The impact of lower limb chronic oedema on patients' quality of life

Impact of Lymphedema on Foot-Health-Related Quality of Life: A Case-Control Investigation

OBJECTIVE

To evaluate the foot-health-related quality of life in individuals with versus without lower-limb lymphedema.

METHODS

A case-control study was carried out in an academic clinic in Lisbon, Portugal. Eighty participants (40 controls and 40 with lymphedema) were included in the study. The researchers examined sociodemographic and clinical data and foot-health-related quality of life in both groups. In the group with lymphedema, lower-limb lymphedema was also characterized.

RESULTS

Individuals with lower-limb lymphedema had significantly lower scores on all dimensions of the Foot Health Status Questionnaire in comparison with the control group.

CONCLUSIONS

Individuals with lower-limb lymphedema appear to have a poorer foot-health-related quality of life than the general population.

Hit by the wave: The experiences of adult males living with lymphoedema

Lymphoedema arises when the lymphatic system has been damaged and may occur secondary to cancer treatment. While much of the extant literature focuses on quality of life in females with breast cancer- related lymphoedema, this study explores the impact of living with lymphoedema secondary to cancer treatment in males. Semi-structured interviews were conducted with 13 male participants, aged between 50 to 85 years. Data collected were analysed using interpretative phenomenological analysis. The super-ordinate theme 'Hit by a wave' encompasses the profound impact of lymphoedema on the participants' quality of life. The males expressed body image concerns and struggled with feelings of frustration, anger, anxiety and depression. Physical changes such as weight increase, disrupted sleep, pain, swollen genitals and urinary difficulties were experienced. Changes in lifestyle were also expressed, such as an increased dependence on carers; work-related and role changes. Nevertheless, many participants endorsed the need to focus on the present moment and expressed a heightened appreciation of authenticity in life. By understanding the unique narratives of males with lymphoedema, health care practitioners together with patients can formulate care plans that truly resonate with the needs, concerns, and experiences of males living with lymphoedema.

Etiology of Drug-Induced Edema: A Review of Dihydropyridine, Thiazolidinedione, and Other Medications Causing Edema

Edema is an accumulation of fluid in the body's tissues that affects millions of Americans yearly. It can affect multiple body parts, for example, the brain or eyes, but often occurs in the periphery, including the feet and legs. Medications, such as dihydropyridine and thiazolidinediones (TZDs), can be the etiology of edema. Edema can develop in association with problems in the vasculature or lymphatic flow. In recent years, a better understanding of these drug-induced mechanisms has been appreciated. Specifically, dihydropyridines can increase hydrostatic pressure and cause selective pre-capillary vessel vasodilation. TZDs can cause edema through increased vascular permeability and increased hydrostatic pressure. Specifically, peroxisome proliferator-activated receptor gamma (PPARγ) stimulation increases vascular endothelial permeability, vascular endothelial growth factor (VEGF) secretion, renal sodium, and fluid retention. Other drugs that can cause edema include neuropathic pain agents, dopamine agonists, antipsychotics, nitrates, nonsteroidal anti-inflammatory (NSAIDS), steroids, angiotensin-converting enzyme (ACE) inhibitors, and insulin. There are various clinical presentations of edema. Since multiple mechanisms can induce edema, it is important to understand the basic mechanisms and pathophysiology of drug-induced edema. Edema can even become fatal. For example, angioedema can occur from ACE inhibitor therapy. In this regard, it is considered a medical emergency when there is laryngeal involvement. This review aims to thoroughly appreciate the multiple causes of drug-induced edema and the ways it can be treated or prevented.

Lower Quadrant Edema Patient-Reported Outcome Measure Is Reliable, Valid, and Efficient for Patients With Lymphatic and Venous Disorders

OBJECTIVE

The main aims of this study were: (1) to create a patient-reported outcome measure (PROM) item bank for measuring the impact of lower quadrant edema (LQE) on physical function using item response theory and (2) to assess reliability, validity, and administration efficiency of LQE PROM scores based on computerized adaptive test (CAT) and the reliability of a 10-item short form (SF).

METHODS

This retrospective study included data from patients treated in outpatient rehabilitation clinics for lower quadrant edema who responded to all 30 candidate items at intake. Item response theory model assumptions of unidimensionality, local item independence, item fit, and presence of differential item functioning (DIF) were evaluated. LQE-CAT-generated scores were assessed for reliability, validity, and administration efficiency. LQE-SF-generated scores were assessed for reliability.

RESULTS

The total cohort included 4894 patients (mean [SD] age = 65 [14] years; range = 14-89 years). A set of 20 items was selected for the item bank based on support for its unidimensionality and fit to the item response theory model, with reliability estimates greater than 0.92 for CAT and SF administration modes. No items demonstrated DIF with respect to tested variables. After controlling for scores at intake, scores discriminated among multiple patient groups in clinically logical ways with better outcomes observed for patients who were younger with less chronic symptoms and fewer comorbidities. Scores were responsive to change but the effect size was small (0.4). There were negligible floor and ceiling effects. CAT administration of the item bank required an average of 6.1 items (median = 5). Scores correlated highly with full-bank scores (Pearson correlation coefficient = 0.98).

