Palliative Care Competence Framework for Physiotherapists: Difference between revisions

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<div class="noeditbox">Welcome to [[Contemporary and Emerging Issues in Physiotherapy Practice|Queen Margaret University's Current and Emerging Roles in Physiotherapy Practice project]]. This space was created by and for the students at Queen Margaret University in Edinburgh, UK. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div><div class="editorbox">
<div class="editorbox"> '''Original Editor '''- [[User:User Name|Jane Hislop]] '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>
'''Original Editor '''- Your name will be added here if you created the original content for this page.  
==Introduction==
The Palliative Care Competence Framework for Physiotherapists was designed to standardise education for undergraduates and postgraduates in Europe. It provides a guide for the acquirement of knowledge, skills and attributes needed for clinical practice in health and social care professions. This document provides flexibility and autonomy in order to develop core and discipline specific competencies which can be applied to both generalist and specialist palliative care.&nbsp;<ref name="Competence Framework">Palliative Care Competence Framework Steering Group. Palliative Care Competence Framework. http://www.hse.ie/eng/about/Who/clinical/natclinprog/palliativecareprogramme/Resources/competencyframework.pdf (accessed 20 Nov 2015).</ref>


'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}&nbsp;&nbsp;
== Core Competencies ==
When caring for people with life-limiting conditions who may have complex care needs, a multidisciplinary approach is preferred.  The core competencies outlined in the guide are common to all health professionals and convey the primary level of understanding that is essential to provide palliative care.


<br>
'''There are 6 domains of competency:'''
</div>
# Principles of palliative care
== Introduction and Learning Outcomes ==
# Communication
# Optimising comfort and quality of life
# Care planning and collaborative practice
# Loss, grief and bereavement
# Professional and ethical practice in the context of palliative care
Each domain is defined with a statement which remains the same regardless of the setting where care is provided. Each domain has an indicator that outlines the competences required by professionals depending on the context of their roles and the level that palliative care is provided. The indicators are based on advanced knowledge, skills and understanding and clinical expertise. The indicators are named “ALL”, “SOME” and “FEW” and&nbsp;are outlined below -


Welcome to this online learning resource focussing on “The role of the Physiotherapist in Palliative Care for people with Lymphoedema”. This has been designed by a group of fourth year Physiotherapy students from Queen Margaret University as part of the “Contemporary and Emerging Issues in Physiotherapy” module.<br><u></u>
[[Image:Competence.jpg|center]]


This learning resource is for indivudal study, aimed at final year Physiotherapy students and new graduates to prepare them for work in the health service. From our own experience and discussing with expert clinicians, the role of a physiotherapist in lymphoedema and palliative care is rarely covered throughout univerisity. Furthermore, only a select few students will gain palliative care experience during their placements. Hence this learning resource is designed to provide students with essential information that they can use throughout their final year and beyond.&nbsp;
== Principles of Palliative Care ==
The aim of palliative care is to improve the quality of life of people who are suffering with life-limiting conditions. This care does not only include the physical facet of their condition but the social, psychological and spiritual aspects also. Palliative care is applicable for people of all ages and may be introduced at any point in a disease trajectory.[[Image:Competence 1.png|center|500x400px]]


<br>
== Communication ==
Communication is an essential component to the delivery of palliative care. When caring for people with complex and life-threatening conditions, good communication is important particularly when bad news needs to be relayed or when difficult decisions regarding treatment need to be made. Communication is imperative when circumstances are uncertain or when distress and strong emotions arise.


Overall the resource should take 10 hours to complete. The learning resource will cover a range of topics including:&nbsp;
Communication is a method of:
*Enabling therapeutic relationships with patients and families
*Ensuring that the patient and family are key components in decision making regarding care
*Enabling effective inter-professional or inter-agency teamwork
[[Image:Competence 2.png|center|500x300px]]


*Overview of palliative care (1.5 hours)
== Optimising Comfort and Quality of Life ==
*Overview of lymphoedema (1.5 hours)
People receiving palliative care are not only affected by the physical symptoms of their condition but also the psychological, spiritual and social aspects. Optimising quality of life for people is a dynamic process that involves acknowledging, anticipating, continuously assessing and responding to a range of complex symptoms and needs. The process must be done in a proactive manner to relieve suffering.[[Image:Competence 3.png|center|550x350px]]
*Lymphoedema - treatment and management (3.5 hours)
*Physiotherapist's role (2.5 hours)
*Physiotherapy competencies (1 hour)


<br>
== Care Planning and Collaborative Practice ==
In palliative care, care planning involves co-ordinating and integrating person-centred care to promote quality of life. Patients and their families should engage in the process and concerns from families or carers should be considered.


Throughout the resource there will be a variety of learning activities, including reflections, quizes, additional reading and videos.&nbsp;
Planning involves:
*Assessing need
*Promoting and preserving a person’s choice
*Predicting likely problems
*Planning for the future in the wake of a changing or deteriorating disease trajectory.
Care planning should ensure that multi- disciplines and agencies can be referred to as required.[[Image:Comp 4.png|center|550x350px]]


<br> [[Image:Intro sections.png|center|250]]  
== Loss, Grief and Bereavement ==
Dealing with loss, grief and bereavement is an intrinsic part of palliative care. A minority of people may be at risk of developing difficulties during their grieving. Professionals using a palliative care approach have an essential role to play for all but in particular for those who may require bereavement therapy or counselling by providing support and information.[[Image:Competence 5.png|center|600x300px]]


<u>'''Aims'''</u><br>
== Professional and Ethical Practice in the Context of Palliative Care ==
There may be a time when specific treatments or interventions are futile or burdensome. Deference in palliative care refers to the importance of respecting the patient’s wishes, needs and values when dealing with a life-limiting condition. Professional and ethical practice concerns the best way to provide continuing care as people’s care needs change during the course of their condition. It guides professionals to reflect on their contribution to a person’s care and the contribution of other professionals. [[Image:Competence 6.png|center|550x200px]]


The aim of this wiki is to present a learning resource for final year physiotherapy students and new graduates to develop their knowledge and understanding of:<br>  
== Guidelines ==
While the principles of palliative care have remained relatively the same over the past number of years, the evidence base surrounding interventions and how care should be delivered is constantly evolving.&nbsp; The NICE guidelines - End of Life Care for Adults is one of the most recent guidelines available<ref name="NICE guideline">[https://www.nice.org.uk/guidance/NG142 End of life care for adults]: service delivery NICE guideline [NG142]Published: 16 October 2019 Available:https://www.nice.org.uk/guidance/NG142 (accessed 13.12.2023)</ref>. NICE guidelines are classed as high quality evidence and is an excellent resource for not only newly qualified professionals but for anyone working in the field of palliative care. &nbsp;


#The role of a physiotherapist in the management of people with lymphoedema<br>  
==References==
#The implications for physiotherapy practice when managing people with lymphoedema in a palliative care setting
<references />


'''<u></u>'''
[[Category:Current and Emerging Roles in Physiotherapy Practice]]
[[Category:Palliative Care]]
[[Category:Queen Margaret University Project]]


'''<u></u>'''
[[Category:Older People/Geriatrics]]
 
[[Category:Clinical Guidelines]]
'''<u>Learning Outcomes</u>'''<br>
[[Category:Older People/Geriatrics - Guidelines‏‎ ]]
 
[[Category:Quality of Life]]
'''<u></u>'''Learning outcomes are set in relation to Blooms Taxonomy (ref)- as this learning resource is designed for final year students and new graduates, the outcomes are mostly set appropriately at higher levels of the taxonomy.&nbsp;
 
<br>
 
[[Image:Blooms taxonomy 2.png|center|250]]<br>
 
<u>By the end of this wiki you should be able to:</u><br>
 
[[Image:Learning Outcomes.png|center]]<br>
 
'''Activity:''' see the bow below for the first activity of this learning resource.&nbsp;
 
[[Image:Intro_reflection.png]]
 
Once you have completed this reflection - do not worry if you do not know much about the topic, that's what this resource is for - progress onto the next section where the history and service delivery of palliative care will be discussed.&nbsp;
 
 
 
<br>
 
== Overview of Palliative Care  ==
 
=== Definition and history<br>  ===
 
When you hear the term palliative care, what does it mean to you? Take a moment to think about this and take note of your answer.
 
<br>'''Definition:'''<br>The WHO defines palliative care as “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual” (WHO 2015). <br>A more general description may define palliative care as any care that helps to alleviate symptoms whether or not there is hope for a cure.<br>
 
<br>
 
'''Aims of palliative care:'''
 
*To maintain quality of life until death
*Provide relief from pain or other symptoms which may cause distress
*Help patients to live as actively as possible
*Help family members to cope during a patient’s illness and during their own bereavement
*Integrate spiritual and psychological aspects into a patient’s care
*Be applied early and in conjunction with other therapies (NHS 2004)
 
<br>
 
'''History:'''<br>Hospices in the UK and Ireland have been around since the 1900s, however, they were few in number and run by religious foundations to provide care to the poor.
 
<br>During the 1950s, there was considerable professional and public interest in cancer but the main focus was on curative treatment. Patients who were considered terminal and were dying from cancer were overlooked and were told to go home as there was nothing that could be done or were scattered in various hospital wards, abandoned by doctors.
 
<br>In the postwar years, a shift began to emerge in the published work with new studies showing both the clinical and social aspects of care for patients who were dying from cancer. This work in oncology helped to shape the worldwide development of palliative care (Clark 2007).<br>Cicely Saunders may be recognized as the founder of the palliative care movement around the 1970’s. <br>Having trained as a nurse and then a social worker, in 1959, Saunders qualified in medicine and began working in St. Thomas’s Hospital in London (Baines 2011).
 
<br>In 1960, Saunders focused her attention on patients who were in the final stages of cancer, especially those patients with complex problems from the point of view of pain and general distress. Her research and writings were built on the individual experiences of her patients and by 1967 she had collected data for 1100 cases, where she described the physical and mental suffering of each patient (Clark 2007). Saunders inspired the concept of total pain which includes physical, emotional, social, mental and spiritual components and believed in constant pain management to relieve suffering.
 
<br>In 1967, Cicely Saunders opened St. Christopher’s Hospice in London which was the world’s first modern hospice. Here, she brought together large numbers of patients with terminal illness and staff to take care of them (Baines 2011). The hospice quickly became an inspiration and established itself as a centre of excellence, giving equal importance to clinical care, education and research. Research was done on pain control and the administration of strong opiates. These clinical and organizational studies would go on to play a major role in the advancement on palliative care (Clark 2007).
 
<br>The success of St. Christopher’s Hospice soon became a catalyst for the development of hospices in the UK. During the 1980s, about 10 new hospices were opened a year, some were funded by the NHS and others were privately or charity funded. <br>There was also a development among hospitals and in 1976 a terminal care team was established in St. Thomas’s Hospital, London. Between 1982 and 1996 the number of hospitals with a multidisciplinary palliative care team or a specialist nurse more than quadrupled to 275 from 5.
 
<br>During this time, two well known UK charities also assisted in influencing change. The first of these charities was the Macmillan organization which was founded in 1911. During the 1970s the organisation went through a period of phenomenal expansion. The organisation became more involved in palliative care and supporting specialist professional posts, academic positions and service development. <br>The second charity is the Marie Curie Memorial Foundation, established in 1948. This foundation was involved in creating a domiciliary nursing service for patients with cancer. It created nursing homes and ran a laboratory-based research programme. During the 1980s when new hospices were opening across the UK, the Marie Curie nursing homes evolved into specialist palliative care centres and the charity supported more research and educational activities in palliative care (Clark 2007). <br>By the 1990s there were over 1000 specialist Macmillan nurses and 5000 Marie Curie nurses working across the UK in palliative care. <br>By 1987, palliative medicine was established as a subspecialty of general medicine and in 1995 the specialty of palliative care was formally approved (Clark 2007).
 
