Manual Lymph Drainage for Post-COVID-19 Related Cough, Breathlessness, and Fatigue; Two Case Reports.

BACKGROUND: Persistent symptoms after SARS CoV-2 infection such as fatigue, shortness of breath, and cognitive dysfunction that cannot be explained by an alternative diagnosis have been termed long COVID and present a significant emerging public health problem. Current approaches include rehabilitation and symptom management involving multiple health disciplines and as yet there are no pharmaceutical approaches other than routine symptom management. Manual lymph drainage (MLD) has been used to support recovery during pulmonary rehabilitation and reduce chronic inflammation including symptoms associated with long COVID. CASE DESCRIPTION AND OUTCOMES: Two adult females who had reported long-COVID symptoms more than 10 weeks after the resolution of the acute infection were treated with MLD by Remedial Therapists trained in the Dr Vodder method of MLD. Respiratory function (Peak Flow Meter) and blood oxygen levels (Oximeter) were recorded before and after a one-minute sit-to-stand test prior to the treatment. The Dyspnea-12 Questionnaire, the Revised Piper Fatigue Scale, and Likert scales were used to collect client-reported outcomes. Six 45-min treatments were applied weekly, with a follow-up review and treatment at three months. In both cases, all outcomes improved after the third treatment with further improvement noted at three months. CONCLUSIONS: MLD may offer a non-invasive, non-pharmaceutical approach to the resolution of long-COVID symptoms such as cough, breathlessness, and fatigue.

Bayesian Network Analysis of Lymphatic Filariasis Serology from Myanmar Shows Benefit of Adding Antibody Testing to Post-MDA Surveillance.

The elimination of lymphatic filariasis (LF) is achieved through repeated mass drug administration (MDA) of anti-filarial medications, which interrupts transmission and prevents new infections. Accurate transmission assessments are critical to deciding when to stop MDA. Current methods for evaluating transmission may be insufficiently sensitive, resulting in post-MDA resurgence. We, therefore, evaluated potential diagnostic testing scenarios for post-MDA surveillance. Data were used from two surveys (a household cluster and a cohort) conducted in an area of Mandalay Region, Myanmar, with ongoing transmission following several rounds of MDA. First, age- and sex-adjusted seroprevalence were estimated for the area using the household survey. Next, three Bayesian networks were built from the combined datasets to compare antigens by immunochromatic testing (ICT) and/or Og4C3 enzyme-linked immunosorbent assay (ELISA) and antibody (Ab) detection methods (Wb123 or Bm14 Ab ELISA). The networks were checked for validity and then used to compare diagnostic testing scenarios. The adjusted prevalence from the household survey for antigen, Wb123 Ab and Bm14 Ab were 4.4% (95% CI 2.6-7.3%), 8.7% (5.96-12.5%) and 20.8% (16.0-26.6%), respectively. For the three networks, the True Skill Statistic and Area Under the Receiver Operating Characteristic Curve for antigen, Wb123 and Bm14 Ab were 0.79, 0.68 and 0.55; and 0.97, 0.92 and 0.80, respectively. In the Bayesian network analysis, a positive case was defined as testing positive to one or more infection markers. A missed result was therefore the probability of a positive case having a negative test result to an alternate marker. The probability of a positive case prior to any testing scenario was 17.4%, 16.8% and 26.6% for antigen, Wb123 Ab and Bm14 Ab, respectively. In the antigen-only testing scenario, the probability of a missed positive LF result was 5.2% for Wb123 and 15.6% for Bm14 Ab. The combination of antigen plus Bm14 Ab testing reduced the probability of missing a positive LF case as measured by Wb123 Ab to 0.88%. The combination of antigen plus Wb123 Ab was less successful and yielded an 11.5% probability of a missed positive result by Bm14 Ab testing. Across scenarios, there was a greater discordance between Bm14 and both antigen and Wb123 Ab in the 1-10 age group compared to older ages. These findings suggest that the addition of Bm14 Ab improves the sensitivity of LF testing for current or past infection. The combination of antigen plus Bm14 Ab should therefore be considered for inclusion in post-MDA surveillance to improve the sensitivity of transmission surveys and prevent the premature cessation of MDA.

Infrared Thermal Imaging as a Novel Non-Invasive Point-of-Care Tool to Assess Filarial Lymphoedema.