CONCLUSION

Scores on the LQE PROM were reliable, valid, and efficient for assessing perceived physical function of patients with lower quadrant edema. The LQE, CAT, and SF are suitable for research and routine clinical care. Reasons for the small effect size for change scores should be studied.

IMPACT

The newly developed LQE PROM was reliable and valid and offered efficient administration modes for assessing perceived physical function of patients with LQE, both for research and routine clinical care in busy outpatient rehabilitation settings. As an item response theory-based measure, the LQE PROM allows administration of condition-specific functional questions with low response burden for patients. The 10-item LQE-SF offers a feasible alternative administration mode when CAT administration is not available. This study supports a transition to PROMs that are based on modern measurement approaches to achieve the combined benefits of high accuracy and efficiency.

Depressive symptoms and their severity in a sample with lymphedema: a case-control investigation

Objectives

Depression is a condition that can be associated with other illnesses, especially chronic illnesses. Lower limb lymphedema is a chronic, disabling condition that can affect the quality of life and be related to psychological and psychosocial factors that interfere with people's lives. This study aims to characterize and analyze the depressive symptoms and their severity reported by people with lower limb lymphedema and compare them with a matched group without lymphedema.

Methods

A case-control study was carried out (n = 80) with participants divided into a case group (40 people with lower limb lymphedema) and a control group (40 people without lower limb lymphedema). Both groups were anthropometrically, sociodemographically, and clinically characterized. In the case group, a characterization of lymphedema was performed. Participants completed the Beck Depression Inventory-II.

Results

Individuals with lower limb lymphedema have higher BDI-II scores than the matched group without lymphedema. Somatic depressive symptoms were, in general, the most reported and the ones with the highest scores. The depressive symptoms most reported by the case group were tiredness or fatigue, loss of energy, and changes in sleeping. Tiredness or fatigue, loss of energy, and loss of interest in sex were the most severe depressive symptoms reported by individuals with lower limb lymphedema.

Conclusion

Considering the apparent tendency to depression, greater attention should be given to the mental health of people with lower limb lymphedema.

Factors associated with health-related quality of life in gynaecologic cancer survivors with lower limb lymphedema: a cross-sectional study in Taiwan

BACKGROUNDS

Gynaecological cancer survivors may develop lower limb lymphoedema after surgery, which negatively impacts quality of life. The purposes of this study were (1) to assess the levels of symptom distress, depression, body image, and health-related quality of life (HRQoL); (2) to recognize factors associated with HRQoL related in gynaecologic cancer survivors with lower limb lymphoedema.

METHODS

A cross-sectional study was conducted with convenience sampling of gynaecologic cancer survivors with lower limb lymphoedema. Gynaecologic cancer survivors were assessed for symptom distress, depression, body image, and HRQoL. Multiple regression analysis was conducted to recognize the factors associated with HRQoL. Independent-samples t-test was used to compare symptom distress, depression, body image, and HRQoL by grade of lymphoedema.

RESULTS

The most common distressing symptoms of lower limb lymphoedema were lower extremity oedema, lower extremity tightness, and lower extremity stiffness. Worse HRQoL was associated with more symptom distress, less satisfaction with body image, a high grade of lymphoedema, and a longer duration of lower limb lymphoedema. These factors explained 76.5% of the variance in HRQoL. Gynaecologic cancer survivors with late grade lymphoedema experienced lower HRQoL and higher levels of symptom distress, depression, and greater dissatisfaction with body image than those who had early grade lymphoedema.

CONCLUSIONS

Symptom distress had the strongest association with overall HRQoL and with all individual domains of HRQoL, except mental function. These results suggest that educating gynaecologic cancer survivors to assess lower limb lymphoedema-related problems, providing symptom management, and guiding survivors in physical activity to relieve lower extremity discomfort can improve HRQoL.

[Diagnosis of leg edema]

Edema of the lower extremities is always associated with a pathological condition that should be treated, especially in patients with chronic wounds. Because the underlying causes of edema can vary greatly and sometimes be complex, clinical and, if necessary, various diagnostic tests should also be performed. Often, a suspected clinical diagnosis can already be made after clinical inspection with testing of Stemmer's and Godet's signs. Sonographic examination should then be performed as the next diagnostic test. Although measurement techniques such as water plethysmography are currently considered gold standard for volume measurements, they are very complex and prone to error, so that they are rarely used in clinical routine today. In summary, it is recommended to perform a clinical examination, if possible in combination with sonography, for edema diagnosis. Especially at the beginning of the decongestion phase, regular circumferential measurements should be performed and documented. This documentation is of high relevance for evaluation of therapeutic success.