=== Causes of death  ===
 
When looking at who needs palliative care and who should provide it, we need to look at epidemiology and the causes of death across the world. Epidemiology is important when planning health services as it can provide information about disease and symptom occurrence to guide healthcare needs. Life expectancies vary worldwide. Variations are associated with certain demographic characteristics such as political, occupational, cultural and lifestyle risks while also including gender, ethnicity and genetics. Low-income countries may have lower life expectancy then developed countries. In 2012, life expectancy was estimated globally at 66yrs for men and 71yrs for women. However, in more developed countries, life expectancy is estimated at 76.9years for both sexes and 58.4years in the least developed countries.<br>
 
 
 
[[Image:2012.jpg|center|650px|]]
 
 
 
This is only a broad reflection of the figures as reported causes vary among countries at different levels of economic development. <br>Future projections – mortality projections may aid the planning of health services and the knowledge and skills clinicians will require in order to meet the needs of future populations<br>
 
<h3> Service delivery  </h3>
<p>Since the inception of the modern hospice and palliative care movement led by Cicely Saunders, palliative care has continued to evolve, has developed into a medical specialty and is now integrated into mainstream medicine in many countries. Palliative care was originally seen as something only concerned with the end of life but has now been incorporated with other services offered throughout the entire disease trajectory.<br />
</p><p><br />
</p><p>Palliative care is now a more seamless process through the disease trajectory, either from the point of diagnosis or at any point in the disease compared to the original concept where care was offered once curative treatment had failed and patients were seen at an end of life stage.&nbsp;<br />
</p><p>Due to the aging population in developed countries, the burden of disease on healthcare will continue to increase, challenging the knowledge and skills of professionals. With the advances in treatments for cancer and other conditions, patients are living with more co-morbidities and palliative care services must be prepared to provide care over longer periods of time throughout the disease trajectory.<br />
</p>
 
=== Where care is provided?  ===
 
Palliative care takes place in many different settings.<br>
 
Can you think of any settings where palliative may take place?<br>
 
Hospices possibly being the most known setting. Hospices can be a ward or unit within a hospital or can be a stand-alone service. Hospices in the UK are generally stand-alone services with the aim of alleviating disease or therapy-related discomfort and stabilising the status of patient by offering psychological and social support. Cicely Saunders once said that hospices should be a welcoming environment and have a sense cheerfulness and peace. <br>
 
[[Image:care settings.jpg|centre|650px|]]
 
Hospital palliative support teams – provide advice to patients, their family, carers and other clinical staff. The teams provide education and liaise with other services both in and out of hospital. An aim of the team is to alleviate multiple symptoms patients may have by sometime prescribing directly or will advise on the management of symptoms. <br>
 
Home care teams – provide specialist direct care to patients in their home where they support families and carers. The team may provide specialist advice to GPs, nurses or other clinicians involved in the patient’s case. There is good evidence to show the benefits of home specialist palliative care compared with usual care. <br>
 
Outpatient services – this service is available for patients who live at home but are able to attend clinics. These services may be offered from a hospital or inpatient palliative care unit. This service can help to introduce patients to the palliative care process earlier where advanced care planning can be put in place. There is little to no evidence on the effect of these services. <br>
 
Day care centres – these are spaces in hospitals, hospices or the community which are specially designed to provide additional support to patients and their families. Usually patients who attend a day centre are already in the care of a home palliative care team. The nature of the service offered may vary depending on the patient’s needs, from medical/health orientated to more recreational or social services where complementary therapies may also be offered<br>
 
=== Who provides care?  ===
 
Palliative care uses a team approach to affirm life and help support patients to live as actively as possible until death by enhancing their quality of life. Care should be offered as patient needs develop and should be an integral part of care in any setting (WHO 2004). Care is focused on controlling pain and other symptoms based not on disease prognosis but on the needs of the patient and must be flexible to adapt to these needs (WHO 2004). <br>
 
Professionals involved – multidisciplinary teams are the key to all palliative care services. Specialist palliative nurses or physicians are usually part of all services but other professionals may be involved depending on the service. Social workers, physiotherapists, occupational therapists, psychologists, pharmacists and religious officials may be part of a patient’s care.<br>
 
[[Image:MDT.jpg|center|600px]]
 
== Overview of Lymphoedema  ==
 
=== Introduction  ===
 
This section of the wiki will aim to provide an overview of:<br>
 
*The pathophysiology of lymphoedema
*The two types of lymphoedema - primary and secondary
*The four stages of the condition
*Clinical features (physical and psychological) those with the condition may present
*Two of the main leading causes related to lymphoedema - cancer and infection
*Epidemiology regarding the condition
 
=== Epidemiology  ===
 
Epidemiology focuses on why diseases or conditions develop in different societies and how common the occurnace is. The prevalance is the volume of people who are 'at risk' of having the condition at the same time. The incidence is the portion of new people that have acquired the condition over a specific period of time<ref name="Franks et al. 2006">Franks P, Williams A, Moffatt C. A review of the epidemiology of BCRL. J Lymphoedema. 2006;1:66-70. http://www.journaloflymphoedema.com/journal-content/view/a-review-of-the-epidemiology-of-bcrl (accessed 24 January 2016)</ref>.
 
The epidemiology regarding lymphoedema isn't widely reported because it isn't a notifiable disease<ref name="Foldi and Foldi 2006">Foldi M, Foldi E. Foldi’s Textbook of Lymphology. 2nd ed. Germany: Elsevier, 2006.</ref>. However, the condition is becoming more common and the cost of healthcare required can put financial strain on the NHS. Therefore, it is important to understand the prevalance to help improve current and future healtcare and disease management<ref name="BMJ 2016">BMJ. Chapter 1. What is epidemiology? http://www.bmj.com/about-bmj/resources-readers/publications/epidemiology-uninitiated/1-what-epidemiology (accessed 17 January 2016)</ref>.<br>
 
*Lymphoedema occurs in approximately 240,000 people in the UK with older adults more susceptible than the younger population '''(Nazarko 2015).'''
*Cellulitis is a one of the leading causes in developing lymphoedema. In 2003-2004 there were 45,522 cellulitis admissions reported by the NHS Institue for Innovation and Improvement '''(MacMillan 2011).'''
 
*Approximately 90% of people with lymphoedema are affected in their lower body, 9% are affected in the upper body and the remaining 1% are affected in the genital region<ref name="Greene 2015">Greene AK, Epidemiology and Morbidity of Lymphedema. In: Greene AK, Slavin SA, Brorson H editors. Lymphedema: Presentation, Diagnosis and Treatment. Switzerland: Springer, 2015. p33-44.</ref>.<br>
*One third of females with damaged axillary nodes combined with radiation will develop lymphoedema<ref name="Greene 2015" />.&nbsp;A study looked at 744 patients who were treated for breast cancer in British Columbia. They found that 5% of those who had axillary surgery developed lymphoedema, but when radiotherapy was provided in addition to this surgery the percentage increased to 30%<ref name="Franks et al. 2006" />.<br>
*Undergoing surgery as part of breast cancer treatment is one of the most frequent causes of developing secondary lymphoedema. 1 in 5 patients will develop this type of lymphoedema 6 months after receiving the surgery<ref name="Harmer 2009">Harmer V. Breast cancer-related lymphoedema: implications for primary care. Br J Community Nurs. 2009;14:S15-S19. http://www.magonlinelibrary.com/doi/abs/10.12968/bjcn.2009.14.Sup5.44505?url_ver=Z39.88-2003&amp;rfr_id=ori:rid:crossref.org&amp;rfr_dat=cr_pub%3dpubmed (accessed 10 October 2015)</ref>.<br>
*Hampton<ref name="Hampton 2015">Hampton S. Lymphoedema: a common but often misunderstood condition. Nurs Residential. 2015;17:492-497. http://web.a.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=69d3e2eb-40db-4061-a94d-3902bd3bb3b2%40sessionmgr4001&amp;vid=9&amp;hid=4207 (accessed 7 October 2015)</ref> studied a population of 600,000 people over the age of 65 and concluded 1 in 200 people had chronic lymphoedema. 50% of these people had a reduced quality of life and hospital care cost the NHS £2300.
*'''Rockson and Rivera (2015)''' mention that 1.15 in 100,000 people under the age of 20 will acquire primary lymphoedema.<br>
 
*A study surveyed 308 centres (2743 people) in Spain and found that 36.8% suffered from primary lymphoedema. Of the 36.8%, 2% had acquired it at birth, 30% during adolescence and 68% were older adults '''(Williams et al 2005).'''<br>
*'''Ridner (2013)''' discussed the incidence rates of cancer survivors developing lymphoedema. It was reported that one study concluded from a total of 287 breast cancer survivors, 48% had upper limb swelling at least once and 34% had clinical symptoms of lymphoedema 6 years post treatment.<br>
 
=== Lymphatic system  ===
 
The lymphatic system is part of the body's immune system that plays a role in fighting harmful cells, for example, bacteria. It consists of lymph fluid, lymph nodes, lymph vessels and lymph tissue. <br>
 
Lymph tissue insulates and protects the lymphatic system from damaging cells. Lymph fluid contains infection-fighting white blood cells. It circulates throughout the lymphatic system and is formed when interstitial fluid is collected through lymph channels (vessels, ducts and capillaries).&nbsp;Lymph is primarily made up of a white watery substance.<br><br><u>'''PICTURE OF LYMPH COMPOSITION'''</u><br><br>
 
[[Image:Lymphatic system.png|420x460px]]<br><br>'''The main lymphatic functions:'''<br><br>1. Helps immune system respond to the body<br>2. Redistribution of fluid in the body<br>3. Lymph carries proteins, solids, and liquids away from tissue space<br>a. Remove waste products from interstitial space (between all body tissue) <ref name="Seifter et al. 2005">Seifter j, Ratner A, Sloane D. Concepts in Medical Physiology. London: Lippincott Williams &amp;amp; Wilkins, 2005.</ref><br>b. Bacteria, toxins and foreign bodies are removed from tissues<br>4. Controls the flow of large molecules around the body<ref name="National Lymphedema Network 2013">National Lymphedema Network. What is Lymphedema? http://www.lymphnet.org/le-faqs/what-is-lymphedema (accessed 11 January 2016)</ref><br>5. Controls tissue fluid homeostatsis '''(Ridner 2013) '''to maintain the structure and functional aspects of tissue.<br><br>The flow of lymph fluid is unidirectional, towards the heart to provide cells with oxygen. It is protein-rich and fights abnormal cells due to its white cell content '''(Cancer Research UK 2014). '''<br> <br>Lymph nodes tend to be found in clusters ingrained within adipose tissue (contains fat cells). Their shape and size varies depending on gender and where the nodes are located in the body<ref name="Foldi and Foldi 2006" />. &nbsp;There are approximately 600 to 700 lymph nodes located around the body, specifically under the arm, in the abdomen, groin and neck<ref name="Hampton 2015" />. Their role involves receiving lymph fluid via afferent vessels and transporting it&nbsp;around the body via efferernt vessels using specific lymph channels located on left and right sides. The fluid then passes through superficial primary lymph vessels (that drain the skin) and is emptied into deep secondary lymph vessels (which also contains drainage from internal organs). Adequate flow of lymph fluid is dependant on muscle contractions and an efficient respiratory system, for example, exercise<ref name="Kerchief et al. 2008">Kerchner K, Fleischer A, Yosipovitch G. Lower extremity lymphedema: Update: Pathophysiology, diagnosis, and treatment guidelines. J Am Acad Dermatol. 2008;59:324-331. http://www.sciencedirect.com/science/article/pii/S0190962208004842 (accessed 12 January 2016)</ref>.<br><br>{{#ev:youtube|tjkHzEVcyrE}}<br>'''<u></u>'''
 
Examples of lymph nodes located in the upper body include: axillary; lateral; subscapular; pectoral; upper and lower; central; infraclavicular; subpectoral and interpectoral nodes. Some of the lymph nodes located in the lower extremities include: inguinal; superficial inguinal and the intercalated nodes. As stated above, there are a number of lymph nodes located in the abdomin and pelvic areas, for example, iliac; lumbar; gastric; pancreaticosplenic; mesenteric; hepatic and rectal lymph nodes.
 
