The role of a community conversation intervention in reducing stigma related to lower limb lymphoedema in Northern Ethiopia.

BACKGROUND: Stigma related to lower-limb lymphoedema poses a major psychosocial burden to affected persons and acts as a barrier to them accessing morbidity management and disability prevention (MMDP) services. Community Conversation (CC), which actively engages community members and disseminates health information amongst them, is believed to break the vicious cycle of stigma by enhancing disease-related health literacy at the community level. METHODS: A quasi-experimental study was conducted in Northern Ethiopia to assess the role of the CC intervention in reducing stigma. In two control districts, a comprehensive and holistic MMDP care package was implemented that included physical health, mental health and psychosocial interventions, whilst in the intervention district the CC intervention was added to the MMDP care package. A total of 289 persons affected by lymphoedema and 1659 community members without lymphoedema were included in the study. RESULTS: Over the course of the intervention, in all sites, community members' knowledge about the causes of lymphoedema increased, and perceived social distance and stigmatizing attitudes towards people with lymphoedema decreased in the community, whilst experienced and internalized stigma decreased amongst affected persons. There were no significant changes for perceived social support. However, the changes were greater in the control sites overall, i.e. those districts in which the holistic care package was implemented without CC. CONCLUSION: The findings suggest that the CC intervention provides no additional stigma reduction when used alongside a holistic MMDP care package. Provision of comprehensive and holistic MMDP services may be adequate and appropriate to tackle stigma related to lower-limb lymphoedema in a resource-constrained setting like Ethiopia.

Knowledge, attitude and practice of physiotherapists about lymphedema: A Turkish perspective.

BACKGROUND: Physiotherapists are important members of the healthcare team in the management of lymphedema. Therefore, the level of knowledge and awareness of physiotherapists on this disease is substantial. This study was planned to investigate knowledge, attitude, and practice of physiotherapists about lymphedema in Turkey. METHOD: This study was a qualitative, prospective, and cross-sectional research. Data were collected with the web-survey which consisted of the demographical characteristics information, evaluation of their own knowledge and practice in lymphedema management, and current knowledge of physiotherapists about lymphedema based on the current literature. RESULTS: Two hundred seventy-four physiotherapists (174 Female: 100 Male; mean age: 29.87 ± 6.9 years) completed the web-survey. From 274 physiotherapists, 52.60% of them had no education about lymphedema, 13.90% of them had never seen any patient with lymphedema, and 57.70% of them had not taken part in the management of a patient with lymphedema. 71.90% of the physiotherapists did not think they have enough knowledge about lymphedema. It was identified that physiotherapists' general and risk factors knowledge about lymphedema was sufficient. However, physiotherapists showed a lack of knowledge on the evaluation, treatment, and recommendations for lymphedema. CONCLUSION: Physiotherapists' education and experience in lymphedema management are crucial as they are important members of the multidisciplinary team. To raise qualified physiotherapists in this field, from undergraduate education, special training programs about lymphedema should be added to their lifelong learning process.

Managing lymphoedema following treatment for head and neck cancer: is complete decongestive therapy an effective intervention to improve dysphagia outcomes?

PURPOSE OF REVIEW: The purpose of this review is to summarize current evidence regarding management of head and neck lymphoedema (HNL) to improve dysphagia outcomes following head and neck cancer (HNC) treatment. This review aims to support complete decongestive therapy (CDT) comprising compression, manual lymphatic drainage (MLD), exercises and skincare as an adjunct of dysphagia rehabilitation. RECENT FINDINGS: Research in the limbs supports the use of CDT to improve lymphoedema outcomes. Emerging evidence supports the use of CDT for the head and neck, though, there is no consensus on optimal treatment required to improve dysphagia outcomes. Current evidence is limited due to a paucity of randomized controlled trials, case series or cohort studies with small participant numbers, and a lack of functional and instrumental dysphagia outcome measures. This provides a foundation to design and test an individually tailored programme of HNL intervention to evaluate swallowing outcomes post CDT. SUMMARY: As the incidence of HNC is increasing with HPV, with patients living for longer with late effects of HNC treatment, it is vital to understand how the presence of HNL impacts on the swallow, and if functional dysphagia outcomes improve following treatment of HNL. Prospective, longitudinal research with objective and functional outcome measures are required to help determine optimal management of HNL and its impact on the swallow.