Peripheral edema: A common and persistent health problem for older Americans

Peripheral edema (i.e., lower limb swelling) can cause pain, weakness, and limited range of motion. However, few studies have examined its prevalence in the U.S. or its association with demographics, comorbidities, activity, or mobility. This study used data from the Health and Retirement Study, a nationally representative longitudinal survey of U.S. adults (age 51+/ N = 19,988 for 2016), to evaluate time trends and correlates of peripheral edema using weighted descriptive statistics and logistic regressions, respectively. Peripheral edema was assessed with the question "Have you had… // Persistent swelling in your feet or ankles?" The weighted prevalence of edema among older U.S. adults was 19% to 20% between 2000 and 2016. Peripheral edema was associated with older age, female sex, non-white race, low wealth, obesity, diabetes, hypertension, pain, low activity levels, and mobility limitations (odds ratios ranging from 1.2-5.6; p-values ≤0.001). This study provides the first estimates of national prevalence and correlates of peripheral edema among older Americans. Peripheral edema is common and strongly associated with comorbidities, pain, low activity levels, and mobility limitations, and disproportionately affects poorer and minority groups. Peripheral edema should be a focus of future research in order to develop novel and cost-effective interventions.

Intermittent Pneumatic Compression for the Treatment of Lower Limb Lymphedema: A Pilot Trial of Sequencing to Mimic Manual Lymphatic Drainage Versus Traditional Graduated Sequential Compression

Background:

Recent advances in technology have allowed intermittent pneumatic compression (IPC) devices to develop so that their function mimics the process and principles of manual lymphatic drainage (MLD); however, research into the effectiveness of such devices is lacking. This study aimed to investigate the effectiveness of a patented IPC technique designed to mimic MLD (the LymphAssist), compared with a typical sequential IPC regimen.

Methods and Results:

Forty patients with a confirmed diagnosis of lower limb ISL (International Society of Lymphology) stage II or III lymphedema were recruited into this three-phased study. A bilateral leg volume assessment and quality-of-life assessment were completed at four clinic visits across the course of the study. The LymphAssist IPC regimen was significantly more effective in reducing distal leg volume than the sequential mode (mean volume reduction: 230 ± 135 mL vs. 140 ± 84 mL, respectively, p = 0.01). Improvements in leg volume were transient as both groups demonstrated a rebound or increase in volume during the washout period (LymphAssist: 238 ± 168 mL, sequential: 276 ± 158 mL, p = 0.3). Overall, IPC was effective in improving quality-of-life scores (mean reduction: 10 ± 11, p < 0.001).

Conclusion:

IPC is effective in reducing limb volume and improving quality of life for patients with lower limb lymphedema. IPC that mimics the MLD process has been shown to be more effective in reducing leg volume compared with traditional sequential IPC in the distal aspect of the leg. The increase in leg volume observed after discontinuation of IPC suggests that regular treatment is required to maintain its associated effects.

Clinical Trial Registration Number: NTC 03856281.

Treatment Outcomes of Manual Lymphatic Drainage in Pediatric Lymphedema

BACKGROUND

Pediatric lymphedema can result in irreversible, debilitating limb swelling, tissue fibrosis, skin ulcers, infection, and impaired limb function in children at an early age. Manual lymphatic drainage (MLD) is a noninvasive technique, which is a part of intensive decongestive therapy to reroute lymphatic flow to healthy channels used to manage lymphedema. Outcomes of this treatment option in children have not been studied. We evaluated the effect of decongestive therapy involving MLD in pediatric patients with complex lymphatic anomalies by measuring treatment progress and functional outcomes via changes in limb circumference, limb functionality, dexterity, skin quality, and pain.

METHODS

A single-institution retrospective study on a cohort of 8 pediatric patients with lymphatic anomalies who completed a course of MLD was conducted from 2015 to 2017 to investigate the role MLD plays in their lymphedema reduction. Pain scores were measured on a scale of 0-10, with 0 being no pain and 10 being the worst pain imaginable. The functional performance was measured by the Canadian Occupational Performance Measurement questionnaire.

RESULTS

Among all patients, there were 4 cases affecting the upper extremities, 4 affecting the lower extremities, and 3 affecting the truncal region. Five of 8 patients demonstrated a reduction in lymphedema with an average girth reduction of 8.2% in the lower extremities, 3.0% in the upper extremities, and 7.4% in the truncal regions. In unilateral cases, the difference in limb circumference between the affected and normal extremity decreased by an average of 25.6%. Four patients completed the Canadian Occupational Performance Measurement questionnaire with an average improvement of 30% in daily task performance. Three patients reported complete resolution of pain.

CONCLUSIONS

MLD can be used as a reliable noninvasive method for decongestion and analgesia to delay the onset of lymphedema-associated fibrosis and long-term disability in children with complex lymphatic malformations.