Lymphatic filariasis causes disfiguring and disabling lymphoedema, which is commonly and frequently exacerbated by acute dermatolymphangioadenitis (ADLA). Affected people require long-term care and monitoring but health workers lack objective assessment tools. We examine the use of an infrared thermal imaging camera as a novel non-invasive point-of-care tool for filarial lower-limb lymphoedema in 153 affected adults from a highly endemic area of Bangladesh. Temperature differences by lymphoedema stage (mild, moderate, severe) and ADLA history were visualised and quantified using descriptive statistics and regression models. Temperatures were found to increase by severity and captured subclinical differences between no lymphoedema and mild lymphoedema, and differences between moderate and severe stages. Toes and ankle temperatures detected significant differences between all stages other than between mild and moderate stages. Significantly higher temperatures, best captured by heel and calf measures, were found in participants with a history of ADLA, compared to participants who never had ADLA, regardless of the lymphoedema stage. This novel tool has great potential to be used by health workers to detect subclinical cases, predict progression of disease and ADLA status, and monitor pathological tissue changes and stage severity following enhanced care packages or other interventions in people affected by lymphoedema.

Risk factors for lymphatic filariasis and mass drug administration non-participation in Mandalay Region, Myanmar.

BACKGROUND: Myanmar commenced a lymphatic filariasis (LF) elimination programme in 2000. Whilst the country has made considerable progress since then, a number of districts have demonstrated persistent transmission after many rounds of mass drug administration (MDA). The causes of unsuccessful MDA have been examined elsewhere; however, there remains little information on the factors that contribute in Myanmar. METHODS: We conducted an analysis of factors associated with persistent infection, LF-related hydrocoele and MDA participation in an area with ongoing transmission in 2015. A cross-sectional household survey was undertaken in 24 villages across four townships of Mandalay Region. Participants were screened for circulating filarial antigen (CFA) using immunochromatographic tests and, if positive, for microfilaria by night-time thick blood slide. Individuals 15 year and older were assessed for filariasis morbidity (lymphoedema and, if male, hydrocoele) by ultrasound-assisted clinical examination. A pre-coded questionnaire was used to assess risk factors for LF and for non-participation (never taking MDA). Significant variables identified in univariate analyses were included in separate step-wise multivariate logistic regressions for each outcome. RESULTS: After adjustment for covariates and survey design, being CFA positive was significantly associated with age [odds ratio (OR) 1.03, 95% CI 1.01-1.06), per year], male gender (OR 3.14, 1.27-7.76), elevation (OR 0.96, 0.94-0.99, per metre) and the density of people per household room (OR 1.59, 1.31-1.92). LF-related hydrocoele was associated with age (OR 1.06, 1.03-1.09, per year) and residing in Amarapura Township (OR 8.93, 1.37-58.32). Never taking MDA was associated with male gender [OR 6.89 (2.13-22.28)] and age, particularly in females, with a significant interaction term. Overall, compared to those aged 30-44 years, the proportion never taking MDA was higher in all age groups (OR highest in those < 5 years and > 60 years, ranging from 3.37 to 12.82). Never taking MDA was also associated with residing in Amarapura township (OR 2.48, 1.15-5.31), moving to one's current village from another (OR 2.62, 1.12-6.11) and ever having declined medication (OR 11.82, 4.25-32.91). Decreased likelihood of never taking MDA was associated with a higher proportion of household members being present during the last MDA round (OR 0.16, 0.03-0.74) and the number visits by the MDA programme (OR 0.69, 0.48-1.00). CONCLUSIONS: These results contribute to the understanding of LF and MDA participation-related risk factors and will assist Myanmar to improve its elimination and morbidity management programmes.

Effect of an Enhanced Self-Care Protocol on Lymphedema Status among People Affected by Moderate to Severe Lower-Limb Lymphedema in Bangladesh, a Cluster Randomized Controlled Trial.

BACKGROUND: Lymphatic filariasis (LF) is a major cause of lymphedema, affecting over 16 million people globally. A daily, hygiene-centered self-care protocol is recommended and effective in reducing acute attacks caused by secondary infections. It may also reverse lymphedema status in early stages, but less so as lymphedema advances. Lymphatic stimulating activities such as self-massage and deep-breathing have proven beneficial for cancer-related lymphedema, but have not been tested in LF-settings. Therefore, an enhanced self-care protocol was trialed among people affected by moderate to severe LF-related lymphedema in northern Bangladesh. METHODS: Cluster randomization was used to allocate participants to either standard- or enhanced-self-care groups. Lymphedema status was determined by lymphedema stage, mid-calf circumference, and mid-calf tissue compressibility. RESULTS: There were 71 patients in each group and at 24 weeks, both groups had experienced significant improvement in lymphedema status and reduction in acute attacks. There was a significant and clinically relevant between-group difference in mid-calf tissue compressibility with the biggest change observed on legs affected by severe lymphedema in the enhanced self-care group (∆ 21.5%, -0.68 (-0.91, -0.45), p < 0.001). CONCLUSION: This study offers the first evidence for including lymphatic stimulating activities in recommended self-care for people affected by moderate and severe LF-related lymphedema.

