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?

References

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