Development of the Lymphoedema Patient Reported Outcome Measure (LYMPROM)

To ensure lymphoedema patients in Wales receive the right care, at the right time, by the right person, patient-reported outcome measures (PROMs) were routinely completed within the All-Wales lymphoedema assessment documentation. This evaluation describes the development of the Lymphoedema Patient Reported Outcome Measure (LYMPROM), which is a tool developed by Lymphoedema Network Wales clinicians and key stakeholders. The tool was explored for face, form and content validity during 3 months in 2019; 128 anonymised completions of LYMPROM were reviewed to establish feasibility, acceptability and internal validity using Cronbach's alpha. LYMPROM was feasible and acceptability was high. Face and content validity were reported (i-CVI [item content validity index] range=0.43 - 1; s-CVI/Ave=0.94) and internal consistency was excellent (0.958). LYMPROM was easily integrated within lymphoedema services in Wales, promoting patient-led care and supporting value-based health care. Further evaluations of reliability and validity of LYMPROM are proceeding along with digital integration.

Quality of Life evaluation and lack of correlation with volumetric results after lymphovenous anastomoses in lymphedema therapy of the lower extremity

OBJECTIVE

Chronic primary or secondary lymphedema has a huge impact on quality of life (QOL) because of associated swelling, pain, decreased range of motion, depression and anxiety, and generally requires numerous adaptations. Many studies have shown a positive objective effect of lymphovenous anastomoses (LVAs) on chronic lymphedema. In this study, we assessed the effect of LVAs on QOL in patients with primary or secondary lymphedema of the lower extremity 6 months after surgery, and examine the correlation between changes in QOL and volumetric measurements.

METHOD

Only patients with either primary or secondary lymphedema of the lower extremity who had LVAs were included in the study. To assess QOL, a specially designed questionnaire based on the "Lymphedema Quality of Life Inventory" (LyQLI) was used to evaluate the subjective therapeutic results from the patients' perspectives. Objective therapy success was assessed by 3D volumetric measurements of the lower leg. Measuring points, for both subjective and objective measurements, were the day before and 6 months after therapy.

RESULTS

The mean volume change 6 months after LVAs was -6.5% (sd 5.6, p < 0.001). A significantly better quality of life in terms of physical (37.6%, sd 25.2) and psychosocial (27.0%, sd 43.0) suffering as well as practical restrictions (22.3%, sd 24.8) was found (p values < 0.001). No correlation was found between QOL improvement and volume decrease (p values > 0.05).

CONCLUSION

In patients suffering from lymphedema of the lower extremity, lymphovenous anastomoses lead to a significant volumetric decrease and quality of life improvement six months after treatment with no demonstrable relationship between QOL improvement and volume reduction.

Non-cancer-related lower limb lymphoedema in complex decongestive therapy: the patient experience

OBJECTIVE

Lymphoedema is a debilitating condition that results in the swelling of one or more limbs, leading to a significant impairment of mobility. From a psychosocial perspective, body image and quality of life (QoL) are also adversely affected. To date, non-cancer lymphoedema has been under-researched. The primary objectives of this study were to explore QoL and limb volume in patients with primary and secondary non-cancer-related lower limb lymphoedema during the intensive, maintenance and self-care phases of complex decongestive therapy over a 24-week period. Secondary objectives included exploring patients' experiences of living with lymphoedema and the challenges of self-care maintenance.

METHOD

A sequential mixed methodology, using quantitative and qualitative methods, was used. The quantitative part of the study involved the use of tape measurements at 4cm intervals to ascertain limb volume alterations. Measurements were taken during the intensive phase at weeks 1, 2, 3 and 4; and during the maintenance phase at weeks 8, 16 and 24. QoL was measured using the lymphoedema QoL (LYMQOL) leg, at baseline and weeks 8 and 24. The qualitative part of the study involved the use of semi-structured interviews with patients at week 8. Interviews explored the experiences of patients living with lymphoedema and their experiences of complex decongestive therapy.

RESULTS

A total of 20 patients were recruited, two male and 18 female, with a mean age of 58.8 years (standard deviation (SD): 16 years), and all receiving complex decongestive therapy. At baseline, for all patients, the mean QoL score was 4.3 (SD: 2.4); and 8 (SD: 1.5) after 8 weeks of complex decongestive therapy. Mean difference was 4.00 (95% confidence interval: 2.76-5.24; p=0.00001) indicating a positive treatment effect. Limb volume measurements demonstrated a reduction in oedema from baseline to week 8. However, there were fluctuations in limb volume over the maintenance period of four months after treatment as the patients endeavoured to engage in self-care. Analysis of the interviews identified themes pertaining to lack of knowledge of lymphoedema among health professionals, a negative impact of living with lymphoedema and the positive therapeutic effect of complex decongestive therapy.

CONCLUSION

Lower limb lymphoedema is a chronic condition that impacts negatively on the individual. Complex decongestive therapy improves QoL and reduces oedema. However, given the fluctuations in oedema post-treatment, individuals need greater support to maintain active engagement in effective self-care strategies.