The lymphatic system can become blocked from localised fluid retention and tissue swelling within the body – known as Lymphoedema (a chronic inflammatory disease).&nbsp;It occurs when the function of the lymphatic system is compromised in some way. Lymph pathways are unable to exchange nutrients effectively within the interstitial spaces, causing a build up of excess fluid. Upper and lower extremities are affected depending on which area of the body is damaged. The cause of onset determines whether the affected person has either primary or secondary lymphoedema.<br>
 
<br>
 
'''Activity:''' take 10 minutes to undertake the following quiz and ensure you understand the key points from this section. The answers can be found throughout the above text.<br>
 
[[Image:Activity 1 table.png|450x410px]][[Image:Lymphatic system key points.png|350x270px]]<br>
 
=== Types of lymphoedema  ===
 
<u>'''Primary'''</u><br><br>Approximetaly 1 in 6000 people develop primary lymphoedema. This form of lymphoedema isn’t inherited through family history and wouldn’t be passed onto future generations. However, people can develop primary lymphoedema in relation to other genetic and congenital abnormalities wehre the lymph nodes or lymph vessels don't develop properly<ref name="Foldi and Foldi 2006" />. Currently there is not a large body of evidence regarding the causes of lymphoedema. Future research is required to further investigate developmental causes to ensure effective treatments are provided<ref name="Woods 2007">Woods M. Lymphoedema Care. Oxford: Blackwell Publishing, 2007.</ref>.
 
Primary lymphoedema can be either idiopathic, intrinsic or spontaneous. Idiopathic means there is no know cause, intrinsic results from an abnormal lymphatic system and sponanetous means the condition has developed on its own without any interference<ref name="Woods 2007" />.<br><br>There are three classifications depending on the onset of symptoms<ref name="Greene 2015" />:<br>
 
[[Image:Primary lymphoedema pic.png|center|500x380px]]<br>
 
<u>'''Secondary<br>'''</u>
 
Secondary lymphoedema is more common than the primary form. The lymphatic system is damaged due to an external cause compromising the function of the lymph nodes. Consequently, swelling accumulates in the affected part of the body. <br>
 
Causes of secondary lymhoedema include<ref name="NHS Choices 2014">NHS Choices. Lymphoedema – Causes. http://www.nhs.uk/Conditions/Lymphoedema/Pages/Causes.aspx (accessed 15 January 2016)</ref>:
 
<br>
 
[[Image:Secondary causes pic.png|center|450x350px]]<br>
 
*Malignant tumours - the presence of cancer tumours can block the flow of lymph fluid&nbsp;
*Surgery (cancer and non-cancer related) – increases the risk of disturbing the function of lymphatic pathways
*Radiotherapy - destroys cancerous tissue but can also damage healthly lymph nodes
*Infections – contributes to increased swelling in the affected area
*Inflammation – contributes to excess fluid build up in the affected area
*Obesity – increased the pressure on the lymphatic system that could ultimately damage lymph nodes
*Disease - for example, venous, joint, diabetes<br>
*Trauma - lymphoedema can occur followng severe trauma, for example, compound fractures<br>
 
In more developed countries malignancy and the treatments associated with the condition are the main root of cause for acquiring secondary lymphoedema<ref name="Kerchief et al. 2008" />.&nbsp;Although the treatments have a number benefits, their outcomes can lead to disruption of the lymphatic system. If a patient receives radiation treatment in addition to cancer surgery, they are at a higher risk of aquiring lymphoedema.<br>
 
In developing countries the most common cause of secondary lymphoedema is filiariasis, a parasitic infection with filarial worms<ref name="WHO 2016">WHO. Filarisasis. http://www.who.int/topics/filariasis/en/ (accessed 13 January 2016)</ref>. It commonly occurs in areas of poverty where there is poor sanitation and diseased water<ref name="Woods 2007" />. An infected female mosquito bites the human and a parasite enters the lymph vessel causing lymph vessel paralysis. The condition occurs in appproximately 120 million people in the world<ref name="Foldi and Foldi 2006" />. The physical and psychological effects of filiariasis intensify poverty because those affected become socially isolated and unable to carry out daily activities.<br>
 
<br>
 
Causes of upper limb lymphoedema include '''(The Lymphoedema Support Network year)''':<br>
 
*Trauma or injury – removal of lymph nodes during breast cancer surgery, upper body radiotherapy, burns, and scarring
*Cancer that has spread to the upper body compromising the function of the lymph nodes
*Following deep vein thrombosis (DVT) or high doses of intravenous (IV) drugs
*Reduced upper limb mobility as a result of an illness, for example, multiple sclerosis or stroke
 
'''<u>Activity</u>'''
 
The following links will be used in the reflective activity:
 
*http://www.lymphoedemasupport.com/articles/focus-on-primary-lymphoedema&nbsp;
*http://www.lymphoedemasupport.com/articles/focus-secondary-lymphoedema <br>
 
[[Image:Activity 3b.png|360x280px]][[Image:Activity 3a.png|360x240px]]
 
=== Clinical Features  ===
 
There are both physical and psychological effective of the chronic condition. Early diagnosis is vital to ensure the correct treatment is chosen.<br>
 
'''<u>Physical changes<ref name="CRUK symptoms 2014">Cancer Research UK. Symptoms of lymphoedema. http://www.cancerresearchuk.org/about-cancer/coping-with-cancer/coping-physically/lymphoedema/lymphoedema-symptoms (accessed 1 April 2014)</ref></u>'''
 
*In the early stages pitting oedema occurs where the skin is pressed leaving an indent in the swelling. Elevating the arm creates a draining effect to reduce swelling
*Limbs can feel heavy and achy
*There is altered sensation, for example, pins and needles
*Reduced mobility and range of movement of the affected limb/s
*Pain and joint discomfort
*Skin changes, for example redness and increased temperature
*Nail discoloration<ref name="Lyons and Modarai 2013">Lyons OTA, Modarai B. Lymphoedema. Surgery (Oxford). 2013;3:218-223. http://www.sciencedirect.com/science/article/pii/S0263931913000355 (accessed 12 January 2016)</ref>
*Hyperkeratosis (thickening of the skin) and lymphangiectasia (dilated superficial lymph vessels)<ref name="The Lymphoedema Support Network - recognise lymphoedema 2015">The Lymphoedema Support Network. How to recognise lymphoedema. http://www.lymphoedema.org/Menu4/1How%20to%20recognise%20lymphoedema.asp (accessed 12 January 2016)</ref>&nbsp;
 
('''McCallin et al 2005)'''
 
When the condition affects the lower extremities, over time the affected person’s gait pattern is altered, leading to a higher risk of disability.<br>
 
[[Image:Lymphoedema red leg.png|180x250px]]&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;[[Image:Lymphoedema leg no. 2.png|180x250px]]&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;[[Image:Lymphoedema leg no. 3.png|180x250px]]<br> <br><u>'''Psychological effects'''</u><br>There are psychological effects associated with the condition as a result of changes to body image.
 
*Swelling and weight gain impact physical appearance that can affect one’s perception of how they look, consequently decreasing their self-confidence<ref name="Harmer 2009">Harmer V. Breast cancer-related lymphoedema: risk factors and treatment. Br J Community Nurs. 2009;18:166-172. Available from: http://www.magonlinelibrary.com/doi/abs/10.12968/bjon.2009.18.3.39045?url_ver=Z39.88-2003&amp;amp;rfr_id=ori:rid:crossref.org&amp;amp;rfr_dat=cr_pub%3dpubmed (accessed 10 October 2015)</ref> (;'''McCallin et al 2005''')
*People commonly detach themselves from social events with family and friends leading to social isolation<ref name="Ridner 2009">Ridner SH. The Psycho-Social impact of Lymphedema. Lymphat Res Biol 2009;7:109-112. http://www.ncbi.nlm.nih.gov/pubmed/19534633 (accessed 12 January 2016)</ref>
*Disturbed sleeping pattern
*Some people may feel they have a lack of support
*Financial concerns as a consequence of treatment cost and potential job loss/change<ref name="Ridner 2009" />
*Some cancer survivors that have aquired secondary lymphoedema feel that it can be a constant reminder of previously having cancer<ref name="Greene 2015" />
*For those that experience unilaterael lymphoedema, commonly different sizes of garmets have to be worn on each side of the body and oversized clothes have to be worn because items such as jeans dont fit the limbs<ref name="Greene 2015" />. Psychologically this can largely impact the person because they may not feel comfortable with the way they look and therefore exclude themselves from public situaitons
 
'''Mason et al (2008)''' conducted a systematic review of literature that looked at the psychosocial aspects related lymphoedema. It was found that people with the condition experience anger, depression, anxiety and relationship issues. People can feel embarrassed having to wear different clothes due to compression bandaging, swelling and weight gain. Ultimately, there is an overall decrease in quality of life (QoL) from reduced social and leisure activities. The study concluded more research is required that focuses on improving specific psychosocial issues rather targeting QoL to reslove issues such as anger and depression.<br>
 
Another study<ref name="Ridner 2009" /> looked at the incidence, cost of treatment and complications of lymphoedema following breast cancer treatment. It concluded that 10% of the 1877 participant showed signs of lymphoedema 2 years after breast cancer treatment. A complication of the condition was the high medical costs for treatment. This lead to increased length of stay in hospital and ultimately reduced the patient’s quality of life<ref name="Ridner 2009" />.<br>
 
It is important for health professionals to recognise and fully understand the psychological and psychosocial implications for each individual patient to ensure person-centred care is provided. Communication and appropriate referrals to other health professionals is important in overall management of the condition, for example social workers and psychologists.
 
<br>
 
Below is a summary of the key points to remember from this section:
 
[[Image:Key points clinical features.png|470x380px]]<br>
 
=== Stages of lymphoedema ===
 
This section will introduce the stages of lymphoedema, there are 4 stages which are discussed in the table below<ref name="Breast cancer.org stages">Breastcancer.org. Stages of Lympedema. http://www.breastcancer.org/treatment/lymphedema/how/stages (accessed 20 January 2016)</ref>.&nbsp;Lymphoedema is a chronic and incurable condition so treatment strategies focus on reducing disease progression through the stages. For example, management may focus of swelling reduction and infection prevention.:&nbsp;<br>
 
[[Image:Stages table pic.png|650x450px]]<br>
 
<br>
 
The picture below shows how each of the above stages appear in the lower limb.&nbsp;
 
[[Image:Stages picture.png|600x400px]]
 
=== Leading causes  ===
 
'''<u>Cancer<br></u>'''
 
'''<u></u>'''Lymphoedema following breast cancer surgery is the highest overlooked cause of secondary lymphoedema. Harmer<ref name="Harmer 2009" />&nbsp;states approximately 20% of people will acquire lymphoedema after receiving this treatment. The procedure involves removing one or more lymph nodes located under the arm, leaving fewer lymph nodes to drain all the lymph. Continually working under high pressures eventually causes the remaining lymph nodes to become damaged and lymph leaks into the lymph vessels. Consequently&nbsp;excess fluid builds up in the affected area<ref name="Breast cancer.org lymphedema">Breastcancer.org. Lymphedema. http://www.breastcancer.org/treatment/lymphedema (accessed 7 October 2015)</ref>.<br>
 
Cancer Research UK<ref name="CRUK immune system">Cancer Research UK. The immune system and cancer. http://www.cancerresearchuk.org/about-cancer/what-is-cancer/body-systems-and-cancer/the-immune-system-and-cancer (accessed 9 October 2015)</ref>&nbsp;discusses the vicious cycle between cancer and the body’s immune system. Cancerous cells are destroyed by the immune system and treatments for cancer. However, the condition can weaken the immune system if lymph nodes are blocked by cancerous tissue and unable to function properly.<br>
 
A combination of surgery and radiotherapy treatment leads to a higher risk of acquiring secondary lymphoedema. Radiation therapy aims to stop cancer from coming back by using high-radiation energy to destroy cancerous cells<ref name="National Cancer Institute 2010">National Cancer Institute. Radiation Therapy for Cancer. http://www.cancer.gov/about-cancer/treatment/types/radiation-therapy/radiation-fact-sheet (accessed 7 October 2015)</ref>. It either occurs before surgery to reduce the size of a tumour, or after surgery to abolish the remainder of the tumour. Lymphoedema can occur as a result of this treatment when the function of the lymphatic system has been comprised and fluid isn’t drained away<ref name="NHS Choices 2014" />.<br>
 
'''<u>Infection<br></u>'''
 