Manual lymphatic drainage: the evidence behind the efficacy.

Manual lymphatic drainage (MLD), a specific type of massage performed by specialists that aims to enhance the filling and emptying of lymph vessels, is often recommended as an essential part of a successful management strategy for lymphoedema. However, the literature on its efficacy is often contradictory, and its addition may not always be necessary. To ensure optimal understanding of practitioners and benefit to patients, Francesca Ramadan summarises the evidence-based advantages and limitations of MLD.

A new lymphedema treatment using pyro-drive jet injection.

Lymphedema, resulting from impaired lymphatic drainage, causes inflammation, fibrosis and tissue damage leading to symptoms such as limb swelling and restricted mobility. Despite various treatments under exploration, no standard effective therapy exists. Here a novel technique using the pyro-drive jet injection (PJI) was used to create artificial clefts between collagen fibers, which facilitated the removal of excess interstitial fluid. The PJI was used to deliver a mixture of lactated Ringer's solution and air into the tail of animals with secondary skin edema. Edema levels were assessed using micro-CT scanning. Histopathological changes and neovascularization were evaluated on the injury-induced regenerative tissue. Regarding tissue remodeling, we focused on connective tissue growth factor (CTGF) and vascular endothelial growth factor (VEGF)-C. PJI markedly diminished soft tissue volume in the experimental lymphedema animals compared to the non-injected counterparts. The PJI groups exhibited a significantly reduced proportion of inflammatory granulation tissue and an enhanced density of lymphatic vessels and α-smooth muscle actin (αSMA)-positive small vessels in the fibrous granulation tissue compared to the controls. In addition, PJI curtailed the prevalence of CTGF- and VEGF-C-positive cells in regenerative tissue. In a lymphedema animal model, PJI notably ameliorated interstitial edema, promoted lymphatic vessel growth, and bolstered αSMA-positive capillaries in fibrous granulation tissue. PJI's minimal tissue impact post-lymph node dissection indicates significant potential as an early, standard preventative measure. Easily applied in general clinics without requiring specialized training, it offers a cost-effective and highly versatile solution to the management of lymphedema.

Initiating and Maintaining Complete Decongestive Therapy Self-Management of Lymphedema Among Breast Cancer Survivors: Descriptive Qualitative Study.

PURPOSE: This study aimed to identify determinants that promote the initiation and maintenance of complete decongestive therapy (CDT) as well as effective strategies for mitigating barriers to self-management of lymphedema among breast cancer survivors. METHODS: A descriptive and qualitative design was used. In-depth interviews were conducted with 13 breast cancer survivors who were managing breast cancer-related lymphedema. Interviews were transcribed verbatim. An iterative descriptive data analysis method was employed to examine the data, compare codes, challenge interpretations, and inductively identify themes. RESULTS: A realization that lymphedema requires daily self-management was the primary determinant leading breast cancer survivors to initiate CDT self-management. The determinants for maintaining daily CDT self-management included the perceived effectiveness of CDT, being willing to assume accountability, and perceived efficacy to undertake CDT. Developing strategies to integrate CDT regimens into daily life is key to maintaining CDT self-management of lymphedema. Three core concepts mediate initiation and maintenance of CDT self-management: understanding lymphedema as a chronic condition that can be managed with CDT self-management, being worried about lymphedema exacerbation, and having support from patient peers and family. CONCLUSIONS: Interventions should be tailored to promote the initiation and maintenance of CDT self-management. While clinicians provided knowledge-based and clinical skills-based information, patient peers provided daily life examples, and real-life implementation strategies for CDT self-management. Ongoing patient-provider and patient-peer communication functioned as effective support for maintaining CDT self-management. Reliable and realistic methods of symptom self-assessment are important for maintaining CDT at home.

