Palliative Care Competence Framework for Physiotherapists

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Introduction and Learning Outcomes

Aims

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:

1. The role of a physiotherapist in the management of people with lymphoedema
2. The implications for physiotherapy practice when managing people with lymphoedema in a palliative care setting

Learning Outcomes

By the end of this wiki you should be able to:

1. Discuss the background of lymphoedema and describe the key presenting symptoms
2. Discuss the physiotherapist’s role in the management of people with lymphoedema
3. Critically reflect on the physiotherapist’s approach in the management of people with palliative care needs who have lymphoedema
4. Critically appraise and synthesise the literature relating to the end of life care for a person with lymphoedema

Treatment and Management of Lymphoedema

Introduction

The Lymphoedema Framework (2006) states that the treatment of people with lymphoedema should be specifically tailored based on the site, severity and complexity as well as their psychosocial situation. Furthermore the success of treatment does not solely rest on the therapist, patients and carers must play an active role from an early stage.

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, the psychosocial issues can be reduced to enhance the individual’s quality of life (Kim and Park 2008).

Decongestive lymphatic therapy (DLT) is viewed as the gold standard of care for lymphoedema (Chang and Cormier 2013). Kim and Park (2008) found this treatment approach effective and significantly reduced the percentage excess limb volume as well as improving quality of life.

Decongestive lymphatic therapy encompasses four main components (Todd 2009);
• Compression
• Skin care
• Exercise
• Massage

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 (Korpan et al. 2011). This is achieved through a number of approaches aiming to reduce the load and decongest the lymphatic system, stimulate the function and encourage drainage through various routes (Lymphoedema Framework 2006). 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.

Over the next four sections of this wiki you will learn more about each of the components of DLT.

Take 5 minutes -
Can you…

• Think of any psychological issues that you may encounter if treating a patient with lymphoedema?
• Name the four cornerstones of lymphoedema treatment?
• List the goals during intensive therapy?

By this stage you should be able to identify the four cornerstones of DLT and state the general aims of the intensive and maintenance stages of treatment.

Over the next section this wiki will discuss the four components of DLT in detail with reference to the supporting evidence.

Compression Therapy

Compression therapy consists of two main methods – multilayer lymphoedema bandaging (MLLB) and compression garments. Overall, compression therapy increases lymphatic drainage, reduces capillary function, promotes fluid movement to less compressed areas of the body and improves the action of the venous pump (Cooper 2015). Furthermore, bandaging aims to improve the shape of the limb, soften fibrosclerotic tissue, support and improve skin condition and manage symptoms (Foldi et al. 2005; Williams and Keller 2005).

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 (Lymphoedema Framework 2012). However MLLB may also be used as part of long-term management if compression garments are not suitable (Moffatt et al. 2005).

The combined treatment of bandaging followed by compression garments has been found to yield better results for reduction of moderate to severe lymphoedema compared with bandaging alone. This benefit was observed as being maintained for at least six months (Badger et al. 2000), hence this is the recommended course of treatment for people with lymphoedema (Lymphoedema Framework 2012).

Indications for compression therapy as stated by the Lymphoedema Framework (2006) are:

• Fragile, damaged or ulcerated skin
• Distorted limb shape
• Limb too large for compression garments
• Areas of tissue thickening
• Lymphorrhoea
• Lymphangiectasia
• Pronounced skin folds

Not all patients will be suitable for compression therapy and this decision needs to be made by patient and clinician. There are a number of contraindications stated below (Lymphoedema Framework 2006):

• Severe arterial insufficiency
• Uncontrolled heart failure
• Severe peripheral neuropathy

If patients present with any of the above conditions, a decision regarding different methods of treatment will need to be discussed.

<uPICTURE 1

MLLB:
MLLB generally consists of a tubular lining, digit bandages, padding and layers of inelastic bandages. Due to the rapid change in limb shape and oedema reduction during the first 1-2 weeks bandages need to be changed daily to maintain the pressure (Williams and Keller 2005).

The pressure applied through bandages is based on Lapase’s Law (Urgo Medical 2009) –

PICTURE 2

<uP = pressure under the bandage (in mmHg),
T = bandage tension (Kgf)
N = number of layers
C = limb circumference (cm)
W = bandage width (cm)

Bandages used are inelastic which result in high and low pressures exerted during movement and rest respectively (Moffatt et al. 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 (Lymphoedema Framework 2006).

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 (Lymphoedema Framework 2006). 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 (Williams and Keller 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 (Williams and Keller 2005).

Bandaging a lymphoedema arm: (approx. 10 mins)

YOUTUBE VIDEO 1

Bandaging a lymphoedema leg: (approx. 10 mins)

YOUTUBE VIDEO 2<u

Inelastic and elastic bandages have been discussed, however more recently, a new bandaging system known as Coban 2 has been developed which can be used an alternative to MLLB. Coban 2 consists of a comfort layer and a compression layer that cohesively bond together (Lamprou et al. 2011). This eliminates the need for a thick padding layer that MLLB requires, resulting in a much less bulky appearance allowing patient’s more mobility and freedom.