'''<u></u>'''Infection is a key issue commonly related to lymphoedema. It either results from swelling or causes it to develop<ref name="Hampton 2015" />. Lymph nodes help fight infections but when they are damaged infections can develop quicker. Infection usually develops follwing a break in the skin, for example a cut. It is important patients receive treatment quickly to prevent the infection becoming acute and spreading within the affected area, a common antibiotic used is penecilin<ref name="Greene 2015" />. The Lymphoedema Support Network<ref name="The Lymphoedema Support Network 2010">The Lymphoedema Support Network. How to recognise lymphoedema. http://www.lymphoedema.org/Menu4/1How%20to%20recognise%20lymphoedema.asp (accessed 12 January 2016)</ref>&nbsp;defines cellulitis as “acute spreading inflammation of the skin and subcutaneous tissue”. It causes the skin to become warm, red, swollen and painful with onset either sudden or progressing over a few hours. If the lymph tissue is damaged there is added strain on the lymphatic system. In an infected limb, the inflammatory process cause attracts fluid causing an increase in swelling. Consequently, lymphoedema is exacerbated during this period of infection '''(McGilvray year).'''<br>
 
75-90% of cellulitis occurs in the lower body and is caused by bacteria entering inflamed or broken skin. Al-Niaimi and Cox<ref name="Al-Niaimi and Cox 2009">Al-Niaimi F, Cox N. Cellulitis and lymphoedema: a vicious cycle. J Lymphoedema. 2009;4:38-42 http://www.journaloflymphoedema.com/media/issues/851/files/content_11173.pdf (accessed 10 Oct 2015)</ref> state that cellulitis is responsible for 3% of UK hospital admissions. This common occurrence puts financial strain on the NHS; therefore, infection prevention is a large part of lymphoedema treatment. There is a strong link between leg cellulitis and lymphoedema, where progression of the condition can lead to ulceration and septicaemia. Each cellulitis episode exacerbates secondary lymphoedema, which in turn increases the risk for a further infection episode. A Cochrane review found that a quarter of lymphoedema patients would acquire cellulitis<ref name="Al-Niaimi and Cox 2009" />.<br><br>
 
[[Image:Cellulitis.png|150x200px]]&nbsp;
 
Picture above: Cellulitis in a lower limb<br>
 
<br>
 
<u>'''Activity'''</u><br>
 
Now it's time to get your thinking hat on...&nbsp;
 
By now you should have an understanding of the causes of lymphoedema and the presenting symtoms. Use the information provided in this section and in the link below to complete the following activity:
 
*http://be.macmillan.org.uk/Downloads/CancerInformation/CancerTypes/MAC11651Lymphoedema-E13.pdf
 
[[Image:Activity 2.png|420x240px]]<br>
 
=== Activity  ===
 
Well done, you have successfuly completed this section of the learning resource! Now it's time to test yourself and put your newfound knowledge into practice.<br>
 
Take approximately 15 minutes to complete the following&nbsp;[https://www.onlinequizcreator.com/what-do-you-know-about-the-background-of-lymphoedema/quiz-145006 quiz]. The aim of the quiz is to answer all the questions correctly before the time runs out, good luck!
 
[[Image:Good luck pic.png|center|400x190px]]
 
=== Conclusion  ===
 
The aim of this section is to provide an overview of lymphoedema. It’s important to understand the background of how lymphoedema develops and the presenting symptoms associated with the condition so that clinicians choose the most appropriate treatment strategy.
 
You should also feel comfortable discussing the following areas:
 
#Epidemiology
#Pathophysiology
#Types and Stages of lymphoedema
#Clinical features
#Leading causes
 
'''By now you should have achieved learning outcome 1:'''
 
''Discuss the background of lymphoedema and describe the key presenting symptoms''
 
The next section of the learning resource will focus on discussing the physiotherapist’s role in managing lymphoedema and critically analyses a range of available treatments. Before progressing onto this section, please ensure you have taken time to complete all the activities above.<br>
 
== Lymphoedema - Treatment and Management  ==
 
=== Introduction  ===
 
This section will discuss the treatment and management options for people with lymphoedema. By the end of this section you should have achieved learning outcome number 3 - "''critically evaluate the role of the physiotherapist in the treatment of lymphoedema with reference to current literature''".
 
Throughout the section a number of learning activities including reflections, quizzes and a case studies will be used to help consolidate your learning.&nbsp;Additional reading links will also be provided throughout to expand on what is included in the resource.
 
The Chartered Society of Physiotherapy (CSP) produced a document outlining the background and treatment of lymphoedema<ref name="CSP">Chartered Society of Physiotherapy. Physiotherapy Works: Lymphoedema. http://www.csp.org.uk/publications/physiotherapy-works-lymphoedema (accessed 20 January 2016)</ref>. This&nbsp;document states that patients will undergo 3-4 weeks of intensive therapy, followed by lifelong monitoring, which includes self-management and 6 month reviews.&nbsp;The need for early access to specialist physiotherapy intervention in order to prevent serious complications is also highlighted.
 
'''Activity:''' Take 5 minutes to read through [http://www.csp.org.uk/publications/physiotherapy-works-lymphoedema the document<ref name="CSP" />] and note down the key points (please note this document is only available for CSP members). <br>
 
<br>Decongestive lymphatic therapy (DLT) as discussed by the CSP is viewed as the gold standard of care for lymphoedema<ref name="Chang and Corimer 2013">Chang CJ, Corimer JN. Lymphoedema Interventions: Exercise, Surgery and Compression Devices. Seminars in Oncology Nursing 2013;29(1):28-40. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23375064 (accessed 15 January 2016).</ref>.This treatment approach is effective and significantly reduces the percentage excess limb volume as well as improving quality of life<ref name="Kim and Park 2008">Kim SJ, Park YD. Effects of complex decongestive physiotherapy on the oedema and the quality of life of lower unilateral lymphoedema following treatment for gynaecological cancer. European Journal of Cancer Care 2007;17:463-468. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18637114 (accessed 15 January 2016).</ref>&nbsp;.&nbsp;
 
Decongestive lymphatic therapy encompasses four main components<ref name="ILF">Lymphoedema Framework. Best Practice for the Management of Lymphoedema. International consensus. http://www.woundsinternational.com/media/issues/210/files/content_175.pdf (accessed 15 January 2016)</ref>;<br>
 
[[Image:DLTpicture.png]]<br> The treatment of lymphoedema should be specifically tailored based on the site, severity and complexity as well as their psychosocial status<ref name="ILF" />. The success of treatment does not solely rest on the therapist; patients and carers must play an active role from an early stage.&nbsp;<br><br>Alongside the physical difficulties that people with lymphoedema face - emotional and social implications may also arise. Evidence has suggested that through specific management and targeting of the physical symptoms, these psychosocial issues can be reduced to enhance the individual’s quality of life<ref name="Kim and Park 2008" />.<br><br>The management of lymphoedema is split into intensive and maintenance stages, both of which have very different approaches. The goals during the intensive stage of therapy are to reduce and control the swelling, maintain skin quality and educate the patient in order for them to reach a stage where they are ready to progress into the maintenance phase of treatment<ref name="Korpan et al. 2011">Korpan ML, Crevenna R, Fialka-Moser V. Lympedema A Therapeutic Approach in the Treatment and Rehabilitation of Cancer Patients. American Journal of Physical Medicine and Rehabilitation 2011; 90(5):69-75. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21765266 (accessed 15 January 2016).</ref>. This is achieved through a number of approaches aiming to reduce the load,&nbsp;decongest the lymphatic system, encourage system function and stimulate drainage through various routes<ref name="ILF" />. <br><br>Once swelling is bought under control patients will progress to the maintenance stage. During this stage people with lymphoedema are educated to self manage their condition and will be reviewed less frequently by a specialist. <br> Over the next four sections of this learning resource you will learn about the different components of DLT with reference to the literature which supports their use.&nbsp;<br>''<br>'''''Activity:'''
 
Prior to moving on, take 5 minutes to complete the following quiz (the answers can be found in the text and additional reading above).&nbsp;
 
[[Image:Introduction DLT quiz.png]]<br>
 
=== Compression therapy  ===
 
This section will discuss the first of the four elements of DLT known as compression therapy.
 
Compression therapy consists of two main methods – multilayer lymphoedema bandaging (MLLB) and compression garments. Overall, compression therapy increases lymphatic drainage, reduces capillary filtration, promotes fluid movement to less compressed areas of the body and improves the action of the venous pump<ref name="Cooper 2015">Cooper G. Compression therapy in oedema and lymphoedema. British Journal of Cardiac Nursing 2015;8(11):547-551. Available from: http://www.magonlinelibrary.com/doi/10.12968/bjcn.2015.20.3.118 (accessed 15 January 2016).</ref>. Furthermore, bandaging aims to improve the shape of the limb, soften fibrosclerotic tissue, support and improve skin condition<ref name="EWMA 2005">European Wound Management Association. Lymphoedema bandaging in practice. http://ewma.org/fileadmin/user_upload/EWMA/pdf/Position_Documents/2005__Lymphoedema/English_focus_doc_05.pdf (accessed 16 January 2016)</ref>.
 
Once no further benefit is being obtained from compression bandaging during the intensive phase, patients should be managed by compression garments for long-term maintenance<ref name="ILF 2012">Lymphoedema Framework. Best Practice for the Management of Lymphoedema – 2nd Edition. Compression Therapy: A position document on compression bandaging. http://www.lympho.org/mod_turbolead/upload/file/Resources/Compression%20bandaging%20-%20final.pdf (accessed 17 January 2016)</ref>. MLLB may also be used as part of long-term management if compression garments are not suitable <ref name="EWMA 2005" />.
 
<br>The combined treatment of bandaging followed by compression hosiery has been found to yield better results for reduction of moderate to severe lymphoedema, which was maintained for at least 6 months, compared with hosiery alone <ref name="Badger et al. 2000">Badger CMA, Peacock JL, Mortimer PS. A Randomised, Controlled, Parallel-Group Clinical Trial Comparing Multilayer Bandaging Followed by Hosiery versus Hosiery Alone in the Treatment of Patients with Lymphedema of the Limb. Cancer 2000;88(12):2832-2837. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10870068 (accessed 15 January 2016).</ref>. These results came from a relatively large randomised controlled parallel-group trial. Hence the International Consensus recommends this as the optimal course of treatment for people with lymphoedema.<br>
 
<br>
 
The resource will now go on to discuss the stages of compression therapy in further detail with reference to the available evidence. This will facilitate the achievement of learning outcome number 3 (see section 1 to remind yourself of this).
 
&nbsp;
 
<u>'''Compression bandaging'''</u>
 
Compression bandaging is considered if the patient presents with any of the following factors<ref name="ILF" />:&nbsp;<br>
 
*Fragile, damaged or ulcerated skin
*Distorted limb shape
*Limb too large for compression garments
*Areas of tissue thickening
*Lymphorrhoea
*Lymphangiectasia
*Pronounced skin folds<br>
 
There are a number of contraindications stated below<ref name="ILF" />:
 
*Severe arterial insufficiency
*Uncontrolled heart failure
*Severe peripheral neuropathy<br>
 
Once indications and contraindications have been considered, the health professional is required to make a decision regarding the course of treatment.&nbsp;Based on the patient's presenting symptoms, condition and medical history, they may require slightly modified treatment. The following flow chart visualises the decision making process that occurs at this stage:
 
<br>
 
[[Image:Treatment flow chart - picture.png]]<br>
 
<br>
 
'''Additional reading: '''refer to pages 6-7 of [http://www.cslr.cz/download/English_focus_doc_05.pdf this document<ref name="EWMA 2005" />] to read more about how the modifications are made (approx. 10 minutes)&nbsp;
 
<br>The bandages used for MLLB are inelastic which result in high and low pressures exerted during movement and rest respectively<ref name="EWMA 2005" />. Elastic bandages produce less variation of pressure; these may be indicated if patients are immobile, have venous ulceration, lymphatic or venous disease or if the expected time of application is longer than normal<ref name="ILF" />.
 
As with most treatments, MLLB can be adapted to suit the patient needs by either adjusting pressure, frequency of reapplication, bulk of bandage and type of bandage<ref name="ILF" />. If pressure is not applied correctly venous and lymphatic flow can be compromised, therefore the proximal movement of fluid is reduced and swelling may present in the extremities<ref name="EWMA 2005" />. When applied to the lower limb, care must be taken to ensure that the patient is still able to wear shoes during treatment as normal gait pattern is encouraged to maintain an effective calf and foot muscle pump<ref name="EWMA 2005" />.
 