Psychological Changes During Inpatient Conservative Treatment for Lymphedema.

Background: Learning self-care for lymphedema is essential for patients to maintain their quality of life; however, it is sometimes difficult and stressful. There are only few studies about the psychological changes in patients hospitalized for conservative therapy. The purpose of this study was to evaluate the psychological changes in patients admitted for conservative therapy and training in self-care for lymphedema. Methods and Results: Nine patients who were hospitalized for conservative treatment of lymphedema of the lower limbs were administered the Profile of Moods States questionnaire twice: day of admission or the following day and after 5 days of hospital stay. Eight female patients and one male patient were included in this retrospective study. The mean age was 67.2 years. We provided standard compression therapy, manual lymph drainage, and exercise therapy to the patients. The Profile of Moods States 2nd edition, Japanese version of the Profile of Moods States, was used as an evaluation method of the psychological state. The results of the psychological tests were evaluated by a certified public psychologist. The scores for negative mood (anger or hostility, confusion or bewilderment, depression or rejection, fatigue or inertia, and tension and anxiety) were all lower on the fifth day of hospitalization compared with those at admission. In particular, the tension or anxiety scores decreased significantly (p = 0.019). However, the vigor or activity scores tended to increase. Conclusions: It was found that inpatient conservative therapy for lymphedema had a positive effect on the psychological state of the patients. Despite stressors such as a change in environment and introduction of new treatments (compression therapy and exercise therapy), the improvement in edema helped elevate the mood of the patients by the fifth day of hospitalization.

Application of Complete Decongestive Therapy in Patients with Secondary Bilateral Lower Limb Lymphedema after Comprehensive Treatment of Gynecological Malignant Tumor.

Objective: The purpose of this study is to investigate the effect of complete decongestive therapy (CDT), based on fluoroscopy-guided manual lymph drainage (FG-MLD), combined with intermittent pneumatic compression (IPC) on patients with secondary bilateral lower limb lymphedema after comprehensive treatment for gynecological malignant tumors. Methods: After comprehensive treatment for gynecological malignant tumors, 18 patients suffering from bilateral lower limb lymphedema were evaluated and treated by specialist nurses (with the qualification of lymphedema therapists). The treatment course included manual drainage, IPC, bandaging, functional exercise, and skincare etc., which are performed once a day for a total of 18 times. Results: After performing the treatment 18 times, a significant reduction is observed in the patient's bilateral lower limb circumference, extracellular water (ECW) content, and lower limb segment ECW ratio. Moreover, the 50-kHz bioelectrical impedance and quality of life (QoL) scores are found to be significantly higher than before treatment (all p < 0.05). Subjective symptoms also improve significantly (p < 0.05), except for local swelling (p = 0.289 > 0.05). Conclusions: CDT based on FG-MLD, combined with IPC, effectively relieves secondary bilateral lower limb lymphedema after comprehensive treatment of gynecological malignant tumors. It also improves subjective symptoms and patients' QoL, thus deserving clinical reference and promotion.

Effectiveness of manual lymphatic drainage in intensive phase I therapy of breast cancer-related lymphedema-a retrospective analysis.

BACKGROUND: The standard therapy for lymphedema of any origin is complex physical decongestive therapy (CDT). It comprises manual lymph drainage (MLD), compression therapy (CT), exercise therapy (ET), skincare, and patient education. Additionally, intermittent pneumatic compression (IPC) can be applied. However, the contribution of MLD to decongestion is repeatedly questioned. PATIENTS AND METHODS: This study re-analyzes a previous study during a 3-week decongestion period, comparing two different types of compression bandaging at the weekend. Sixty-one patients with unilateral breast cancer-related lymphedema were included. The patients received the same therapy (CDT + IPC) except for the different weekend compression bandaging. MLD was performed twice a day on weekdays. The volume of the affected arm was measured on days 1, 5, 8, 12, 15, 19, and 22. For the analysis, the data of both study groups were pooled. RESULTS: During the week, the patients showed a significant volume reduction (- 155.23 mL (week 1), - 101.02 mL (week 2), - 61.69 mL (week 3), respectively; p < 0.001 each) with a high effect size. On the weekends without MLD, they showed a slight, but also significant increase (12.08 mL (weekend 1), 8.36 mL (weekend 2), 4.33 mL (weekend 3), respectively; p < 0.001 each) with a medium effect size. CONCLUSIONS: We showed a strong effect of MLD on volume reduction. Differences from other studies are the larger study population and the more intensive application of MLD. If applied intensively, MLD is strongly decongestive during a 3-week decongestion therapy for breast cancer-related lymphedema.

