From despair to elation
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Introduction The management and treatment of lymphoedema in an ulcerated limb can prove a challenge to the clinician and can significantly reduce patient’s quality of life. This case study follows the path of a patient with a long standing history of leg ulceration associated with lymphoedema. Mr A was retired and had been treated for leg ulceration at various centres since 1982 with little success. After 3 years he developed lymphoedema and was treated by his GP for recurrent episodes of cellulitis. Mr A was not very mobile due to osteoarthritis. He lived in his own home which had been adapted by social services to assist his daily living activities. Mr A had tried various treatments, including slimming pills which possibly affected his immune system but did not heal his wounds. He suffered from additional complications such as recurrent cellulitis and osteoarthritis which all added to his misery. Multiple pathologies led to compromised healing, leading to exacerbation of his lymphoedema. Past regimes had focused on local skin treatment but did not address the systemic problems. Mr A was in considerable pain and the cellulitis presented a difficult challenge to manage. Lack of mobility restricted exercising needed to encourage lymph flow. Method Past treatments by Mr A’s GP included various dermatological preparations, including manuka honey and steroid cream, applied topically to treat the flaky skin and open ulceration. Additionally, oral antibiotics were administered for recurrent episodes of cellulitis. Changes in the skin structure and an increased susceptibility to acute cellulitis in patients with lymphoedema often results in hospitalisation and the use of long term antibiotics (Mortimer, 1995). On referral to the specialist clinic a full assessment was undertaken to determine suitability for compression bandaging. Short stretch bandages have variations in working and resting pressures which are recommended to treat oedema. It was decided to use a cohesive short stretch bandage (Actico ® ) to prevent slippage once the oedema had reduced. The active management phase comprised of Manual Lymphatic Drainage (MLD) by the specialist, in conjunction with the Actico ® bandage regime. MLD was delivered once a week due to lack of funding, but was later increased to three times a week once funding was granted. This led to an improvement in Mr A’s skin condition and volume reduction - resulting in significant pain relief. Results The use of the Actico ® bandage regime provided a high working and therapeutic resting pressure regime, resulting in a comfortable bandage system for Mr A. Despite the need for more frequent MLD treatments (this was restricted to once weekly due to lack of funds), once the correct MLD regime and Actico ® short stretch bandaging was implemented Mr A’s condition improved significantly. It has been shown that, in the management of long term oedema, a course of bandaging followed by hosiery is more effective than hosiery alone (Badger et al, 2000). The maintenance phase continued using MLD, high stiffness compression hosiery (ActiLymph ® ) and infra red magnetic light which was applied to one ulcer. ActiLymph ® hosiery incorporates higher levels of fabric stiffness than British Standard hosiery, therefore enabling greater management of oedema. Electro-magnetic stimulation therapy was applied to the whole body including his knees. Conclusion Under the care of the specialist centre, using MLD and appropriate compression bandaging the leg ulcers healed, remained healed with no recurrent infection and the oedema reduced, much to the patient’s delight. Discussion A full understanding of lymphoedema management using specialist knowledge and resources is the key to successful treatment of complex cases. References Badger, C.M.A, Peacock J.L, Mortimer P.S (2000) A Randomised, controlled trial parallel group clinical trial comparing multi layer bandaging followed by hosiery versus hosiery alone in the treatment of patients with Lymphoedema of the limb. Cancer, 88; 12: 2832-2837. Mortimer P.S (1995) Managing Lymphoedema. Clinical Experimental Dermatology 20: 98-106. From despair to elation Gudrun Collins, Lymphoedema Specialist, Co Author: Mary O’Connor Lymphoedema Nurse - both are based at GeeCol Lymphoedema Service, Bury St Edmunds, Suffolk. Independent poster kindly printed by Activa Healthcare (an L&R Company) Rear of right leg healed Front of right leg Rear of left leg before MLD Rear of right leg before MLD Slim legs with only one new wound Slim feet with only one new wound Front of legs healed 16.06.2009 Rear of legs healed 16.06.2009
Transcript of From despair to elation
IntroductionThe management and treatment of lymphoedema in an ulcerated limb canprove a challenge to the clinician and can significantly reduce patient’s qualityof life. This case study follows the path of a patient with a long standinghistory of leg ulceration associated with lymphoedema.