<br>
 
Pressure applied is calculated using Lapase's Law:
 
[[Image:Equation.png]]<br>
 
P = pressure under the bandage (in mmHg), <br>T = bandage tension (Kgf)<br>N = number of layers <br>C = limb circumference (cm)<br>W = bandage width (cm)
 
<br>
 
The basic principles of MLLB have been discussed.&nbsp;The following two videos show the application of MLLB to upper and lower limb lymphoedema. By watching these, you should gain a clearer idea of the appearance of MLLB and how it is applied by a specialist physiotherapist or other health care professional.&nbsp;
 
<br>'''Bandaging a lymphoedema arm: (approx. 10 mins)'''
 
'''Bandaging a lymphoedema leg: (approx. 10 mins)'''
 
<br>
 
{| width="100%" cellspacing="1" cellpadding="1"
|-
| {{#ev:youtube|uSBwkGWUcHA|300}}
| {{#ev:youtube|-jC6LzOlI1w|300}}
|}
 
<br>
 
MLLB has been discussed, however more recently, a new bandaging system known as Coban 2 has been developed which can be used an alternative to MLLB. MLLB consists of a thick padding layer covered by multiple compression bandage layers, however Coban 2 differs and only consists of a comfort layer and a compression layer that cohesively bond together<ref name="Lamprou et al. 2011">Lamprou, DAA, Damstra RJ, Partsch H. Prospective, Randomised, Controlled Trial Comparing a New Two-Component  Compression System with Inelastic Multicomponent Compression Bandages in the Treatment of Leg Lymphoedema. Dermatologic Surgery 2011;37(7):985-991. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22002586 (accessed 15 January 2016).</ref>. Coban 2 bandaging eliminates the need for multiple thick layers, resulting is a much less bulky appearance and allowing the patient more mobility and freedom.
 
<br>Lamprou and colleagues<ref name="Lamprou et al. 2011" /> conducted a prospective randomised controlled trial comparing Coban 2 with traditional bandaging methods in the treatment of lower limb lymphoedema. The results of this study found Coban 2 to be equally as effective in reducing limb volume.<br>Franks and colleagues<ref name="Franks et al. 2012">Franks PJ, Moffatt CJ, Murray S, Reddick M, Tilley A, Schreiber A. Evaluation of the performance of a new compression system in patients with lymphoedema. International Wound Journal 2012;203-209. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22432947 (accessed 15 January 2016).</ref> studied the use of Coban 2 in arm and leg lymphoedema. Again this study supported the use of Coban 2 in the effective management of lymphoedema with the lower limb showing a greater reduction in swelling.
 
<br>
 
Although both of the above studies had relatively small sample sizes (40 and 24 participants respectively) resulting in low statistical power, they both showed encouraging results for the use of the new bandaging system.
 
<br>A multicentre randomised controlled trial with 82 participants investigating the frequency of application of Coban 2<ref name="Moffatt et al. 2012">Moffatt CJ, Franks PJ, Hardy D, Lewis M, Parker V, Feldman JL. A preliminary randomised controlled study to determine the application frequency of a new lymphoedema bandaging system. British Journal of Oncology 2012;166(3):624-632. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22059933 (accessed 20 January 2016)</ref>. Results found constant therapeutic effect was maintained when bandages were reapplied every four days. Compared with MLLB, which requires reapplication daily at certain stages of treatment, the Coban 2 bandages allow patients to have more freedom and independence.
 
<br>
 
As discussed the evidence for Coban 2 is encouraging, however to fully evaluate the efficacy of the new system larger high quality studies are required.
 
<br>
 
This next video shows the application of Coban 2 bandaging and explains some more information about this new system.&nbsp;
 
'''Activity:''' Take 5 minutes after watching this video to note down the differences between the two types of bandaging systems.&nbsp;
 
<br>
 
'''Coban 2 bandaging: (approx. 10 mins)'''
 
{{#ev:youtube|5iGA9tCyFyA|500}}
 
<br>
 
Now that compression bandaging has been considered, this wiki will now move on to discuss the use of compression garments which are used for the long-term management of limb shape and swelling<ref name="ILF" />.
 
<u>'''<br>Compression Garments/Hosiery'''</u>
 
Compression garments will be considered when a patient is reaching the end of the intensive phase of treatment once regular limb shape has been restored and the patient’s skin is fully intact and robust enough to tolerate the use of garments<ref name="Doherty et al. 2009">Doherty D, Morgan P, Moffatt C. Hosiery in lower limb lymphoedema. Journal of Lymphoedema 2009;4(1):30-37. Available from: http://www.journaloflymphoedema.com/ (accessed 15 January 2016).</ref><ref name="Linnitt and Davies 2007">Linnitt N, Davies R. Fundamentals of compression in the management of lymphoedema. British Journal of Nursing 2007;16(10):588-592. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17577161 (accessed 15 January 2016).</ref>. Garments require precise measurement as they are hand-made to measure specifically for the individual patient.<br><br>Although garments are important in the management of lymphoedema, patient and clinician must come to an informed decision regarding the appropriateness of this treatment modality.
 
Doherty et al.<ref name="Doherty et al. 2009" /> explains a number of factors that should be considered when assessing for compression garments (see image below). Once these have been considered and the patient is deemed appropriate for compression garements, meaurements will be taken&nbsp;by a qualified health professional, which may be a physiotherapist.
 
[[Image:Compression condiserations.png]]<br>'''Additional reading:''' Take 10 minutes to refer to the [http://www.woundsinternational.com/media/issues/210/files/content_175.pdf Best Practice for the Management of Lymphoedema<ref name="ILF" />] pages 40-41 where you will find more information about fitting and measuring for lymphoedema compression garments
 
Once the progression from bandages to garments has been made, swelling and other symptoms must be monitored. If swelling is not controlled within the first three months of wearing compression garments, clinician and patient should consider further intensive therapy using MLLB in order to bring the swelling under control<ref name="EWMA 2005" />.<br>
 
Garments are either constructed as a flat knit or a round knit. Flat knit are knitted as a flat garment then joined at the seams, these are generally thicker and firmer. Round knitted garments are viewed as more aesthetically pleasing, as they are thinner than flat knit and are continuously knitted cylindrically without any seams<ref name="ILF" />.
 
Once measurement and construction of the garment is completed, the health professional will assess the garment for fit and check that the patient or carer is able to apply and remove the garment correctly. Advice regarding the care at home will be provided in person and leaflets may also be given to the patient<ref name="ILF" />. If garments are poorly fitted, the swelling may not be contained and damage can occur to the tissues. This could result in discomfort and reduced tolerance leading to patients being unwilling to use compression hosiery as a long-term management option<ref name="Doherty et al. 2009" />.
 
As well as limb compression garments, if patients have trunk or breast lymphoedema garments or specialised bras can be provided<ref name="ILF" />.<br>
 
<br>
 
'''Activity'''
 
Before progressing to the next section please take 15 minutes to check your knowledge:<span style="font-size: 13.28px; line-height: 1.5em;">&nbsp;</span>
 
<span style="font-size: 13.28px; line-height: 1.5em;">[[Image:2 Compression Quiz.png]]&nbsp;[[Image:Compression reflection.png]]</span>
 
By now you should have a clear understanding of the role of compression therapy in the management of lymphoedema and the evidence to support it. The additional reading and YouTube videos should have provided you with more knowledge about modifications of MLLB, application of both bandaging systems and measuring for compression garments.
 
Ensure you are able to answer the questions in the quiz above (all answers are provided throughout the text and additional reading).&nbsp;&nbsp;
 
Below is a summary of the key points to remember from this section.&nbsp;
 
[[Image:Compression key points.png]]<br>
 
<br>
 
=== Skin care  ===
 
This section will discuss the role of skin care in the treatment and management of lymphoedema.
 
As a consequence of swelling, large skin folds can appear where infections may develop <ref name="ILF" />. Infections can also arise if the skin becomes damaged or broken, therefore adequate skin care to maintain the integrity and manage any problems that occur is fundamental in the care of people with lymphoedema<ref name="ILF" /><ref name="Wigg and Lee 2015">Wigg J, Lee N. Managing lymphoedema and chronic oedema. Nursing and Residential Care 2015;17(4):192-197. Available from: http://www.magonlinelibrary.com/doi/10.12968/nrec.2015.17.4.192 (accessed 15 January 2016).</ref>.
 
At both intensive and maintenance stages, it is important to emphasise the need for a skin care regime to maintain the skin integrity.
 
'''The main principles of skin care are:'''<ref name="ILF 2012" /><ref name="Nowiki and Saviour 2013" />&nbsp;[[Image:Skin care .png]]
 
During assessment, health professionals must inspect the skin condition using palpation and observation to check for any changes or damage<ref name="Nowiki and Saviour 2013">Nowicki J, Siviour A. Best Practice skin care management in lymphoedema. Wound Practice and Research 2013;21(2):61-65. Available from: http://www.awma.com.au/journal/2102_03.pdf (accessed 15 January 2016).</ref>. If changes have occurred these must be monitored and managed correctly.
 
Following assessment, the skin will be cleansed and emollients applied.
 
Washing removes dirt and bacteria from the skin, this is essential to prevent infection; however washing can remove the protective lipid layer that prevents water loss and protects the skin from infection. Therefore emollients are applied to re-establish this layer, thus preventing any further water loss and maintaining the protective barrier<ref name="ILF 2012" />. Following cleansing of the skin, it is highly important to ensure the skin, in particular the skin folds are dried properly. If not, these areas will provide the perfect environment for infections and bacteria to develop.
 
Abrasive or scented soaps should be avoided and natural or pH neutral soaps are recommended<ref name="ILF" /><ref name="Nowiki and Saviour 2013" />. This is because normal soaps contain detergents, are often scented and include preservatives, which can all irritate or dry the skin.
 
As shown in the videos in the above section (Compression Therapy) emollients are applied prior to bandaging. These are available in various forms including, moisturisers, soaps substitutes or bath oils. Moisturisers area also available in different forms including creams, lotions and ointments<ref name="Nowiki and Saviour 2013" />. The Lymphoedema Framework<ref name="ILF" />&nbsp;recommends the use of ointments, which contain little or no water; this hydrates the skin better than creams and lotions.
 
The body’s natural response to sunburn is to increase blood flow to the affected area. For people with lymphoedema this will increase the load on an already impaired lymphatic system and may increase swelling. Therefore it is advised that people with lymphoedema take extra care to avoid sunburn<ref name="Nowiki and Saviour 2013" />.
 
Despite the treatment offered infections may still occur that must be managed by thorough close monitoring, skin hygiene, ensuring skin is dried following washing and an anti-fungal powder or cream applied until the infection disappears<ref name="Nowiki and Saviour 2013" />.
 
Although skin care is an integral part of lymphoedema management, some patients experience barriers that prevent adequate skin care and result in infections. James<ref name="James 2011">James S. What are the perceived barriers that prevent patients with lymphoedema from continuing optimal skin care? Wound Practice and Research 2011;19(3):152-158. Available from: http://www.awma.com.au/journal/1903_09.pdf (accessed 15 January 2016)</ref> studied the perceived barriers to skin care, which included physical limitations, expense, poor understanding, anxiety and motivational issues. This indicates that health professionals play a large role in educating patients about the importance of skin care to facilitate self-management. Health professionals should be aware of these potential barriers and be able to overcome them through education and support.
 
The main principles of skin care have been discussed for intact skin, however as discussed a number of skin conditions or infections can arise. Take 10 minutes to undertake this additional reading (from 'Intact Skin' on page 24, stopping before 'Cellulitis/Erysipelas' on page 27 of '[http://www.woundsinternational.com/media/issues/210/files/content_175.pdf Best Practice Management of Lymphoedema]'<ref name="ILF" />.). This reading will provide you with additional information about how different skin conditions are managed in practice. It will also provide you with a description and picture of how the stated condition appears. This is particularly useful as final year and new graduates – you may be involved in the assessment or treatment of this patient group, therefore it is important that you have the knowledge to identify these conditions.
 
You have now reached the end of this section, at this stage you should understand the main principles of skin care and how these are delivered in practice.&nbsp;
 
'''Activity '''– take 5 minutes to complete the following quiz to test your knowledge before progressing. All answers can be found in the text above or throughout the additional reading.
 
[[Image:Skin care quiz.png]]<br>
 
Below is a summary of the key points to remember from this section.&nbsp;
 
[[Image:Skin care key points.png]]&nbsp;<br>
 
=== Exercise  ===
 
This section will discuss exercise for people with lymphoedema. Based on new evidence, traditional beliefs about the effects of exercise on lymphoedema have been disproven.
 
