It can help to ameliorate some of the give clear guidance based on what is subjective symptoms associated with considered to be the effective level of lymphoedema in the absence of any compression for hosiery in primary and discernable swelling. secondary lymphoedema in the upper limb. Garments should be worn when doing repetitive activities that can contribute to Subjective/subclinical lymphoedema swelling or exacerbate symptoms. It is also (low 14–18 mmHg) recommended that they are worn during long- The prophylactic use of compression garments haul fl ights. A study by Graham (2002) found is increasingly being recommended for use with that there was a risk of temporary swelling with patients who are at risk of developing upper overseas fl ights. Patients may choose to wear extremity lymphoedema (Lymphoedema the garment during the daytime, for several Framework, 2006). hours or only during high-risk activities. The true potential for using compression to prevent progression and complications in Early/mild lymphoedema (low 15–21 mmHg, subclinical lymphoedema has not been fully RAL, 2008) examined; what is known is discussed on p. 17 Mild lymphoedema is characterised by pitting 30 TEMPLATE FOR PRACTICE

BOX 11 General points regarding bra ﬁ tting

■ Should be done by an appropriately trained fi tter ■ Straps and side/back sections should be suffi ciently wide to provide an even pressure over the tissues without cutting into or causing creases in the skin, particularly in an oedematous area or at the axilla Bra size ■ The centre front of the bra should lie fl at against the chest wall; if not, this may indicate an incorrectly-sized cup 8cm ■ The size of the cup must be big enough to lift and encase the whole breast, and not allow breast tissue to bulge out at the top or under the armpit as this can lead to bands of fi brosis in the breast tissue. Some versions with a wider band below the breast are preferable for larger breasted women ■ Sports bras can be useful as the cup material is generally stiffer, allowing minimal bounce of the deposits and subcutaneous skin changes may breast tissue and reduced movement to the side also be present. when moving and exercising ■ In some women, a softer bra should be worn at night to provide support, particularly in the Complex lymphoedema early stages (high 34–46 mmHg, RAL, 2008) The oedema is predominantly non-pitting, with excess adipose tissue, skin thickening, which can subside, or occurs when the excess involvement of three joints, with worsening limb volume is <10–20% compared to the oedema and skin infections (ISL, 2003). unaffected limb (International Society of Deepened skin folds may also be present. It Lymphology [ISL], 2003). is rare for high pressures to be used on the Individuals who develop a dependent arm upper limbs and should only be prescribed following a cerebrovascular accident or in by a specialist practitioner. conditions such as motor neurone disease (MND) can benefi t from wearing garments FITTING AND EVALUATION with low levels of compression. There are a variety of garments on the Low levels of compression can also be used market offering a great deal of choice. in patients with fragile skin and low levels of compression tolerance. This level of BOX 12 Tips for checking fi t compression is recommended for On fi rst application, check that the: lymphoedema of the extremities where gloves ■ Ordered garment meets the specifi cation and mittens are used. It also facilitates layering of the prescription of garments which may be suitable for patients ■ Garment fully covers the area requiring treatment who may be unable to apply a single higher ■ Material of the garment is evenly distributed compression garment (Lymphoedema with no folds, wrinkles or tight bands Framework, 2006). Additionally, lower ■ Garment is comfortable and is not too tight compression garments can be used in the or loose ■ Attachments or fi xations are comfortable and presence of some neurological defi cit and, keep the garment in place where lipoedema exists, to improve quality of life and palliate symptoms. Additionally at follow-up: ■ Assess patient motivation and use of the garment Moderate/severe lymphoedema ■ Check that the garment: (medium 23–32 mmHg, RAL, 2008) ~ stays in place and that there is no slippage This is predominantly non-pitting oedema requiring a need for or a change in fi xation characterised by tissue thickening with an ~ does not cause skin reactions or localised skin trauma excess limb volume of 20–40%, or >40% in ~ is not folded back at the top, and has not severe lymphoedema (Lymphoedema been cut or reshaped Framework, 2006). Deepened skin folds, fatty TEMPLATE FOR PRACTICE 31