Mr A was retired and had been treated for leg ulceration at various centressince 1982 with little success. After 3 years he developed lymphoedema andwas treated by his GP for recurrent episodes of cellulitis. Mr A was not verymobile due to osteoarthritis. He lived in his own home which had beenadapted by social services to assist his daily living activities. Mr A had triedvarious treatments, including slimming pills which possibly affected hisimmune system but did not heal his wounds. He suffered from additionalcomplications such as recurrent cellulitis and osteoarthritis which all added tohis misery.
Multiple pathologies led to compromised healing, leading to exacerbation ofhis lymphoedema. Past regimes had focused on local skin treatment but didnot address the systemic problems. Mr A was in considerable pain and thecellulitis presented a difficult challenge to manage. Lack of mobility restrictedexercising needed to encourage lymph flow.
MethodPast treatments by Mr A’s GP included various dermatological preparations,including manuka honey and steroid cream, applied topically to treat the flakyskin and open ulceration. Additionally, oral antibiotics were administered forrecurrent episodes of cellulitis. Changes in the skin structure and an increasedsusceptibility to acute cellulitis in patients with lymphoedema often results inhospitalisation and the use of long term antibiotics (Mortimer, 1995). Onreferral to the specialist clinic a full assessment was undertaken to determinesuitability for compression bandaging. Short stretch bandages have variationsin working and resting pressures which are recommended to treat oedema. It was decided to use a cohesive short stretch bandage (Actico®) to preventslippage once the oedema had reduced.
The active management phase comprised of Manual Lymphatic Drainage(MLD) by the specialist, in conjunction with the Actico® bandage regime. MLD was delivered once a week due to lack of funding, but was laterincreased to three times a week once funding was granted. This led to animprovement in Mr A’s skin condition and volume reduction - resulting insignificant pain relief.
ResultsThe use of the Actico® bandage regime provided a high working andtherapeutic resting pressure regime, resulting in a comfortable bandagesystem for Mr A. Despite the need for more frequent MLD treatments (thiswas restricted to once weekly due to lack of funds), once the correct MLDregime and Actico® short stretch bandaging was implemented Mr A’scondition improved significantly.
It has been shown that, in the management of long term oedema, a course ofbandaging followed by hosiery is more effective than hosiery alone (Badger etal, 2000). The maintenance phase continued using MLD, high stiffnesscompression hosiery (ActiLymph®) and infra red magnetic light which wasapplied to one ulcer. ActiLymph® hosiery incorporates higher levels of fabricstiffness than British Standard hosiery, therefore enabling greatermanagement of oedema. Electro-magnetic stimulation therapy was applied tothe whole body including his knees.
ConclusionUnder the care of the specialist centre, using MLD and appropriatecompression bandaging the leg ulcers healed, remained healed with norecurrent infection and the oedema reduced, much to the patient’s delight.
DiscussionA full understanding of lymphoedema management using specialistknowledge and resources is the key to successful treatment of complexcases.
ReferencesBadger, C.M.A, Peacock J.L, Mortimer P.S (2000) A Randomised, controlled trial parallel group clinical trialcomparing multi layer bandaging followed by hosiery versus hosiery alone in the treatment of patients withLymphoedema of the limb. Cancer, 88; 12: 2832-2837.
Mortimer P.S (1995) Managing Lymphoedema. Clinical Experimental Dermatology 20: 98-106.
From despair to elationGudrun Collins, Lymphoedema Specialist, Co Author: Mary O’Connor Lymphoedema Nurse - both are based at GeeCol Lymphoedema Service, Bury St Edmunds, Suffolk.
Independent poster kindly printed by Activa Healthcare (an L&R Company)
Rear of right leg healed Front of right leg
Rear of left leg before MLD Rear of right leg before MLD
Slim legs with only one new wound Slim feet with only one new wound
Front of legs healed 16.06.2009 Rear of legs healed 16.06.2009