Intra-Rater Reliability and Agreement of the Indurometer When Used to Assess Mid-Calf Tissue Compressibility Among People Affected by Moderate to Severe Lymphedema in Bangladesh and Ethiopia.

Background: Lymphedema is a chronic skin disease that induces tissue fibrosis (stiffness). Tissue tonometry has been used to assess skin and tissue compressibility in lymphedema, primarily in research on arm lymphedema after breast cancer. A digital tonometer, the Indurometer (Flinders and SA Biomedical Engineering, Australia), has shown excellent intra-rater reliability in young healthy people in Australia and Myanmar and was able to detect covert changes in young, asymptomatic Myanmar people infected with lymphatic filariasis. It has not been tested in overt lower-limb lymphedema. Methods and Results: The Indurometer was used in a cluster randomized trial in Bangladesh and Ethiopia to measure tissue compressibility among adults affected by moderate to severe lymphatic filariasis- or podoconiosis-related leg lymphedema. The study compared different self-care intervention and after baseline there were follow-ups at 4, 12, and 24 weeks. Three consecutive Indurometer scores were collected by two data collection teams in each country at the mid-calf of each leg. Indurometer scores were available for three time-points in Bangladesh and four time-points in Ethiopia. An intra-class correlation coefficient (ICC) was calculated for each data collection team, and a coefficient of variation (CV) was used to assess measurement agreement in moderate and severe stages of lymphedema. The intra-rater reliability among local research assistants was good to excellent in both countries at all time-points (ICC range 0.829 [95% confidence interval; CI 0.730-0.896]-0.992 [95% CI 0.989-0.995]). In Bangladesh, agreement between measures was highest among unaffected legs (range 16%-22%) and lowest in severe lymphedema (range 19%-39%). CV scores in Ethiopia showed no distinct pattern for lymphedema stage (range 15%-32%). Conclusion: The Indurometer is an inexpensive and easy-to-use device to assess skin and tissue compressibility and should be considered in clinical research on lower-limb lymphedema.

An Enhanced Self-Care Protocol for People Affected by Moderate to Severe Lymphedema.

Lymphedema is a chronic skin disease that has many causes and leads to significant disfigurement and disability worldwide. Recommendations for lymphedema self-care vary by setting and the World Health Organization guidelines for people affected by lymphatic filariasis- and podoconiosis-related lymphedema are centered around a basic daily hygiene regimen. Research on cancer-related lymphedema in developed country settings suggests that deep-breathing exercises and self-massage can improve lymphedema status, but these exercises are not routinely taught to people affected by lymphedema in developing country settings. To determine if the activities proven in cancer-related lymphedema can improve outcomes for people affected by lymphatic filariasis- or podoconiosis-related lymphedema, an enhanced self-care protocol for lower limb lymphedema was developed and trialed in Nilphamari District in Bangladesh and Simada Woreda in Ethiopia. Enhanced self-care activities were chosen on the basis that they would not add financial burden to patients or their families and included recommendations to perform deep-breathing exercises and self-massage, drink clean water, and eat fresh fruits and vegetables. The enhanced-care protocol was developed in collaboration with implementing partners in both countries and may be applicable in other populations affected by lower-limb lymphedema. Trial methods and results will be submitted for peer reviewed publication. Current recommendations for lymphedema self-care may be less effective for people with more advanced disease and new or cross-cutting methods are needed to improve outcomes for these populations.

Comparison of Staging Systems to Assess Lymphedema Caused by Cancer Therapies, Lymphatic Filariasis, and Podoconiosis.