Update in the management of lipedema

Lipedema is a chronic feminine disease that causes abnormal fat deposition in lower limbs and occasionally upper limbs. Easy bruising and pain are common. Lipedema patients suffer from both physical and psychological disability. Despite the relatively high prevalence and the impact on the quality of life, little is known about the disease. The majority of patients are misdiagnosed as lymphedema or obesity. The objective was to perform a non-systematic review on lipedema literature, related to diagnosis and therapy. Regarding pathophysiology, alterations are not exclusively confined to adipose tissue. Lymphatic dysfunction, cardiovascular variations, blood capillary fragility and increased permeability are common. Patients often present with neurological alterations and hormonal malfunction. Elevated cutaneous sodium has been documented. Due to the absence of a defined etiology, evidence-based research is difficult in the management of lipedema. The setting of realistic expectations is important for both patient and medical care provider. The major aims of the management are multimodal for improvements in the quality of life; reduction in heaviness and pain, reshaping the affected limbs, weight control, improvements in mobility. Compression garments, physical therapy, exercise regimens, diet and psychological counseling are necessities. For selected patients, surgical treatment is an added option.

Challenges and opportunities identified for lymphoedema services in Wales during the COVID-19 pandemic

BACKGROUND

During the COVID-19 pandemic, lymphoedema staff adapted services, providing care remotely, and worked in other NHS sectors. The impact on services and staff must be understood in order to safeguard patient care and foster workforce resilience.

AIMS

To evaluate the experiences of clinical and non-clinical lymphoedema staff in Wales during the COVID-19 pandemic.

METHODS

An anonymous online survey, based on scoping work, was sent out via the Welsh lymphoedema services mailing list.

FINDINGS

71% (68/96) of eligible lymphoedema staff completed the survey. More than half supported lymphoedema services (40/68) with the remaining staff deployed elsewhere. Overall, staff and services felt prepared for new ways of working. Concerns about others and the future burden on services when life returned to normal were reported. Opportunities identified included education initiatives and virtual services.

CONCLUSION

Lymphoedema services were well prepared to deliver virtually, enable effective care and share knowledge. Co-ordinated efforts to uphold patient advocacy will support virtual services to meet their needs.

Gravity magnetic resonance imaging measurement of muscle pump change accompanied by aging and posture

AIM

To date no age-comparative study has been reported about effect of exercise on muscle pump action change, while its effect is suggested to differ in ages. This study aims to clarify the changes in muscle pump action with aging by measuring the muscle and vein area, and blood flow in lower legs.

METHODS

Subjects were healthy volunteers and consisted of three groups: young age group (N = 20), middle age group (N = 20) and old age group (N = 16). The lower leg flexor muscle area and popliteal vein area were measured by using T1-weighed magnetic resonance imaging at the condition pre- and post-ankle exercise in three positions. Moreover, popliteal blood flow velocity was also measured using phase contrast magnetic resonance imaging.

RESULTS

The elderly had the highest number of individuals who had exercise habits (p < .001). In a multiple linear regression analysis, sitting posture, leg muscle volume, and rate of change in the soleus muscle were significantly related to blood flow velocity change.

CONCLUSIONS

No difference was found in the changes in muscle pump action with age. The study results suggested that elderly people with exercise habits might be able to maintain the muscle pump action.

Influences of lower limb edema on daily lives of elderly individuals in an elderly day care center

AIM

The purpose of this study is to describe the influences of lower limb edema on the daily lives of elderly individuals in elderly day care to describe the necessity of care for lower limb edema.

METHODS

Semi-structured interviews based on a quality of life questionnaire for limb lymphedema were conducted. Two types of text mining analysis methods were used: a frequent word analysis and a content analysis. The edema severity was graded on a scale of 0 to 3, and the sum of the numerical values of the grades for each person was defined as the pitting score.

RESULTS

The seven participants had a mean age of 83.4 ± 4.6 years (mean ± SD). The pitting scores ranged from 1 to 25 in the participants. The words "think" (389 times), "walk" (136 times), and "put on" (135 times) were extracted frequently. The content analysis focused on the words "walk" and "put on." The participants complained of difficulty walking, pain, and numbness when walking, weakness of their lower limbs, difficulty putting on shoes, restrictions on shoe types, and difficulty finding shoes.

CONCLUSIONS

These results demonstrate that elderly individuals experienced troubles during their daily lives caused by lower limb edema, which highlights the necessity of symptom management. Active interventions for edema by nurses are necessary to improve quality of life in elderly individuals.

A Method for Designing a Patient Burden Questionnaire in Dermatology

Introduction

In recent years, the concept of “disease burden” has been given a central role in evaluating patient care, particularly in skin diseases. Measuring patient-reported outcomes (PRO) such as symptoms and disease burden may be useful.

Aim

To present a methodology that facilitates the development and validation of burden questionnaires for patients suffering from skin diseases.

Methodology

Based on past published burden questionnaires, a methodology for designing skin disease burden questionnaires was to be developed.

Results

Based on 16 burden questionnaires developed and published over the last 10 years, the authors propose a standardized methodology for the easy design and validation of disease burden questionnaires for patients with chronic skin diseases. The authors provide detailed guidance for the conception, development and validation of the questionnaires, including reliability, internal consistency, external validity, cognitive debriefing, testing–retesting, translation and cross-cultural adaptation, as well as for statistical analysis.