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.

Franks et al. (2012) 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.

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.

A multicentre randomised controlled trial with 82 participants (Moffatt et al. 2011) investigating the frequency of application of Coban 2. 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.

Coban 2 bandaging: (approx. 15 mins)
YOUTUBE VIDEO 3

As discussed, a number of trials have evaluated the effects of compression bandaging for lymphoedema, which have found positive results. The development of Coban 2 bandages is encouraging, however this still requires larger scale trials to fully evaluate the efficacy.

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 (Lymphoedema Framework 2006).

Compression Garments/Hosiery
These made-to-measure, handmade garments will be considered once regular limb shape has been restored and the patient’s skin is fully intact and robust enough to tolerate the use of garments (Doherty et al. 2009; Linnitt and Davies 2007).

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. (2009) explains that patient’s stage and severity of lymphoedema, shape and size of limb, skin resilience, shape distortion, ability to tolerate, lifestyle, mobility, age, psychological status and dexterity should be assessed and considered prior to measurement and fitting.

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 (Moffatt et al 2005).
Measurement for hosiery will be undertaken by a qualified health professional, which may be a physiotherapist

<uPICTURE 3

Garments are either constructed as a flat knit or a round knit. Flat knit 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 (Lymphoedema Framework 2006).

Once measurement and construction of the garment is completed advice regarding the care at home will be provided in person and leaflets may also be given to the patient (Lymphoedema Framework 2006). 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 (Doherty et al. 2009).

As well as limb compression garments, if patients have trunk or breast lymphoedema garments or specialised bras can be provided (Lymphoedema Framework 2006).

Activity

Before progressing to the next section please take 15 minutes to check your knowledge of the following:

• List 3 indications for compression therapy
• Name 3 contraindications to compression therapy
• List the components of MLLB
• Understand (discuss with a partner) how bandaging can be altered to suit the patients needs
• Discuss the differences between MLLB and Coban 2 bandaging
• What are the benefits of using Coban 2 over MLLB?
• Name and explain the 2 kinds of compression hosiery
• What should be considered when assessing for compression hosiery?

Skin Care

Lymphoedema cause changes to the skin including thickening, hyperkeratosis, hyperpigmentation and papillomatous or verrucous nodules (Nowicki and Siviour 2013). As a consequence of swelling, large skin folds can appear where infections may develop (Lymphoedema Framework 2006). Furthermore infections may 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 (Lymphoedema Framework 2006; Wigg and Lee 2015). At both intensive and maintenance stages, it is important to emphasise the need for a skin care regime to maintain the skin integrity.

The Lymphoedema Framework (2012) outlines the main principles of skin care:
• Wash daily
• Ensure skin folds are clean and dry
• Monitor the skin for changes
• Apply emollients
• Avoid scented products
• Using vegetable-based products in tropical climates rather than petrolatum or mineral oil based products

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 barrier to protect from bacteria and other irritants (Lymphoedema Framework 2012).

Any soap that is abrasive or scented are to be avoided, natural or pH neutral soaps are recommended (Lymphoedema Framework 2006; Nowicki and Sivour 2013). This is because normal soaps contain detergents, are often scented and include preservatives, which can irritate or dry the skin.

During assessment, health professionals must inspect the skin condition using palpation and observation to check for any changes or damage (Nowiki and Siviour 2013). If changes have occurred these must be managed and monitored correctly.

Following assessment and cleansing of the skin emollients are applied to maintain skin hydration. These can either be moisturisers, soaps substitutes or bath oils. Moisturisers come in different forms including cream, lotion and ointments (Nowicki and Siviour 2013). The Lymphoedema Framework (2006) recommends the use of ointments, which contain little or no water; this hydrates the skin better than creams and lotions.

Despite the treatment offered infections may still occur that must be managed by thorough skin hygiene, ensuring skin is dried following washing and an anti-fungal powder or cream applied until the infection disappears (Nowicki and Sivour 2013).

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 (Nowicki and Siviour 2013).

Despite being an integral part of lymphoedema management, some patients experience barriers that prevent adequate skin care and result in infections. James (2011) 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 to facilitate self-management.

''Activity

Take 10 minutes –

Can you…

List the main principles of skin care?
Explain why are emollients important?
True or false – is ointment recommended over lotions?
Take 5 minutes to think of how you would explain the importance of skin care to a patient you are treating? If possible discuss this with a partner.

Exercise

MacMillian Cancer Support (2013) 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 (NHS Choices 2015), studies report that cancer survivors often fail to return to their pre-diagnosis levels of physical activity (Irwin et al. 2003; Harrison et al. 2009).