Background: Lymphedema is a disease of the skin and subcutaneous tissue resulting from a disturbance in lymph flow. Anyone can be affected, and causes include cancer therapy when lymph nodes are removed or irradiated, the parasitic disease lymphatic filariasis, and damage caused by exposure to irritant soils known as podoconiosis. Manifest lymphedema is progressive and a major contributor to disability, stigma, and social isolation for affected people. Although the pathogenesis of connective tissue changes in lymphedema will follow a similar course regardless of the disease of causation, several systems are used to stage progression. Disparity in these staging systems leads to inconsistency in reporting of the severity of lymphedema and prevents meta-analysis of research results. In the global health environment, integrated morbidity management for chronic illness is essential to meet the needs of affected people and to be sustainable for health care systems. Clinical descriptors for staging criteria within each system may assist clinicians in assessment and provide a format for consistency in reporting by lymphedema researchers. Methods and Results: Lymphedema staging systems used in oncology, filariasis, and podoconiosis settings were reviewed and the assessment techniques, diagnostic procedures, and clinical observations used by each system are described. The most commonly used staging systems are compared to identify similarities, and a matrix approach to lymphedema staging is proposed. Conclusion: A universal staging system would contribute to more consistent reporting of research on and clinical management of lymphedema arising from multiple causes.

Preventive chemotherapy reverses covert, lymphatic-associated tissue change in young people with lymphatic filariasis in Myanmar.

OBJECTIVES: This longitudinal comparative study investigated the effect of preventive chemotherapy (PC) on covert tissue changes associated with lymphatic filariasis (LF) among young people living in an LF-endemic area in Myanmar. METHODS: Tissue compressibility and extracellular free fluid in the lower limbs of people aged 10-21 years were measured using indurometry and bioimpedance spectroscopy (BIS). Baseline measures were taken in October 2014, annual mass drug administration (MDA) of PC was delivered in December, and in March 2015 further PC was offered to LF-positive cases who had missed MDA. Follow-up measures were taken in February and June 2015. RESULTS: A total of 50 antigen-positive cases and 46 antigen-negative controls were included. Self-reported PC consumption was 60.1% during 2014 MDA and 66.2% overall. At second follow-up, 24 of 34 cases and 27 of 43 controls had consumed PC. Significant and clinically relevant between-group differences at baseline were not found post-PC. Bayesian linear mixed models showed a significant change in indurometer scores at both calves for antigen-positive cases who consumed any PC (dominant calf: -0.30 [95% CI -0.52, -0.07], P < 0.05 and non-dominant calf: -0.35 [95% CI -0.58, -0.12], P < 0.01). Changes in antigen-negative participants or those not consuming PC were not significant. CONCLUSION: This study is the first attempt to use simple field-friendly tools to track fluid and tissue changes after treatment of asymptomatic people infected with LF. Results suggested that PC alone is sufficient to reverse covert lymphatic disturbance. Longer follow-up of larger cohorts is required to confirm these improvements and whether they persist over time. These findings should prompt increased efforts to overcome low PC coverage, which misses many infected young people, particularly males, who are unaware of their infection status, unmotivated to take PC and at risk of developing lymphoedema. Indurometry and BIS should be considered in assessment of lymphatic filariasis-related lymphedema.

OBJECTIFS: Cette étude comparative longitudinale a investigué l'effet de la chimiothérapie préventive (CP) sur les modifications tissulaires cachées associées à la filariose lymphatique (FL) chez les jeunes vivant dans une zone d'endémie pour la FL au Myanmar. MÉTHODES: La compressibilité des tissus et le liquide libre extracellulaire dans les membres inférieurs des personnes âgées de 10 à 21 ans ont été mesurés par indurométrie et spectroscopie de bioimpédance (BIS). Les mesures de base ont été prises en octobre 2014, la distribution en masse de médicament (DMM) annuelle a été administrée en décembre et en mars 2015, et une CP additionnelle a été offerte aux cas positifs pour la FL qui avaient manqué la DMM. Des mesures de suivi ont été prises en février et juin 2015. RÉSULTATS: 50 cas positifs pour l'antigène et 46 témoins négatifs ont été inclus. L'administration de CP auto-déclarée était de 60,1% durant la DMM de 2014 et de 66,2% au total. Au deuxième suivi, 24 des 34 cas et 27 des 43 témoins avaient pris la CP. Des différences significatives et cliniquement pertinentes entre les groupes au départ n'ont pas été trouvées après la CP. Les modèles mixtes linéaires bayésiens ont montré un changement significatif des scores d'indurometrie aux deux mollets pour les cas positifs pour l'antigène qui prenaient une CP (mollet dominant: -0,30 [IC95%: -0,52, -0,07], p <0,05, mollet non dominant: - 0,35 [IC95%: -0,58, -0,12], p <0,01). Les changements chez les participants négatifs pour l'antigène ou ceux qui ne prenaient pas de CP n'étaient pas significatifs. CONCLUSION: Cette étude est la première tentative d'utilisation d'outils simples, conviviaux sur le terrain, pour suivre les modifications du tissu conjonctif après le traitement de personnes asymptomatiques infectées par la FL. Les résultats suggèrent que la CP seule est suffisante pour inverser les modifications lymphatiques cachées. Un suivi plus long de plus grandes cohortes est nécessaire pour confirmer ces améliorations et déterminer si elles persistent ou non. Ces résultats devraient inciter à redoubler d'efforts pour surmonter la faible couverture en CP, qui rate beaucoup de jeunes infectés, en particulier les hommes, qui ne sont pas au courant de leur statut d'infection, qui ne sont pas motivés pour prendre une CP et risquent de développer un lymphœdème. L'indurométrie et la BIS devraient être considérées dans l'évaluation du lymphoedème associé à la filariose lymphatique.