Conclusion

The proposed methodology enhances the design and validation of disease burden questionnaires in dermatology. Burden questionnaires may be used in clinical research as well as in daily clinical practice.

Comprehensive Decongestive Therapy as a Treatment for Secondary Lymphedema of the Lower Extremity and Quality of Life of Women After Gynecological Cancer Surgery

Background

Lymphedema is a clinical manifestation of lymphatic system failure, caused by an imbalance between the transport capacity of the lymphatic system and the volume of the produced lymph. Lymphedema is complication and significantly worsens quality of life (QoL).

Material/Methods

There were 50 patients diagnosed with secondary lymphedema of the lower extremities after gynecological cancer followed by radiotherapy included in this study. The average age was 57.76 years (standard deviation±10.08). Patients were treated at the Department of Physiotherapy, Balneology and Medical Rehabilitation, in hospital NsP in Bardejov. During therapy, we applied manual lymphatic drainage, instrumental lymphatic drainage, multilayer bandage, vascular gymnastics (with loaded external compression), hydrotherapy, and patient education on the adjustment necessary for a life-long regimen. The circumference of the limb was measured using the Kuhnkes disk method, QoL was assessed using the LYMQOL LEG questionnaire, and for assessment of pain the Visual Analogue Scale (VAS) was used.

Results

After treatment, we found a reduction in lymphedema (P<0.001), an increase in QoL (P<0.001), and a reduction in pain (P<0.001). We found a significant relationship between QoL change and pain in the domains of symptoms, function, and overall QoL (P<0.005). The results showed that reduction of lymphedema was not a significant predictor of QoL (P>0.001).

Conclusions

We found a positive effect in the treatment of secondary lymphedema of the lower extremity on the QoL of women after uterine cancer surgery, and also found that reduction of lymphedema and age were not predictors of improvement in QoL.

LIMPRINT: Health-Related Quality of Life in Adult Patients with Chronic Edema

Background: Chronic edema is a condition posing a high burden on patients. The primary aim of the study was to assess the health-related quality of life (QoL) of adult patients living with chronic edema.

Methods and Results: As part of an international, multicenter, prospective study, we prospectively assessed the health-related QoL of adult patients living with a chronic edema using a disease-specific tool and a generic one. In total, 1094 patients were included, aged 57 years on average. The average EQ-5D and LYMQOL visual analogue scale (VAS) scores were equal to 63.6 (SD = 20.2) and 6.3 (SD = 2.0), respectively. After adjustment, the EQ-5D VAS was explained by LYMQOL VAS (β = 7.85; p < 0.001), age (β = −0.08; p = 0.02), obesity (β = −1.89; p = 0.001), and male gender (β = 3.32; p = 0.002). As for the LYMQOL VAS, it was independently associated with EQ-5D VAS (β = 0.07; p < 0.001), LYMQOL function (β = −0.21; p < 0.001), and LYMQOL mood (β = −0.49; p < 0.001).

Conclusion: This study confirms that patients living with a chronic edema experience a poor disease-specific and generic health-related QoL.

LIMPRINT: The UK Experience-Subjective Control of Swelling in Patients Attending Specialist Lymphedema Services

Background and Study Design: This study was undertaken as part of the UK LIMPRINT international study to determine the number of people with chronic edema (CO) and its impact on health services. Overall 7436 with CO were recruited in the main UK study from a range of health settings.

Methods and Results: Factors relating to subjective control of arm and leg CO were defined in the UK. A total of 1565 patients were included in the study with exclusions for: no limb swelling or not recorded (1669), having concurrent arm/leg CO (272), control of assessment missing (5) and professional being unsure of control status of CO (325). Arm swelling occurred in 953 (18.5%) with leg CO in 4212 (81.5%). Poor control was found in 1430 (27.2%) and good control in 3735 (72.3%). Control of arm swelling was worse in men and control increased overall in those aged over 45 years. In contrast control of CO worsened in those with leg CO with increasing age and multiple co-morbidities. Obesity and cellulitis, particularly an episode in the last year were associated with poor control. Independent risk factors for arm CO were : obesity, neurological disease and cellulitis in the last year and for leg CO, obesity, poor mobility, heart disease, presence of a wound, cellulitis in the last year and duration of swelling.

Conclusion: Control of CO within specialized centers is complex due to sociodemographic and clinical comorbidities.

Lower limb chronic edema management program: Perspectives of disengaged patients on challenges, enablers and barriers to program attendance and adherence

Background

Chronic edema (CO) is a progressive, physically disfiguring and currently incurable condition. A multifaceted program has been recommended to manage the swelling. However, there is little evidence investigating patients’ perspectives following the program, particularly for those who have poor adherence and/or are disengaged.

Aim

To investigate the perceived challenges faced by disengaged participants with lower limb CO by identifying their enablers and barriers to participating in a Physiotherapy CO program.