MacMillan Cancer Support<ref name="MacMillan 2013 Cured but at what cost">MacMillan Cancer Support. Cured – but at what cost? http://www.macmillan.org.uk/Documents/AboutUs/Newsroom/Consequences_of_Treatment_June2013.pdf (accessed 16 January 2016)</ref> state that many individuals experience reduced quality of life following cancer treatment due to secondary complications, which can include lymphoedema. Despite the general well known benefits of exercise including reduced risk of chronic diseases and the positive impact it can have on mental health<ref name="NHS choices exercise">NHS Choices. Benefits of Exercise. http://www.nhs.uk/Livewell/fitness/Pages/Whybeactive.aspx (accessed 16 January 2016)</ref>, studies report that cancer survivors often fail to return to their pre-diagnosis levels of physical activity<ref name="Irwin et al. 2003">Irwin ML, Crumley D, McTieran A, Bernstein L, Baumgartner R, Gilliand F, Kriska A, Ballard-Barbash R. Physical Activity Levels before and after a Diagnosis of Breast Carcinoma, The Health, Eating, Activity and Lifestyle (HEAL) Study. Cancer 2003;97(7):1746-1757. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12655532 (accessed 15 January 2016).</ref><ref name="Harrison et al. 2009">Harrison S, Hayes SC, Newman B. Level of physical activity and characteristics associated with change following breast cancer diagnosis and treatment. Psycho-Oncology 2009;18:387-394. Available from: http://onlinelibrary.wiley.com/doi/10.1002/pon.1504/references (accessed 15 January 2016).</ref>.
 
Traditionally strenuous exercise was discouraged in patients with lymphoedema based on the belief that it may exacerbate the condition<ref name="Chiefetz et al. 2010">Cheifetz O, Haley L. Management of secondary lymphoedema related breast cancer. Canadian Family Physician 2010;56:1277-1284. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21375063 (accessed 15 January 2016).</ref>. However recent studies and systematic reviews contradict this statement.<br>
 
Cancer Rearch UK provides an informative section on their website for people with lymphoedema.&nbsp;
 
Before progressing take 10 minutes to read through [http://www.cancerresearchuk.org/about-cancer/coping-with-cancer/coping-physically/lymphoedema/treating-lymphoedema/exercise-positioning this page<ref name="CRUK exercise">Cancer Research UK. Exercise, positioning and lymphoedema. http://www.cancerresearchuk.org/about-cancer/coping-with-cancer/coping-physically/lymphoedema/treating-lymphoedema/exercise-positioning (accessed 21 January 2016)</ref>].&nbsp;By reading this information you will learn about how exercise influences lymphoedema and examples of exercises for different areas of the body. This is a useful resource as it is written in layman language, which is easy to understand by patients. This may also assist you as future clinicians to find ways to explain complex terms to your patients.
 
<br>Now that you have read more about exercise and lymphoedema, the following table summarises some of the studies that have been conducted surrounding this topic. <br>
 
<br>
 
{| width="800" border="1" cellpadding="1" cellspacing="1"
|-
! scope="col" | Study Title
! scope="col" | Design
! scope="col" | Participants
! scope="col" | Intervention
! scope="col" | Outcome Measures
! scope="col" | Results
|-
| Effect of Upper Extremity Exercise on Secondary Lymphedema in Breast Cancer Patients: A Pilot Study<ref name="McKenzie and Kalda 2003">McKenzie DC, Kalda AL. Effect of Upper Extremity Exercise on Secondary Lymphedema in Breast Cancer Patients: A Pilot Study. Journal of Clinical Oncology 2003;21(3):463-466. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12560436 (accessed 15 January 2016).</ref>
| Pilot study
| 14 breast cancer survivors with unilateral upper limb lymphoedema
| Progressive upper body exercise programme – 8 weeks vs. no intervention
| Arm circumference and volume<br>Medical Outcomes Trust Short From 36 – survey
| No changes in lymphoedema<br>Physical, general and vitality components of QOL improved
|-
| Exercise and Secondary Lymphedema: Safety, Potential Benefits, and Research Issues<ref name="Hayes et al. 2009">Hayes SC, Reul-Hirche H, Turner J. Exercise and Secondary Lymphedema: Safety, Potential Benefits, and Research Issues. Medicine and Science in Sports and Exercise 2009;483-489. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19117320 (accessed 15 January 2016).</ref>
| RCT
| 32 breast cancer survivors with lymphoedema
| Mixed type exercise programme – 12 weeks vs. no intervention
| Bioimpedence spectroscopy and perometry
| No changes – did not exacerbate lymphoedema
|-
| Weight lifting in Women with Breast-Cancer-Related Lymphoedema<ref name="Schmitz et al. 2009">Schmitz KH, Ahmed RL, Troxel A, Cheville A, Smith R, Lewis-Grant L, Bryan CJ, Williams-Smith CT, Greene QP. Weight lifting in Women with Breast-Cancer-Related Lymphoedema. The New England Journal of Medicine 2009;361:664-673. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19675330 (accessed 15 January 2016).</ref>
| RCT
| 141 breast cancer survivors with stable arm lymphoedema
| 2x weekly progressive weight lifting vs. no intervention
| Severity of lymphoedema, number and Incidence of exacerbations and symptoms and muscle strength
| No effect on limb swelling, reduced exacerbations and symptoms, increased muscle strength
|-
| Systematic Review and Meta-Analysis of the Effects of Exercise for Those With Cancer-Related Lymphoedema<ref name="Singh et al. 2015">Singh B, Disipio T, Peake J, Hayes SC. Systematic Review and Meta-Analysis of the Effects of Exercise for Those With Cancer-Related Lymphoedema. Archives of Physical Medicine and Rehabilitation 2015;1-30 Available from: http://www.ncbi.nlm.nih.gov/pubmed/26440777 (accessed 15 January 2016).</ref>
| Systematic review and meta-analysis
| Individuals with secondary lymphoedema<br>25 studies included
| Range of exercises
| Lymphoedema and associated symptoms
| No effect on lymphoedema or associated symptoms<br>Insufficient evidence for use of compression during exercise
|-
| Exercise in patients with lymphedema: a systematic review of the contemporary literature<ref name="Kwan et al. 2011">Kwan M, Cohn JC, Armer JM, Stewart BR, Corimer N. Exercise in patients with lymphedema: a systematic review of the contemporary literature. Journal of Cancer Survivorship 2011;5:320-336. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22002586 (accessed 15 January 2016).</ref>
| Systematic review
| Cancer patients with or at risk of lymphoedema<br>19 studies included
| Range of exercises
| Lymphoedema development and exacerbations
| No development or exacerbation of lymphoedema
|-
| Weight training is not harmful for women with breast cancer-related lymphoedema: a systematic review<ref name="Paramanandam and Roberts 2014">Paramanandam VS, Roberts D. Weight training is not harmful for women with breast cancer-related lymphoedema: a systematic review. Journal of Physiotherapy 2014;60:136-143. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25086730 (accessed 15 January 2016).</ref>
| Systematic review and meta-analysis
| Women with or at risk of developing breast cancer related lymphoedema<br>11 studies included
| Progressive weight training exercise
| Severity and incidence of arm lymphoedema, upper limb muscle strength, BMI and QOL
| Increased strength without affecting arm volume or incidence of lymphoedema<br>No effect on BMI<br>Potential to improve some elements of QOL
|}
 
<br>The studies in the table above used a range of different exercise modes, there is little evidence to recommend the optimal mode of exercise for people with lymphoedema; therefore larger scale trials are required to evaluate this. However, the most recent systematic review&nbsp;discussed that by giving people a choice over their exercise method promoted adherence to the programme<ref name="Paramanandam and Roberts 2014" />.
 
Singh et al.<ref name="Singh et al. 2015" />&nbsp;also reviewed the use of compression garments during exercise. Unfortunately due to the range of effects that wearing compression can have during exercise, there was no definitive answer to whether compression garments should be worn or not. The authors suggest that this decision should be made on an individual basis considering factors such as stage, severity, and stability of lymphoedema and patient preference.
 
Evidence suggests that exercise supervised by a qualified professional i.e. a physiotherapist in the first instance - this will ensure correct technique and reduce injury risk<ref name="Kwan et al. 2011" />.
 
It can be concluded from the body of evidence including large randomised controlled trials and recent systematic reviews that strenuous training, as previously thought does not lead to the development or worsening of lymphoedema. Despite showing little effect on lymphoedema, it is important to note the benefits that exercise has on individual’s strength, functioning and quality of life. These benefits outweigh any risks that were previously suggested.
 
To put this in relation to practice, physiotherapists and other health professionals should be encouraging patients with lymphoedema to undertake exercise programmes. Professionals should make individuals aware of the benefits that exercise can have on physical and mental wellbeing and reassure them that exercise will not worsen their lymphoedema.
 
<br>
 
'''Activity''' - take 15 minutes to think about the following case study. This can be discussed in groups if you would like to.&nbsp;<br><br>
 
<u>Case Study</u><br>Mrs. X. is a 34-year-old lady with (R) upper limb lymphoedema who completed her cancer treatment 11 months ago. She independently manages her lymphoedema with skin care; self massage and wears a compression garment. Prior to her diagnosis – Mrs. X. attended a range of gym classes including high intensity training and strength-based classes’ 3x a week, as well as running at weekends. Mrs. X. tells you she would like to return to her previous level of activity but is concerned that exercise may make her lymphoedema worse. She asks you for advice about what exercises are safe for her to do.
 
*What advice would you give her?
*Can you think of any exercises that she could do?
 
<br>
 
Have a think about this yourself at first. However, if you are struggling refer to the [http://www.cancerresearchuk.org/about-cancer/coping-with-cancer/coping-physically/lymphoedema/treating-lymphoedema/exercise-positioning Cancer Research UK<ref name="CRUK exercise" />] document or [http://www.nhs.uk/ipgmedia/national/lymphoedema%20support%20network/assets/recreationalexercise(lsn).pdf this document<ref name="LSN exercise">The Lymphoedema Support Network. Recreational Exercise With Lymphoedema. http://www.nhs.uk/ipgmedia/national/lymphoedema%20support%20network/assets/recreationalexercise(lsn).pdf (accessed 25 January 2016)</ref>] which provide advice about what and how exercise should be undertaken with lymphoedema. &nbsp;
 
<br>
 
You have reached the end of this section. By now you should have an understanding of the types and how exericse is used in the treatment of lymphoedema and the evidence which supports this.
 
 
 
Below is a summary of the key points from this section.&nbsp;
 
[[Image:Exercise key points.png]]
 
=== Manual and simple lymphatic drainage  ===
 
This section will discuss the final part of DLT known as manual and simple lymphatic drainage.
 
Emil Vodder came up with the method of manual lymphatic drainage (MLD) in 1936. He stated that MLD along with other techniques such as deep breathing and improved diet would play play a key role in lymphatic conditions&nbsp;<ref name="Williams 2010">Williams A. Manual lymphatic drainage: exploring the history and evidence base. British Journal of Community Nursing 2010;18-24. Available from: http://www.magonlinelibrary.com/doi/abs/10.12968/bjcn.2010.15.Sup3.47365 (accessed 15 January 2016).</ref>. This method of massage uses gentle strokes to enhance lymph drainage through lymphatic pathways<ref name="ILF" />. The treatment alone is not sufficient to reduce lymphoedema, however it is recommended that MLD is conducted by trained professionals in comjunction with the other components of DLT, which have been discussed previously<ref name="ILF" />.
 
Below the tables show the indications, contraindications and local contraindications of MLD<ref name="ILF" />.
 
<br>
 
[[Image:Indications.png]][[Image:Contraindications.png]][[Image:Local Contraindications.png]]<br><br>
 
'''The principles and technique of MLD''''''&nbsp;are&nbsp;stated below''''''<ref name="ILF" /><ref name="Williams 2010" />:&nbsp;'''
 
*Slow repetitive movements
*Moves proximally to distally
*Aims to increase lymph drainage without altering capillary function
*Alter interstitial pressures by varying hand movements<br>
*Incorporates breathing techniques (deep diaphragmatic breathing) to encourage drainage from deep abdominal lymph nodes and vessels<br>
*Up to one hour daily<br><br>
 
As well as MLD, another form of this treatment is known as Simple Lymphatic Drainage (SLD) - a simplified version of MLD that can be taught to people with lymphoedema or their carers to form part of a self-management programme. MLD can be performed for up to one hour daily, however SLD is performed for 10-20 minutes<ref name="Pyle 2010">Pyke C. Massage: a helping hand for people with chronic oedema and lymphoedema. Clinical Focus 2010:28-30. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20559174 (accessed 15 January 2016).</ref>.
 