Can Acupuncture be a Part of the Treatment for Breast Cancer-Related Lymphedema? A Systematic Review of the Safety and Proposed Model for Care.

Acupuncture is a potential therapy for breast cancer-related lymphedema (BCRL). Despite a recent meta-analysis on efficacy, data on acupuncture safety in BCRL are lacking. Current clinical guidelines recommend avoiding needling in the upper extremity affected by lymph node dissection. We undertook a systematic review focusing on acupuncture safety and treatment protocols in clinical trials for BCRL. Literature searches were conducted in PubMed, Ovid, CINAHL, and Cochrane library. Eight clinical trials on acupuncture for BCRL were analyzed. The Standards of Acupuncture intervention (STRICTA 2010) and Cochrane risk of bias (RoB2 2019) were applied to assess methods for acupuncture interventions within Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework. Quantity and severity of adverse events (AE) were reviewed. A total of 189 subjects participated in 8 clinical trials with 2965 acupuncture treatments. No serious adverse events (SAE) were reported regardless of treatment laterality or protocol, with only a single grade 2 skin infection in 2,965 total treatments (0.034%), including 1,165 bilateral and 225 ipsilateral treatments. Our comprehensive review of clinical trials of acupuncture for BCRL demonstrated no significant adverse events in 2,965 treatments, including 1,390 in the affected limb. An approach for routine integration of acupuncture into BCRL maintenance therapy is proposed.

"Whenever I tell her to wear slippers, she turns a deaf ear. She never listens": a qualitative descriptive research on the barriers to basic lymphedema management and quality of life in lymphatic filariasis patients in a rural block of eastern India.

BACKGROUND: Chronic lymphatic filariasis patients in Bihar, India, need management of lymphedema to live a disability-free life. For patients who have recurrent attacks of acute dermato-lymphangio-adenitis (ADLA), World Health Organization (WHO) has recommended simple home-based measures that include maintaining hygiene, skin care, and limb movement. However, patients in rural areas are unable to adopt them, resulting in a vicious cycle of ADLA attacks. There might be multiple realities from patients' and healthcare workers' perspectives that were unexplored. Qualitative research was deemed best suitable to identify the barriers to carrying out home-based lymphedema practices that adversely affected quality of life. METHODS: The qualitative descriptive study was conducted in two villages in the rural field practice area under a tertiary care hospital in Bihar. Researchers purposively selected ten participants, including patients affected by lymphedema, their caregivers, the grassroots healthcare workers, and the block health manager. In-depth interviews were conducted using a semi-structured interview guide. Data were entered into QDA Miner Lite, where researchers did attribute, in-vivo, process, descriptive, emotion, and holistic coding, followed by content analysis, where categories and themes emerged from the codes. RESULTS: Three themes emerged: the inherent nature of disease, patient-related factors, and healthcare system-related factors. The fifteen identified barriers were low awareness, low adherence, low health-seeking behavior, poor personal hygiene, and categories like signs and symptoms, seasonal factors, hampered activities of daily living, hopelessness from not getting cured, psychosocial difficulty, lack of capacity building and receipt of incentives by healthcare workers, unavailability of laboratory diagnosis and management of complications at the facility, inconsistent drug supply, and no financial assistance. CONCLUSIONS: Accessibility to WaSH, regular training of home-based care, increasing the capacity and motivation of grassroots workers, and the generation of in-depth awareness among the patients are required to achieve the elimination of filariasis, with MMDP as a key component of that strategy for endemic districts across the whole country.