Method

An exploratory qualitative approach was used. A purposive sampling strategy was adopted to recruit participants. Those with more than three months swelling and who had low adherence and/or attendance (disengaged) to the CO program were invited to participate. Semi-structured interviews with six participants from a CO clinic in a tertiary hospital were conducted. Data were thematically analyzed and findings in terms of enablers and barriers were subsequently reflected in the light of a theoretical framework.

Results

All six participants were morbidly obese (BMI 47 ± 4 kg/m²) with multiple chronic comorbidities. Enablers and barriers detected included physical, psychological and social factors that interplay to present multidimensional challenges that influence the participants’ adjustment to managing their CO. For the disengaged participants in this study, their under-managed lower limb CO was a progression towards being housebound and having a gradually increasing level of disability.

Conclusion

This study has identified the multidimensional challenges faced by low adherent and/or disengaged participants with lower limb CO to participating in a hospital-based CO program. Perceived enablers and barriers included physical, psychological and social factors. These were mapped using a health behavior change theoretical framework. Understanding these challenges has implications for developing a multidisciplinary approach aimed at enhancing patient engagement and participation in the physiotherapy CO program.

The Reliability and Validity of Lymphedema Quality of Life Questionnaire-Leg in Turkish Patients with Lower Limb Lymphedema

Background: Accurate information on quality of life (QoL) outcomes among patients with lower limb lymphedema (LLL) is substantially needed to capture lymphedema-specific impairments and make clinical decisions for the management of this suffering condition. No specific instrument for QoL in patients with LLL has been translated to Turkish and validated. This study aims to adapt the Lymphedema Quality of Life Questionnaire-leg (LYMQOL-Leg) to Turkish and to test its reliability and validity in patients with LLL. Methods and Results: The Turkish-LYMQOL-Leg was obtained using forward-backward translation and administered to 138 patients with LLL, along with Short Form 36 (SF-36), and Lower Extremity Functional Scale (LEFS), between May 2015 and October 2017. A test-retest interval of 7 days was used to assess the reliability. Descriptive analysis was applied for demographic variables and validation studies were conducted by means of construct validity using Spearman's rank correlation coefficient. Internal consistency and test-retest reliability were assessed using Cronbach's α and intraclass correlation coefficient (ICC), respectively. All patients with LLL completed the questionnaires. The mean age and lymphedema duration were 52.01 ± 14.73 years and 95.6 ± 108.6 months, respectively. Internal consistency and test-retest reliability of the Turkish-LYMQOL-Leg were good with Cronbach's α (0.85-0.90) and test-retest ICC (0.68-0.85). External construct validity was highly confirmed by expected correlations with comparator scales SF-36 and LEFS (p < 0.01). Conclusion: The Turkish version of the LYMQOL-Leg is a valid and reliable tool for evaluating QoL in patients with LLL that can readily be applied as an outcome measure both in clinical practice and research studies.

Functionality and quality of life of patients with unilateral lymphedema of a lower limb: a cross-sectional study

Background

Lymphedema of the lower limbs is a chronic disease caused by damage to the lymphatic system that influences people's mobility, functionality, and quality of life. Questionnaires and physical test are very practical, easy to apply, and low cost methods that provide important data for evaluation of these patients.

Objectives

To evaluate the influence of unilateral lower limb lymphedema on functionality and quality of life, correlating 3 assessment tools.

Methods

This was a descriptive study investigating 25 patients of both sexes with unilateral lymphedema in a lower limb. Limb volume was assessed using circumferential tape measurements, the Medical Outcomes Study Short Form-36 Health Survey (SF-36) was used to assess quality of life, the Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphoedema (Lymph-ICF-LL) was used to assess physical, mental, and social skills related to lymphedema, and the Timed Up and Go (TUG) test was used for functional assessment.

Results

Lymphedema was present throughout the affected lower limb of participants. The domains most affected by lymphedema were physical aspects (25.0 ± 31.4) and emotional aspects (36.0 ± 42.9) from the SF-36 and the mobility domain (6.0 ± 2.6) from the Lymph -ICF-LL. Patients performed the TUG in 9.88 ± 1.98 seconds. The TUG was correlated with the questionnaires and the questionnaires were correlated with each other.

Conclusions

People with unilateral lower limb lymphedema exhibited negative impacts on quality of life and functionality, as evaluated by questionnaires, which were correlated with each other. TUG performance was within normal limits, but results correlated with the questionnaires used.