Practitioners should be both aware of and should also be taken to avoid turning back an have access to what is available to meet the integral hand piece as this will increase needs of their patients. pressure in the area and make swelling worse. An appropriately trained practitioner Garments should be applied first thing in should check the fit of the garments and the morning when swelling is at a minimum. demonstrate and check application and Fitting the garment soon after bathing or removal. Patients should be reviewed within moisturising should be avoided as this can several days and then two to three weeks make application more difficult. Excessive use after initial fitting with a newly-prescribed of a skin moisturiser will affect the longevity garment. Follow-up should occur three to six of the garment and is best applied at night months thereafter if the garments fit well and when there is time for it to be absorbed the response to compression is satisfactory. before reapplication of the garment next day. More experienced patients may require Ideally, hosiery should be worn for as much of review on a yearly basis. These patients may the day as possible, and should always be be discharged from the lymphoedema service worn during exercise. Two garments are and have their garments prescribed by usually given, one to wash and one to wear their GP. (Box 13). Where skin allergies are an issue, During reassessment practitioners should cotton rich garments are helpful. evaluate the patient/carer’s ability to apply Several aids are available for easier good self-care strategies and incorporate the application and removal of compression patient’s perspective of their progress. It is hosiery (Box 14). They require a fair degree of also important to check with the patient how dexterity and the use of particular techniques often they are wearing the garment, if the which need to be demonstrated and checked style suits their lifestyle, and what their by the practitioner to ensure correct use. perspective is on the garment’s effectiveness. Hosiery can also be specially adapted. This gives the practitioner the opportunity to Garments can be made with zips and velcro ascertain if any additional help and support fastenings to make application and removal is needed. easier (Figure 1). Particular attention should be paid to the presence of pain, skin discolouration or any GARMENT RENEWAL sudden increase in swelling. Practitioners Initially, only one compression garment is should be alerted to the possibility of ordered. This is to ensure that it fits properly infection, thrombosis or ischaemic disease. If and controls the swelling. Once this has been BOX 13 Day-to-day care of lymphoedema is massive/chronic and established and a good fit has been obtained, compression hosiery resistant to treatment, or starts several years a second garment can be ordered. The need after primary surgery without obvious for replacement garments will vary depending ■ Garments should be washed daily, according to the trauma, underlying causes should be on frequency of use, how well the garment is manufacturer’s instructions, investigated. It is particularly important to cared for and the level of activity. Generally, to regain their elasticity exclude the recurrence of tumour or the garments should be replaced every six ■ Garments should dry months or when they start to lose elasticity. naturally, rather than on a development of lymphangiosarcoma. Referral radiator or in a tumble drier for specialist assessment is required for An increase or decrease of five or more ■ Never exceed a wear-time appropriate diagnosis. pounds (2.7 kilograms or more) can also alter of 2–3 days without proper Generally, hosiery should be comfortable the fit of the garment. cleaning and well ﬁtting (Box 11). It should not roll or ■ Do not cut any loose threads or snares, as this may cause mark the skin, or cause pain or numbness. On BODY IMAGE AND holes or runs in the garment application, the material should be evenly COMPRESSION GARMENTS distributed and not wrinkled, as this can Studies have shown that lymphoedema of the damage the skin. Rubber gloves, providing arm can have physical, psychological and BOX 14 Application aids there is no sensitivity to rubber, can be used to social effects on the individual (Johansson et help to grip the material to allow readjustment al, 2003). Furthermore, the difficulties that ■ Ribbed rubber gloves and avoid overstretching. Overstretching can people experience when wearing ■ Glide applicators ■ Applicators to aid removal result in excess material which patients may compression sleeves, e.g. the problems with ■ Metal applicators fold at the wrist or axilla. It can also be a clothing and the stigmatising effect of reason for slippage in ﬂat-knit garments. Care wearing a sleeve or gloves, have been 32 TEMPLATE FOR PRACTICE