Effectiveness of manual lymphatic drainage and intermittent pneumatic compression in lymphedema maintenance therapy.

Background: To compare the effectiveness of intermittent pneumatic compression (IPC) and/or manual lymphatic drainage (MLD) associated to compression stockings in the maintenance treatment of lymphedema. Patients and methods: Patients in the maintenance phase of lymphedema therapy with MLD and compression since more than a year with stable values for weight and circumferences of ankle and calf were asked to participate in a study: Compression had to be worn daily, (1) 4 weeks IPC+MLD, (2) 4 weeks MLD alone, (3) 4 Weeks IPC alone (Order 1 and 3 was randomized). At the beginning and after each 4 weeks, circumference measurements (by hand and by machine: BT600®, Bauerfeind) were documented, pain and discomfort were assessed, and quality-of-life questionnaires were completed. Results: Of 20 participants, 18 (14 female, 4 male), mean age 59.6 years (48-89) could be evaluated. 11 subjects had bilateral, 7 unilateral, 5 primary, 13 secondary lymphedema since 2-20 years (mean 7.7), the subjects had received MLD and compression for 2-14 years (mean 6.4), 1-3 times per week (mean 1.5). The BMI ranged between 21 and 47 (mean 33.7). No differences between any phases were found for: Calf and thigh volume, circumference of calf. Only the ankle circumference was significant less (-0.22 cm) when using "both" (IPC+MLD). Compared to before the study, quality of life was better in all three phases, but with a significantly higher improvement in the phases with IPC than in the phases without. Conclusions: There were no differences in objective measurement between MLD alone, IPC alone or both, excepting the minimal significant difference in ankle circumference after IPC+MLD. QOL favored IPC application. Considering the economic consequences of these results, a change of maintenance therapy with MLD weekly over years in favor of permanent care with IPC and few appointments of MLD per year should be considered and further investigated.

[Lidong needling therapy combined with functional exercise in treatment of upper limb lymphedema after breast cancer surgery: a randomized controlled trial].

OBJECTIVE: To observe the clinical efficacy of lidong needling therapy (acupuncture technique combined with therapeutic movement of the body) on upper limb lymphedema after breast cancer surgery in combination with functional exercise. METHODS: A total of 73 patients with postoperative lymphedema of breast cancer in the upper limbs were randomized into an observation group (36 cases) and a control group (37 cases). The routine nursing care and functional exercise were given in the control group, twice a day, for about 10-15 min each time, lasting 8 weeks. On the basis of the treatment as the control group, lidong needling therapy was applied to the acupionts on the affected upper limb, i.e. Jianyu (LI 15), Waiguan (TE 5), Hegu (LI 4) and ashi points (the most obvious swelling sites), as well as to bilateral Yinlingquan (SP 9) and Zusanli (ST 36), etc. The needles were retained for 30 min. While the needles retained, the patients were asked to move the affected shoulder to 90° by the sagittal anteflexion and keep it elevated. Simultaneously, the hand on the affected side was clenched and opened slowly and coordinately. Lidong needling therapy was delivered once every two days, three times weekly for 8 weeks. Before and after treatment, the difference of the circumference between the affected and healthy limbs, the score of visual analogue scale (VAS) for swelling and the score of disability of arm, shoulder and hand (DASH) were compared in the patients of the two groups. The clinical efficacy was evaluated. RESULTS: After 2, 4, 6 and 8 weeks of treatment, except for the circumference of the area 10 cm below the cubitel crease in the control group, the differences in the circumferences of the rest parts between the affected and healthy limbs were reduced in comparison with those before treatment in the two groups (P<0.01, P<0.05). After 6 weeks of treatment, in the observation group, for the circumference at the level of hand between the thumb and the index finger and that of the wrist, the differences between the affected and healthy limbs was smaller compared with those in the control group (P<0.05). After 8 weeks of treatment, except for the areas 5 cm below and above the cubitel crease, the differences of circumferences between the affected and healthy limbs in the observation group were smaller than those in the control group in the rest parts (P<0.01, P<0.05). After 8 weeks of treatment, the swelling VAS scores were reduced when compared with those before treatment in the two groups (P<0.05), and the score in the observation group was lower than that in the control group (P<0.01). After 4 and 8 weeks of treatment, DASH scores were reduced in comparison with those before treatment in the two groups (P<0.01). The total effective rate of the observation group was 83.3% (30/36), which was higher than that of the control group (35.1%, 13/37, P<0.01). CONCLUSION: Lidong needling therapy combined with the functional exercise obtains the satisfactory clinical effect on the upper limb lymphedema after breast cancer surgery. This treatment effectively relieves swelling and improves the upper limb function.