Role of a Structured Physical Activity Pathway in Improving Functional Disability, Pain and Quality of Life in a Case of Breast and Gynecological Cancer Survivorship

Physical activity (PA) interventions can improve physical functioning, treatment-related symptoms and quality of life (QoL) in cancer survivors. Most investigations have been conducted in breast cancer survivors, while studies on PA interventions in gynecological cancer survivors are scant. Here, we report for the first time the possible benefits of a structured PA pathway (i.e., eight weeks of adapted PA followed by twelve weeks of adapted fitness) on physical side effects, pain and QoL in an uncommon case of survivorship of both primary breast and gynecological cancers. For this purpose, a 69-year-old woman was assessed by functional test battery (shoulder-arm mobility, range of motion, back flexibility) at baseline and after the structured PA pathway. QoL and surgical shoulder, back and lower limb pain intensity were evaluated by Short Form-12 (SF-12) and numerical rating scale questionnaires, respectively. Lower limb circumference was also assessed. Improvement in upper limb function, reduction of lower limb edema and pain perception, as well as an increase in overall QoL were achieved after the completion of structured PA intervention. Our findings suggest that a PA intervention tailored to individual characteristics may represent an effective countermeasure to reduce post-treatment functional disability and pain, and thus to improve QoL in breast and gynecologic cancer survivors.

Translation, reliability, and validation of the Turkish version of the Lymphedema Quality-of-Life tool in Turkish-speaking patients with lower limb Lymphedema

The aim of this study was to translate the original English version of the Lymph Quality-of-Life Questionnaire (LYMQoL) into Turkish language and test its reliability and validity in patients with lower limb lymphedema (LLL). A total of 119 patients (86 women and 33 men) with LLL were enrolled in this study. The Turkish version of the Nottingham Health Profile was used to evaluate the criterion validity of related domains in LYMQoL. The LYMQoL was performed after seven days to evaluate its test-retest reliability. Cronbach's alpha value was found to be 0.94 for internal consistency, and the intraclass correlation coefficient score for test-retest reliability was found to be 0.95. The intraclass correlation coefficient score of domains ranged between 0.83 and 0.92. For the criterion validity, "functional aspects" and "symptoms" domains moderately correlated significantly with the Nottingham Health Profile total score. Kappa values ranged from 0.356 to 0.715. According to the factor analysis, four factors that explain the 71% of the cumulative variance were found. In conclusion, this study indicates that the Turkish version of the LYMQoL is a reliable valid tool for the evaluation of disease-specific health-related quality of life in patients with LLL. It can be safely used in both clinical routine and research.

Manual lymphatic drainage and quality of life in patients with lymphoedema and mixed oedema: a systematic review of randomised controlled trials

Purpose

To assess the impact of manual lymphatic drainage (MLD) on the health-related quality of life (HRQoL) of adults with lymphoedema or mixed oedema, through a systematic review of randomised controlled trials (RCTs).

Methods

MEDLINE, EMBASE, PsycINFO, CENTRAL, the Cochrane Database of Systematic Reviews and ClinicalTrials.gov were searched to identify RCTs evaluating HRQoL after a MLD intervention compared to non-MLD interventions (PROSPERO 2016:CRD42016042255). We extracted the effect of the interventions on the HRQoL (primary outcome) as well as data on volume and functional changes, and adverse events when available (secondary outcomes).

Results

Eight studies were eligible. The studies were heterogeneous in the aetiology of oedema, schemes of MLD applied, additional treatments offered with MLD, length of follow-up, instruments used to assess HRQoL and interventions offered to the control group. Five studies included patients with breast cancer-related arm lymphoedema; one study reported increased HRQoL among patients randomised to the MLD group. The two RCTs that involved patients with leg mixed oedema due to chronic venous insufficiency did not find between-group differences in the overall HRQoL. One trial included patients with hand oedema from systemic sclerosis and showed higher HRQoL in the group that received MLD. No studies reported reductions in HRQoL, or severe adverse events after MLD. The small numbers of patients analysed in all studies may have resulted in lack of power to detect between-group differences in HRQoL.

Conclusions

The effect of MLD on the HRQoL of patients with chronic oedema is unclear.

Electronic supplementary material

The online version of this article (10.1007/s11136-018-1796-5) contains supplementary material, which is available to authorized users.

Chronic oedema 'on-the-ground' education programme

The impact of chronic oedema on community nurses' work, the NHS and those directly affected by the condition is immense. As chronic oedema prevalence is projected to rise and financial austerity continues, innovative, sustainable solutions that ensure positive outcomes for patients must be found. This paper reports findings from a focus group (n=3) investigation of the effects of an innovative workplace education intervention designed to enhance community nurses' knowledge for practice in chronic oedema prevention and management in Wales. The main findings indicated that the programme had enhanced community nurses' awareness, knowledge and understanding of chronic oedema management. By enhancing their knowledge base, benefit might be conferred for patients with chronic oedema in terms of improved quality of life, self-efficacy and self-management. However, the magnitude of perceived benefit was variable and contingent on engagement with and support for self-management. Findings indicate the need for a longitudinal study.

Chronic oedema: its prevalence, effects and management

Ageing affects not only individuals but also society. It occurs throughout the western world. The ageing process may lead to the development of conditions, such as chronic oedema, as well as comorbidities such as osteoarthritis. These comorbidities can make the management of chronic oedema even more difficult. This is an especially important consideration when tailoring individualised care plans, such as exercise, as conditions such as rheumatoid arthritis can limit patients' ability to manage their oedema. Despite challenges, education can improve patient outcomes when evidence-based practice is used.