The prevalence of lymphatic filariasis infection and disease following six rounds of mass drug administration in Mandalay Region, Myanmar.

Lymphatic filariasis is widely endemic in Myanmar. Despite the establishment of an elimination program in 2000, knowledge of the remaining burden of disease relies predominantly on programmatic information. To assist the program, we conducted an independent cross-sectional household cluster survey to determine the prevalence of filariasis infection, morbidity and mass-drug administration coverage in four townships of the Mandalay Region: Amarapura, Patheingyi, Tada-U and Wundwin. The survey included 1014 individuals from 430 randomly selected households in 24 villages. Household members one year and older were assessed for antigenaemia using immunochromatographic test cards and if positive, microfilaraemia by night-time thick blood smear. Participants 15 years and older were assessed for filariasis morbidity by ultrasound-assisted clinical examination. The overall prevalence of infection was 2.63% by antigenaemia (95% confidence interval (CI) 1.71-4.04%) and 1.03% by microfilaraemia (95%CI 0.59-1.47%). The prevalence of hydrocoele in adult males was 2.78% (95%CI 1.23-6.15%) and of lymphoedema in both genders was 0% (95%CI 0-0.45%). These results indicate the persistence of filarial infection and transmission despite six rounds of annual mass drug administration and highlight the need for further rounds as well as the implementation of morbidity management programs in the country.

Moderating Factors in Tissue Tonometry and Bioimpedance Spectroscopy Measures in the Lower Extremity of Healthy Young People in Australia and Myanmar.

BACKGROUND: Expected values for tissue tonometry and bioimpedance spectroscopy (BIS) in the lower extremity of young people have not been established. These measures are commonly used to assess tissue changes in adult, breast cancer-related lymphedema of the arm. In tropical regions, identification of tissue changes in the lower limbs related to lymphatic filariasis is required; hence expected values and factors contributing to variation in tissue tonometry and BIS in two tropical populations were investigated. METHODS AND RESULTS: A convenience sample of healthy volunteers aged 8-21 in Myanmar and Australia was recruited. Tissue compressibility at the calf and anterior and posterior thigh was measured using three tonometry devices and free fluid in each leg was assessed using BIS. Data were collected about possible modifiers: leg dominance, age, gender, body mass index (BMI), hydration, and menstrual cycle. Paired t-test and linear regression compared the objective measures with possible modifiers within each population. Statistical significance was set at p < 0.05 with a 95% confidence interval. In Myanmar, increases in free fluid, tissue compressibility, and limb circumference were associated with being older, female, underweight, or in the second half of the menstrual cycle. In young Australians, increases in tissue compressibility and limb circumference were associated with being older or in the second half of the menstrual cycle. CONCLUSION: When assessing tissue compressibility and free fluid in young people using tonometry and gender, BIS, limb dominance and BMI should be considered in a local context and attempts should be made to minimize the potential influences of hydration and the female menstrual cycle.

Lymphatic Filariasis Increases Tissue Compressibility and Extracellular Fluid in Lower Limbs of Asymptomatic Young People in Central Myanmar.