highlighted (Sneddon et al, 2008). It is BOX 15 Information for patients therefore important that practitioners explore practical and body image issues with To use garments effectively, patients need to know: ■ How compression hosiery works to individuals who are fitted with compression control lymphoedema garments since they have the potential to ■ How to care for their skin — to apply an considerably influence outcome by enhancing emollient at night; to use a cotton liner to concordance and maximising quality of life protect the garment if emollient is applied just before donning, the skin is at risk of trauma or (Lymphoedema Framework, 2006). there is dermatitis ■ When to wear hosiery and the importance of CONCLUSION wearing hosiery each day, including during The main aims of lymphoedema exercise* ■ In very hot weather the patient can shower the management are controlling limb swelling garment, as the evaporation of the water cools and minimising complications. Historically, the arm the incidence of lymphoedema has been ■ How and when to apply the garment, in underestimated and understudied. The particular, to remove all wrinkles, to avoid overstretching the garment by pulling too far number of people who may be affected by up the limb, not to fold the garment down at the upper body lymphoedema is likely to top, to apply the garment in the morning when increase as a result of an ageing population the limb is least swollen and an increasing number of cancer ■ To wash the garment frequently following the manufacturer’s instructions and to dry it away survivors who are at risk of lymphoedema. from direct heat Additionally, the problem of primary ■ Who to contact if the skin appears chafed, cut lymphoedema and non-cancer-related or discoloured, or if pain, pins and needles or causes should not be overlooked. peripheral swelling develop ■ How to monitor swelling and who to inform if Lymphoedema is a condition that cannot there is deterioration be cured: the goal is to educate and support patients in its long-term management (Box *During swimming patients may choose to wear an old 15). Compression garments are used once the garment. Current garment should not be used because chlorine will damage the ﬁbres swelling has reduced and been stabilised. Garments should be comfortable while providing pressure to prevent reaccumulation of swelling in the affected area. There is increasing recognition of the need to provide of lymphoedema. Scand J Caring Sci 17(1): 35–42 a range of garments to meet the varied and Lymphoedema Framework (2006) Best Practice for the changing needs of this patient group. Management of Lymphoedema. International consensus document. London: MEP Ltd Practitioners need to be aware of the Mondry TE, Johnstone PAS (2002) Manual lymphatic available options and be adequately trained drainage fo lymphedema limited to the breast. J Surg to make appropriate choices, together with Oncol 81: 101–4 Morgan PA, Franks PJ, Moffatt CJ (2005) Health-related patients, for the management of quality of life with lymphoedema: a review of the lymphoedema of the upper body. literature. Int Wound J 2(1): 47–62 Michelini S, Campisi C, Failla A, Boccardo F, Moneta G (2006) Staging of lymphedema: comparing different REFERENCES AND FURTHER READING proposals. Eur J Lymphol 16(46): 7–10 Bosompra K, Ashikaga T, O’Brien PJ, Nelson L, Skelly J Parbhoo S (2006) Lymphoedema in young patients with (2002) Swelling, numbness, pain, and their relationship breast cancer. Breast 15(52): 561–4 to arm function among breast cancer survivors: a Pezner RD, Patterson MP, Hill LR, Desai KR, Vora N, Lipsett disablement process model perspective. Breast J 8(6): JA (1985) Breast edema in patients treated 338–48 conservatively for stage 1 and 11 breast cancer. Int J Doherty DC, Morgan PA, Moffatt CJ (2006) Role of hosiery Radiat Oncol Biol Phys 11(10): 1765–8 in lower limb lymphoedema. In: Template for Practice: RAL Deutsches Institut für Gütesicherung und Compression Hosiery in Lymphoedema. MEP Ltd, London Kennzeichnung e. V (2008) Medical Compression Farrant PBJ, Mortimer PS, Gore M (2004) Scleroderma and Armsleeves. Quality Assurance RAL-GZ 387/2. Beuth- the taxanes: is there really a link? Clin Exp Dermatol 29: Verlag GmbH, Berlin 360–2 Sneddon M, Pearson J, Franks P (2008) Lymphoedema: Graham PH (2002) Compression prophylaxis may increase Service Provision and Needs in Scotland. University of the potential for flight-associated lymphoedema after Glasgow and Macmillan Cancer Support. breast cancer treatment. Breast 11(1): 66–71 Stevenson O, Bedlow A, Harries S, Carr R, Charles-Holmes International Society of Lymphology (2003) The diagnosis R (2005) Delayed breast cellulitis; a bacterial infection and treatment of peripheral lymphedema. Consensus or a skin response to lymphoedema? Br J Dermatol 153 document of the International Society of Lymphology. Suppl 1: 48–9 Lymphology 36(2): 84–91 Williams AF, Williams AE (1999) ‘Putting the pressure on’: Johansson K, Holmstrom H, Nilsson I, Ingvar C, Albertsson a study of compression sleeves used in breast cancer- M, Ekdahl C (2003) Breast cancer patients’ experiences related lymphoedema. J Tissue Viability 9(3): 89–94

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