Prior to teaching SLD to individuals, health professionals must consider:
 
<br>
 
<span>&nbsp;</span><br>[[Image:Teaching SLD.png]]<br>
 
 
 
'''What does the evidence say?&nbsp;'''
 
MLD has been found to reduce limb volume, improve quality of life and lymphoedema symptoms in people with cancer related lymphoedema<ref name="Williams et al. 2002">Williams AF, Vadgama A, Franks PJ, Mortimer PS. A randomised controlled crossover study of manual lymphatic drainage therapy in women with breast cancer-related lymphodema. European Journal of Cancer Care. 2002;11(4):254-261. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12492462 (accessed 18 January 2015)</ref>. However, this study had a number of flaws limiting its quality, indicating the need for further research in this area. When comparing MLD to SLD, Sitzia et al.<ref name="Sitzia et al. 2002">Sitzia J, Sobrido L, Harlow W. Manual lymphatic drainage compared with simple lymphatic drainage in the treatment of post-mastectomy lymphoedema: A pilot randomised trial. Physiotherapy 2002; 88(2):99-107. Available from: http://www.sciencedirect.com/science/article/pii/S0031940605609339 (accessed 15 January 2016).</ref>&nbsp;suggests MLD to be more beneficial at reducing limb swelling. However these results were from a small pilot study and did not reach statistical significance.
 
A more recent systematic review<ref name="Huang et al. 2013">Huang TW, Tseng SH, Lin CC, Bai CH, Chen CS, Hung CS, Wu CH, Tam KW. Effects of manual lymphatic drainage on breast cancer-related lymphedema: a systematic review and meta-analysis of randomised controlled trials. World Journal of Surgical Oncology 2013;11(15). Available from: http://www.ncbi.nlm.nih.gov/pubmed/23347817 (accessed 15 January 2016).</ref>&nbsp;evaluated the effects of MLD in preventing and treating breast cancer related lymphoedema. Overall the findings from this review were unable to support the use of MLD in the prevention or treatment of lymphoedema in this patient group.
 
Although the evidence discussed was unable to support the use of MLD and SLD to treat lymphoedema, the Lymphoedema Framework<ref name="ILF" />&nbsp;still recommend it as one of the cornerstones of decongestive lymphatic therapy. The framework suggests that despite the efficacy not being proven, MLD and SLD both have clear psychological and symptomatic benefits. Pyke<ref name="Pyle 2010" /> discussed that massage can reduce fear and reassure patients that although their skin is painful and may be damaged it can still be touched.
 
<br>Overall it can be concluded that further evidence is required to fully evaluate the benefits of MLD or SLD in the management of lymphoedema. The benefits may not reach statistical significance but the impact that MLD or SLD could have on an individual’s quality of life are important to consider. Furthermore SLD, although little evidence to support its use, allows the patient some independence as they are able to take some responsibility for the management of their condition.
 
<br>
 
You have reached the end of this section. You should now be able to discuss the role of MLD and SLD in the treatment of lymphoedema and discuss the evidence supporting this.&nbsp;<br>'''<br>Activity - '''take 5 minutes to complete the following quiz. The answers are provided throughout the text above.&nbsp;
 
<br>[[Image:MLD and SLD quiz.png]]<br>
 
<br>
 
Below is a summary of the key points from this section.&nbsp;
 
[[Image:MLD and SLD key points.png]]
 
=== Conclusion  ===
 
This section has discussed the management options for people with lymphoedema, focussing on the 4 main cornerstones of decongestive lymphatic therapy. <br>The evidence base has been discussed along with the recommendations provided by the Best Practice for the Management of Lymphoedema Framework&nbsp;<ref name="ILF" />.&nbsp;It is important to note that the treatments discussed are not stand alone therapies. Ideally, the treatment of lymphoedema should contain all components of DLT to manage symptoms and reduce complications<ref name="ILF 2012" />.
 
Although the treatment of lymphoedema is a specialist skill, which requires additional training. Based on our discussions with expert clinicians, it is important as students and new graduates to understand the principles of treatment so that they are aware of the reasons why their patients may be recieving certain treatments and are able to explain this to patients or family if required.&nbsp;
 
Despite relatively sound evidence base supporting the use of DLT as a whole, when looking into the separate components the quality of trials is not as reliable. As discussed there is a need for larger scale trials to fully evaluate the use of specified treatments in the management of lymphoedema.
 
Before progressing onto the next section of this wiki, please ensure you have taken the time to answer all the quizzes at the end of each sub-section.
 
'''By now you should be able to –'''
 
''Summarise and explain the physiotherapy management options for people with lymphoedema.''<br>
 
== Physiotherapist Role  ==
 
=== Introduction  ===
 
Physiotherapists help people to maximise their potential and maintain or improve their quality of life. In palliative care, physiotherapists have many roles.
 
<span>&nbsp;</span><br>'''These include:'''
 
*Assessment
*Symptom management
*Education and communication
*Rehabilitation and function
*Some psychological aspects of care<br>
 
=== Assessment  ===
 
This section will detail what is involved in an assessment carried out by physiotherapist's when in a palliative setting and the different types of assessment and outcome measures available.&nbsp;
 
Palliative and specialised palliative care services offer a multidisciplinary team (MDT) approach. Key principles must be applied to the assessment such as considering the patient as a whole person, focusing on quality of life rather than quantity, management should be decided by the patient and there should be good communication for effective assessment and management (ILF 2010). The assessment should involve a patient-centred approach in order to elicit the physical, social and psychological needs of the patient (Todd 2009b). <br><u></u>
 
'''The assessment should aim to:'''
 
*Understand the patient’s main concerns, goals and priorities
*Help the clinician understand the main cause of and the mechanisms behind the swelling
*Understand the underlying condition and how quickly it is progressing
 
<br>
 
Oedema is a direct result of multiple factors relating to a terminal illness. It can be distressing for patients and a management challenge for health professionals. It is estimated that 5-10% of new referrals to palliative care have oedema but this is also thought to be underestimated (ILF 2010). Heavy and swollen limbs can cause proximal pain while patients with active malignancy may experience neuropathic pain due to nerve compression. Up to 67% of patients experience pain as a result of oedema. For patients, lymphoedema may be seen as a constant reminder of their cancer or illness. The swollen limb is heavy and uncomfortable which leads to a reduction in mobility and function (Todd 2009a).
 
'''<br>The assessment includes a full history of the oedema including the following areas:'''
 
<br>[[Image:Assessment table.png|center|550x430px]]
 
<br>
 
All areas are combined with a history of the illness to understand the underlying causes better and a history of medication (ILF 2010).<br>An examination is then carried out and baseline measurements are taken. This helps to plan the programme of care, assess the response to treatment, identifies risks of complications and may show signs that confirm the cause of the oedema. However, the assessment is ongoing with constant reviewing as the disease progresses and patient priorities change (Todd 2009a). From the assessment, the priority will be to negotiate a care plan based on the patient’s problems and the best approach to alleviate these problems (Todd 2009b).<br>
 
<br>
 
<u>'''Hollistic Needs Assessment'''</u>
 
A Holistic Needs Assessment (HNA) is an assessment tool that was specifically developed for cancer patients and should be used during every cancer patient’s care. It can make a large impact on a patient’s overall care experience and can greatly improve outcomes through recognising and resolving any problems quickly (National Cancer Survivorship Initiative 2013).
 
The assessment is a process of collecting and discussing information with the patient to develop a clear understanding of what the patient knows, understands and needs. This holistic assessment considers the whole person as their well-being is discussed along with all physical, emotional, spiritual, mental, social and environmental factors. The results from this assessment are all incorporated to create a specific care plan for the patient (National Cancer Action Team, 2013).
 
It has been shown that having a holistic needs assessment near the end of a patient’s treatment helps to identify the areas that need to be discussed with a healthcare professional. The information from this discussion will then be used to develop a care plan with the patient. The care plan is there to support the patient during and after their treatment and should include;<br>
 
<br>
 
• Addressing any physical or everyday concerns<br>• Direction to local or national support groups<br>• Information about local Health and Wellbeing Clinics,educational events or self management courses available <br>• Referral to appropriate healthcare professionals for support <br>• Lifestyle advise/changes<br>• Information or referral to an appropriate physical activity programme<br>• Information or referral for advice on diet and nutrition<br>• Referral for psychological support<br>• Support related to work and finance concerns <br>• Support for spiritual needs<br>(National Cancer Survivorship Initiative 2013).<br><br><u>'''Outcome Measures'''</u>
 
An outcome measure is a tool used to measure the quality of delivery of patient care and indicator of whether an intervention has had any positive effect or not (CSP 2016).&nbsp;
 
The use of an outcome measure as a tool can be very valuable during an assessment. The main benefits are:<br>
 
• Ensures that the patient’s needs are the main focus<br>• When used effectively, it provides a structured assessment conversation allowing the patient’s worries to be prioritised<br>• Ensures that all areas of assessment are covered <br>• Patients become familiar with the tool and can be carried out by many different healthcare professionals involved in their care<br>(National Cancer Action Team 2013)<br>
 
There are a vast amount of outcome measures and assessment tools available to physiotherapists. The most commonly used within a Palliative setting include:
 
• Distress Thermometer <br>• Sheffield Profile for Assessment and Referral for Care (SPARC)<br>• Palliative Care Problem Severity Score (PCPSS)<br>• The Pepsi-Cola aide-memoire<br>
 
<br>
 
[[Image:Assessment tools-outcome measures NEW.jpg|720x870px]]<br>
 
=== Treatment challenges&nbsp;  ===
 
This section explains the challenges physiotherapist's face when treating and setting goals for palliative patients with lymphoedema.<br>
 
The main aim of palliative rehabilitation is to set treatment goals that allow a patient to maintain or improve functions and delay the effects of their disease for as long as possible. To lose their functional ability can cause a patient to view themselves differently and lose their independence which can be very detrimental to a patient. Therefore, physiotherapists have a huge role in helping patients to maintain their independence and achieve other goals they may have (Frymark et al 2009).
 
<br>Working as a physiotherapist within a palliative care setting can be very challenging as you must have a solid knowledge base about the disease your patient has as well as common physiotherapeutic treatment methods which you will have to adapt for a palliative patient as the treatment goal will be different. Goals need to be short-term and adaptable due to the changing nature of a palliative condition. Therefore, sometimes it is necessary to do a new assessment every time you see a patient due to how much their condition can vary (Frymark et al. 2009).
 
<br>
 
[[Image:Palliative Goals Diagram.jpg|center|550x400px]]
 
<br>When it comes to specifically lymphoedema patients, physiotherapists usually work towards the goal of restoring ‘near normal’ limb shape and size. However, in a palliative setting this goal is often unrealistic, therefore, goal setting must be sensible and based on what the patient needs or wants. When goal setting the patient should; have close involvement with the physiotherapist and other health professionals involved in their care and be educated on how to self-manage symptoms. Acceptable palliative goals may include, slowing down the progression of swelling and reducing other symptoms associated with lymphoedema <ref name="ILF" />.
 
<br>Patients may have dramatically reduced physical capacity. If their illness has compromised neurologic structures, they may be plegic or paretic, and therefore unable to self- bandage or perform remedial exercises. Further, they may be significantly limited by symptoms such as fatigue and dyspnoea due to marked deconditioning. The coordination, dexterity and strength requirements for bandaging and donning compression garments can elude even healthy patients; therefore, these potential difficulties should be considered when formulating a management plan for terminally ill patients <ref name="ILF" />.
 
<br>
 
[[Image:Key_points_-_treatment_challenges_new.jpg|350x300px]]
 
<br>
 
=== Management  ===
 
 
 
Traditionally Lymphoedema is managed with decongestive lymphatic therapy (DLT) and is based on four pillars of care: compression, massage, skin care and exercise (Todd 2009b). However, routine intensive management using decongestive lymphatic therapy may not be appropriate due to weakness and frailty so must be modified and adapted.
 