Assessment and management of upper limb lymphoedema in advanced disease: a case study.

Lymphoedema is thought to affect around 200 000 people in the UK (NHS England, 2023). Secondary lymphoedema is a relatively common complication of cancer and cancer treatment, and in advanced disease it may present a challenging issue for community nursing staff caring for patients approaching the end of their lives. In this article, a case study considers the assessment and treatment of upper limb lymphoedema in a patient with advanced metastatic breast cancer. Management of this complex and distressing condition requires holistic assessment and collaborative care planning with the patient and their wider care team, including onward referral to specialist lymphoedema and palliative care services. The case study considers the typical presentation of lymphoedema in an upper limb, exclusion of reversible causes for oedema, awareness of palliative care emergencies such as superior vena cava obstruction, and the provision of supportive therapeutic interventions in context of the patient's expressed wishes for her ongoing care.

Quality of evidence supporting the role of acupuncture for breast cancer-related lymphoedema: an overview of systematic reviews and meta-analyses.

BACKGROUND: Breast cancer-related lymphedema (BCRL) may benefit from acupuncture as a therapeutic. However, the findings of systematic reviews (SRs) and meta-analyses (MAs) are inconsistent and their quality needs to be evaluated critically. We aimed to provide an overview of the methodological quality, risk of bias, quality of reporting, and quality of evidence for SRs/MAs of acupuncture for BCRL. METHODS: Publications were retrieved from four Chinese databases and four English databases. The methodological quality, risk of bias, reporting quality, and evidence quality of the included SRs/MAs were assessed by two independent researchers using the A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR-2), Risk of Bias in Systematic Reviews (ROBIS), Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and Grading of Recommendations, Assessment, Development and Evaluation (GRADE), respectively. RESULTS: There were a total of 8 SRs/MAs included. By AMSTAR-2, all SRs/MAs were graded as having low or very low methodological quality. By ROBIS, all SRs/MAs in phase 1, domain 1, and domain 4 of phase 2 were at low risk, while in domain 2 were at high risk. By PRISMA, reporting weaknesses in protocol and registration, as well as search method, were identified. By GRADE, the level of evidence quality was "low" to "very low", and the most commonly downgraded factor was the risk of bias. CONCLUSIONS: Acupuncture may be beneficial in improving BCRL. However, due to the identified limitations and conflicting findings, further more prescriptive and rigorous SRs/MAs are required to give strong evidence for final judgments.

Managing the Morbidity: Individualizing Risk Assessment, Diagnosis, and Treatment Options for Upper Extremity Lymphedema.

In the setting where breast cancer-related lymphedema (BCRL) remains a feared and common complication of breast cancer, here we review important factors for the development, diagnosis, prevention, and treatment of BCRL. We find that race/ethnicity affect BCRL development risk, that future studies should focus on understanding the biological reasons behind the increased susceptibility of certain racial minorities to BCRL, that surveillance, early detection, exercise programs, and arm compression can reduce the risk of BCRL, and that surgical techniques to preserve and restore lymphatic drainage being evaluated in randomized trials may become transformative in reducing BCRL risk for high-risk patients.