Traditionally strenuous exercise was discouraged in patients with lymphoedema based on the belief that it may exacerbate the condition (Cheifetz et al. 2010). However recent studies and systematic reviews contradict this statement.

Schmitz et al. (2009) evaluated the effects of a weightlifting programme on 141 participants presenting with breast cancer related upper limb lymphoedema. Due to the relatively large sample size the results of this study are significant in proving that weight lifting did not produce an increase in limb swelling. Furthermore, the study found that the exercise programme resulted in a decrease in lymphoedema exacerbations and symptoms.

Singh et al. (2015) reviewed the effects of single bouts of exercise and regular training with mixed exercise modes on cancer related lymphoedema. Overall this review concluded that independent of the mode of exercise – resistance or aerobic – there were no detrimental effects on the subject’s lymphoedema. Despite showing little effect on lymphoedema, it is important to note that exercise improved the functioning of subjects through improving their ability to carry out activities of daily living. Singh et al. (2015) 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 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.

Further smaller studies found that combined exercise programmes including aerobic and resistance exercises were safe and had no harmful effects for patients with upper limb lymphoedema (Hayes et al. 2009; McKenzie and Kalda 2003). Again both of these studies supported the statement that exercise does not exacerbate lymphoedema but it does have a positive psychological impact, particularly in relation to quality of life.

Kwan et al. (2011) suggest that exercise supervised by a qualified professional i.e. a physiotherapist in the first instance to ensure correct technique and reduce injury risk. Paramanandam and Roberts (2014) made an important point that giving patients a choice in their exercise programme improved their adherence.

Overall it can be concluded from the body of evidence including systematic reviews and large randomised controlled trials that strenuous training as previously thought does not worsen or cause lymphoedema in breast cancer survivors. The benefits of exercise on individual’s strength, functioning and quality of life outweigh any risks. Furthermore, there is little evidence to recommend that one mode of exercise is superior to others, which allows individuals the freedom of choice of exercises. This choice is likely to positively impact the adherence to exercise programmes. Hence physiotherapists and other health professionals should be encouraging their patients with lymphoedema to undertake exercise programmes and make individuals aware of the benefits that exercise can have on physical and mental wellbeing.

Activity

Take 10 minutes to think about the following case study. This can be discussed in groups if you would like to.

Case Study
Lady with (R) UL lymphoedema has completed cancer treatment. She independently manages her lymphoedema with skin care; self massage and wears a compression garment. This lady tells you she would like to get back to her previous levels 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 5 exercises that she could do either at home or in the gym?

Manual and Simple Lymphatic Drainage

Emil Vodder came up with the method of manual lymphatic drainage (MLD) in 1936. He stated “MLD along with breathing and relaxation exercises and improved diet would play a key role in lymphatic disorders” (Vodder 1965, pp *** in Williams 2010). This method of massage uses gentle strokes to enhance lymph drainage through lymphatic pathways (Lymphoedema Framework 2006). The treatment is conducted by trained professionals and is used in combination with the other components of decongestive therapy, as it is not enough to be used alone (Lymphoedema Framework 2006).
Indications:
• Swelling at root of the limb
• Trunk or midline swelling – may be used alone in this instance as it could be the only suitable treatment
• Provision of comfort or pain relief
• Adjunct to pain management
(Lymphoedema Framework 2006)

Contraindications:
• Acute cellulitis/erysipelas
• Renal failure
• Unstable hypertension
• Severe cardiac insufficiency
• Hepatic cirrhosis with abdominal fluid
• Superior vena cava obstruction
• Untreated tuberculosis or malaria
Local contraindications (not to be used at these sites):
• Untreated thyroid dysfunction
• Primary tumours
• Metastases
(Lymphoedema Framework 2006)

Principles and technique:
• Slow repetitive movements
• Aims to increase lymph drainage without altering capillary function
• Alter interstitial pressures by varying hand movements
• Moves proximally to distally
• Incorporates breathing techniques (deep diaphragmatic breathing) to encourage drainage from deep abdominal lymph nodes and vessels
• Up to one hour daily
(Lymphoedema Framework 2006; Williams 2010)
As well as MLD another form of this treatment is 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 (Pyke 2010).
Prior to teaching SLD to individuals, health professionals must consider:
• Motivation of the individual
• Dexterity
• Time allocated for teaching which should be progressive
• Written instructions provided
• Check technique competency and how the individual is coping regularly
MLD has been found to reduce limb volume, improve quality of life and lymphoedema symptoms in people with cancer related lymphoedema (Williams et al. 2002). 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. (2002) 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 (Huang et al. 2013) 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 (2006) 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 (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.
Overall 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.

Activity

Take 5 minutes -
Questions:
What is the difference between MLD and SLD?
True or false – MLD is started distally and works proximally?
What are the contraindications for MLD and SLD?

References

References will automatically be added here, see adding references tutorial. .</div>