In a palliative setting, physiotherapists need to approach lymphoedema management with an understanding that disease processes are dynamic and may progress rapidly. In order to offer patients long-term relief, the chosen treatment plan must also have the ability to adapt quickly therefore treatment must be feasible and flexible. Therefore, DLT is modified to suit the needs of a palliative patient.&nbsp;<br>
 
Modified DLT has the capacity to significantly benefit patients with far advanced disease who have lymphoedema or multi-factorial oedema. DLT can enhance patients’ function and comfort while preventing needless complications and enhancing psychological well-being <ref name="ILF" />.
 
<br> Here is a reminder of the components of DLT that were discussed in section 3:
 
• Compression (bandages or garments)<br>• Manual Lymphatic drainage<br>• Exercises<br>• Skin care<br>
 
=== Modified Decongestive Lymphatic Therapy  ===
 
This section will go on to discuss the modifications made to decongestive lymphatic therapy when working in a palliative setting.<br>
 
<u>'''Compression bandaging&nbsp;'''</u>
 
Patients with mild swelling can be managed in compression garments either ready made or made to measure. Poorly fitted garments can damage the skin and push fluid to areas that have no compression applied, e.g. fingers. Palliative bandaging consists of layers of padding and short-stretch bandaging over a cotton liner and will include bandaging the digits. In palliative patients there is a risk of forcing fluid into adjacent areas, e.g. the genital or breast area. Expertise is required to judge the correct amount of pressure to apply to support the swollen limb but prevent truncal swelling. Any bandaging, therefore, should be carried out or supervised by a lymphoedema practitioner (Todd 2009).
 
<br>
 
<u>'''Manual lymphatic drainage&nbsp;'''</u>
 
Manual lymph drainage (MLD) is highly effective in the palliative setting. It has pain relieving properties and can significantly clear even tight, malignant oedema. MLD should avoid areas of dermal compromise, cancerous invasion, extensive fibrosis, or skin hypersensitivity. However, if MLD has been found to be effective over such areas, the treatment should be continued as the main aim of palliative care is to better a patient’s comfort and quality of life (ILF 2010).<br>
 
<br>
 
<u>'''Exercise'''</u>
 
Normal use of the limb can be sufficient to assist lymphatic flow but even normal use may be restricted in palliative patients. Pain, weight of the limb, fatigue or neurological impairment will impact on limb mobility. Relatives and carers could assist in some passive exercises if tolerated. Elevation of the limb will help reduce the gravitational component of the swelling, e.g. supporting the arm on a pillow or cushion to prevent pooling at the elbow. (Todd 2009) Aerobic activities to stimulate lymphatic return should be encouraged to patient tolerance. Aerobic exercise minimises psychological distress and fatigue among cancer patients, even those with advanced and widely disseminated disease (ILF 2010).<br>
 
<br>
 
<u>'''Skin Care'''</u>
 
In palliative patients, the skin can become very fragile and the aim is to prevent any damage. Care should be taken to wash and dry thoroughly, especially between the digits and any skin folds. Apply an unscented moisturiser to prevent drying of the skin. If compression hosiery is being applied care should be taken to prevent damage during application. Any breaks in the skin will cause lymphorrhoea – lymph fluid leaking onto the surface of the skin. The extent of the lymphorrhoea will depend on the size of the tear in the skin and whether the limb is dependent or not. The fluid causes maceration of the skin, soaking of clothing, footwear and bedding and can be very cold and distressing for the patient. Mild lymphorrhoea can be treated with an absorbent dressing and continuing with compression hosiery. In some cases, however, the management is purely palliative as bandaging may not stop the lymphorrhoea, especially if the patient is sitting in a chair for the majority of the time. Bed rest is occasionally the only cure for lymphorrhoea and this inevitably takes place as the patient gets closer to death (Todd 2009).
 
<br>
 
<u>'''Evidence'''</u>
 
Research is limited in the area of modified decongestive lymphatic therapy. Much of the advice and literature available is based on expert opinion only (ILF 2010).<br>
 
<br>Generally it has been found that patients undergoing decongestive lymphatic therapy for the management of lymphoedema have improved outcome measures when participating in a therapist supervised exercise session as part of treatment compared to carrying out a therapist-taught home exercise programme (ACPOPC 2015).
 
Reducing the size of an oedematous extremity may dramatically enhance patients’ functionality. Many patients are significantly deconditioned therefore eliminating burdensome limb volume can maximise mobility thereby reducing their risk of immobility-associated problems. Limb volume reduction may be a key factor in allowing patients to remain independent in activities of daily living (ILF 2010).
 
<br>
 
More literature that details experience with palliative patients is needed. Randomised trials are difficult to conduct in this population therefore case study based trials would be valuable (Towers 2013).
 
<br>
 
Below is some additional reading that details the<br><br><br>
 
<br>
 
=== Case study<br>  ===
 
== Competency Framework  ==
 
== Conclusion  ==
 
You have now reached the end of this learning resource. Well done!!<br>
 
Although the treatment of lymphoedema is a specialist skill and requires additional training, through communication with expert clinicians we concluded that students and newly qualified professions should be able to identify lymphoedema and understand the treatment that their patients may be receiving. <br>
 
Furthermore, it has been discussed that lymphoedema and palliative care are both current issues in Physiotherapy practice however this is rarely covered throughout university teaching. Due to this, palliative care in particular can often be quite a daunting experience for students or new graduates.
 
Based on the above points, we hope this learning resource has not only provided you with a background to lymphoedema and palliative care, but also provided you with an understanding of the available treatment and how this can be modified in a palliative setting. <br>
 
<br>
 
'''By now you should have achieved the learning outcomes which were introduced at the beginning –&nbsp;'''
 
[[Image:Learning Outcomes.png]]
 
<br>
 
Here are some additional resources that may benefit you as a future clinician. These may be of use when explaining the condition and treatment to patients or family. Furthermore, they are good sources of information to direct patients or family to if they wished for additional information at home.
 
#[http://www.nhs.uk/conditions/Lymphoedema/Pages/Introduction.aspx NHS Information<ref name="NHS Lymphoedema">NHS. Lymphoedema. http://www.nhs.uk/conditions/Lymphoedema/Pages/Introduction.aspx (accessed 26 January 2015)</ref>]
#[http://www.bupacromwellhospital.com/easysiteweb/getresource.axd?assetid=1005&type=0&servicetype=1 Bupa Cromwell Hospital patient information<ref name="Bupa Cromwell">Bupa Cromwell Hospital. Lymphoedema – a patient guide. http://www.bupacromwellhospital.com/easysiteweb/getresource.axd?assetid=1005&amp;type=0&amp;servicetype=1 (accessed 26 January 2016)</ref>]
#[http://www.lymphoedema.org/Menu3/Index.asp Lymphoedema Support Network<ref name="Lymphoedema Support Network">The Lymphoedema Support Network. What is Lymphoedema? http://www.lymphoedema.org/Menu3/Index.asp (accessed 26 January 2016)</ref>]
#[http://www.cancerresearchuk.org/about-cancer/coping-with-cancer/coping-physically/lymphoedema/what-is-lymphoedema Cancer Research UK<ref name="CRUK lymphoedema">Cancer Research UK. What is Lymphoedema? http://www.cancerresearchuk.org/about-cancer/coping-with-cancer/coping-physically/lymphoedema/what-is-lymphoedema (accessed 26 January 2016)</ref>]
 
<br>'''One final reflection – '''<br> [[Image:Conclusion reflection.png]]<br>
 
<br>
 
Thank you for taking the time to complete this learning resouce, we hope you have found it useful and enjoyable!&nbsp;
 
<br>
 
<br>
 
<br>
<div class="researchbox"></div>
 
= References  =
 
References will automatically be added here, see [[Adding References|adding references tutorial]]. <references />.&lt;/div&gt;

Latest revision as of 02:20, 13 December 2023

Original Editor - Jane Hislop Top Contributors - Charlotte Kay, Yasmin Natasha Milne, Emma Clare Sneddon, Sarah Brennan, Lauren Lopez, Kim Jackson, 127.0.0.1, Jane Hislop, Lucinda hampton, Admin and Evan Thomas

Introduction[edit | edit source]

The Palliative Care Competence Framework for Physiotherapists was designed to standardise education for undergraduates and postgraduates in Europe. It provides a guide for the acquirement of knowledge, skills and attributes needed for clinical practice in health and social care professions. This document provides flexibility and autonomy in order to develop core and discipline specific competencies which can be applied to both generalist and specialist palliative care. [1]

Core Competencies[edit | edit source]

When caring for people with life-limiting conditions who may have complex care needs, a multidisciplinary approach is preferred. The core competencies outlined in the guide are common to all health professionals and convey the primary level of understanding that is essential to provide palliative care.

There are 6 domains of competency:

  1. Principles of palliative care
  2. Communication
  3. Optimising comfort and quality of life
  4. Care planning and collaborative practice
  5. Loss, grief and bereavement
  6. Professional and ethical practice in the context of palliative care

Each domain is defined with a statement which remains the same regardless of the setting where care is provided. Each domain has an indicator that outlines the competences required by professionals depending on the context of their roles and the level that palliative care is provided. The indicators are based on advanced knowledge, skills and understanding and clinical expertise. The indicators are named “ALL”, “SOME” and “FEW” and are outlined below -

Competence.jpg

Principles of Palliative Care[edit | edit source]

The aim of palliative care is to improve the quality of life of people who are suffering with life-limiting conditions. This care does not only include the physical facet of their condition but the social, psychological and spiritual aspects also. Palliative care is applicable for people of all ages and may be introduced at any point in a disease trajectory.

Competence 1.png

Communication[edit | edit source]

Communication is an essential component to the delivery of palliative care. When caring for people with complex and life-threatening conditions, good communication is important particularly when bad news needs to be relayed or when difficult decisions regarding treatment need to be made. Communication is imperative when circumstances are uncertain or when distress and strong emotions arise.

Communication is a method of:

  • Enabling therapeutic relationships with patients and families
  • Ensuring that the patient and family are key components in decision making regarding care
  • Enabling effective inter-professional or inter-agency teamwork
Competence 2.png

Optimising Comfort and Quality of Life[edit | edit source]

People receiving palliative care are not only affected by the physical symptoms of their condition but also the psychological, spiritual and social aspects. Optimising quality of life for people is a dynamic process that involves acknowledging, anticipating, continuously assessing and responding to a range of complex symptoms and needs. The process must be done in a proactive manner to relieve suffering.

Competence 3.png

Care Planning and Collaborative Practice[edit | edit source]

In palliative care, care planning involves co-ordinating and integrating person-centred care to promote quality of life. Patients and their families should engage in the process and concerns from families or carers should be considered.

Planning involves:

  • Assessing need
  • Promoting and preserving a person’s choice
  • Predicting likely problems
  • Planning for the future in the wake of a changing or deteriorating disease trajectory.

Care planning should ensure that multi- disciplines and agencies can be referred to as required.

Comp 4.png

Loss, Grief and Bereavement[edit | edit source]

Dealing with loss, grief and bereavement is an intrinsic part of palliative care. A minority of people may be at risk of developing difficulties during their grieving. Professionals using a palliative care approach have an essential role to play for all but in particular for those who may require bereavement therapy or counselling by providing support and information.

Competence 5.png

Professional and Ethical Practice in the Context of Palliative Care[edit | edit source]

There may be a time when specific treatments or interventions are futile or burdensome. Deference in palliative care refers to the importance of respecting the patient’s wishes, needs and values when dealing with a life-limiting condition. Professional and ethical practice concerns the best way to provide continuing care as people’s care needs change during the course of their condition. It guides professionals to reflect on their contribution to a person’s care and the contribution of other professionals.

Competence 6.png

Guidelines[edit | edit source]

While the principles of palliative care have remained relatively the same over the past number of years, the evidence base surrounding interventions and how care should be delivered is constantly evolving.  The NICE guidelines - End of Life Care for Adults is one of the most recent guidelines available[2]. NICE guidelines are classed as high quality evidence and is an excellent resource for not only newly qualified professionals but for anyone working in the field of palliative care.  

References[edit | edit source]

  1. ↑ Palliative Care Competence Framework Steering Group. Palliative Care Competence Framework. http://www.hse.ie/eng/about/Who/clinical/natclinprog/palliativecareprogramme/Resources/competencyframework.pdf (accessed 20 Nov 2015).
  2. ↑ End of life care for adults: service delivery NICE guideline [NG142]Published: 16 October 2019 Available:https://www.nice.org.uk/guidance/NG142 (accessed 13.12.2023)
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