When normal lymphatic function is hampered, imperceptible subcutaneous edema can develop and progress to overt lymphedema. Low-cost reliable devices for objective assessment of lymphedema are well accepted in clinical practice and research on breast-cancer related lymphedema but are untested in populations with lymphatic filariasis (LF). This is a cross-sectional analysis of baseline data in a longitudinal study on asymptomatic, LF antigen-positive and -negative young people in Myanmar. Rapid field screening was used to identify antigen-positive cases and a group of antigen-negative controls of similar age and gender were invited to continue in the study. Tissue compressibility was assessed with three tissue tonometers, and free fluids were assessed using bio-impedance spectroscopy (BIS). Infection status was confirmed by Og4C3 antigen assay. At baseline (n = 98), antigen-positive cases had clinically relevant increases in tissue compressibility at the calf using a digital Indurometer (11.1%, p = 0.021), and in whole-leg free fluid using BIS (9.2%, p = 0.053). Regression analysis for moderating factors (age, gender, hydration) reinforced the between-infection group differences. Results demonstrate that sub-clinical changes associated with infection can be detected in asymptomatic cases. Further exploration of these low-cost devices in clinical and research settings on filariasis-related lymphedema are warranted.

Intrarater Reliability of Tonometry and Bioimpedance Spectroscopy to Measure Tissue Compressibility and Extracellular Fluid in the Legs of Healthy Young People in Australia and Myanmar.

BACKGROUND: Measurements of tissue compressibility and extracellular fluid (ECF) are used to monitor progression of lymphedema, a chronic swelling of the subcutaneous tissue. Later stages of lymphedema are characterized by fibrotic induration in the subcutis and hyperkeratosis of the skin. Several devices are available to measure these changes, but previous reliability and validity studies have been conducted primarily on adult women with unilateral arm lymphedema using contralateral limbs as controls. To date, no studies have included either adolescents or measurement of leg tissue. METHODS AND RESULTS: An intrarater reliability study was conducted to compare three devices measuring skin and subcutaneous tissue compressibility; a mechanical Tonometer, a digital Indurometer, and a SkinFibroMeter. ECF loads were measured using bioimpedance spectroscopy (BIS). Two populations of tropical-dwelling young people were included; Australian residents in North Queensland aged 8-21 years (n = 34) and people aged 10-21 years residing in Central Myanmar (n = 38). Neither cohort had any clinical sign of lymphedema or other leg abnormality. The mechanical Tonometer and the digital Indurometer had excellent intraclass correlation coefficient (ICC) scores between 0.792 (95% CI 0.055-0.901) and 0.964 (95% CI 0.945-0.984) and the SkinFibroMeter had good to excellent reliability with ICC scores of between 0.565 (95% CI 0.384-0.747) and 0.877 (95% CI 0.815-0.840). BIS exhibited the highest reliability with ICC scores approaching 1.0. CONCLUSIONS: These results support the reliable use of tonometry and BIS to assess tissue compressibility and ECF loads in the legs of adolescent populations in developed and developing tropical countries.

Self-Care for Management of Secondary Lymphedema: A Systematic Review.

BACKGROUND: Lymphedema is a debilitating and disfiguring sequela of an overwhelmed lymphatic system. The most common causes of secondary lymphedema are lymphatic filariasis (LF), a vector-borne, parasitic disease endemic in 73 tropical countries, and treatment for cancer in developed countries. Lymphedema is incurable and requires life-long care so identification of effective lymphedema management is imperative to improve quality of life, reduce the burden on family resources and benefit the local community. This review was conducted to evaluate the evidence for effective lymphedema self-care strategies that might be applicable to management of all types of secondary lymphedema. METHODOLOGY/PRINCIPAL FINDINGS: Searches were conducted in Medline, CINAHL and Scopus databases in March 2015. Included studies reported before and after measures of lymphedema status or frequency of acute infections. The methodological quality was assessed using the appropriate Critical Appraisal Skills Program checklist. Descriptive synthesis and meta-analysis were used to evaluate effectiveness of the outcomes reported. Twenty-eight papers were included; two RCTs were found to have strong methodology, and overall 57% of studies were rated as methodologically weak. Evidence from filariasis-related lymphedema (FR-LE) studies indicated that hygiene-centred self-care reduced the frequency and duration of acute episodes by 54%, and in cancer-related lymphedema (CR-LE) home-based exercise including deep breathing delivered significant volume reductions over standard self-care alone. Intensity of training in self-care practices and frequency of monitoring improved outcomes. Cultural and economic factors and access to health care services influenced the type of intervention delivered and how outcomes were measured. CONCLUSIONS/SIGNIFICANCE: There is evidence to support the adoption of remedial exercises in the management of FR-LE and for a greater emphasis on self-treatment practices for people with CR-LE. Empowerment of people with lymphedema to care for themselves with access to supportive professional assistance has the capacity to optimise self-management practices and improve outcomes from limited health resources.