Chapter 27: Living with and beyond cancer
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Assessment of the patient with lymphoedema and calculation of limb volume
Evidence‐based approaches
Rationale
When the use of compression therapy is being considered, a full and careful assessment will highlight the patient's main problems and any co‐existing complications. This information is then used to set realistic treatment goals and to determine the most suitable approach to compression therapy treatment. Clinical and physical indications determined during a full assessment of the patient will facilitate the most appropriate choice of compression therapy for the individual patient. Several treatments are used in combination during the management of lymphoedema; their choice and usefulness can be determined by the therapist and patient at the time of assessment. The experience of living with lymphoedema as a long‐term chronic condition is unique for each patient and can have an impact on many areas of the individual's life (Ridner et al. [238]). The physical and psychological effects are not short‐lived, and enormous motivation and perseverance coupled with adaptation are demanded to achieve control or reduction of the swelling (Nazarko [190], Woods [290]).
Clarifying the influence of the lymphoedema on the patient's lifestyle, occupation and chosen social activities will help to identify patient‐focused problem areas that may require adjustment. By gaining an understanding of the impact that the swelling may be having upon personal feelings and emotions, relevant supportive strategies can be identified (Woods [290]).
Principles of care
Assessment should encompass a person‐centred framework (McCormack and McCance [171]) and include the following elements:
- Details of the patient's medical history: to determine the cause of swelling and whether compression therapy can be used safely. Arterial insufficiency of the lower limb must always be excluded prior to the use of compression therapy. Palpation of the pedal pulses alone is an unreliable predictor of adequate arterial supply. The measurement of the ankle to brachial pressure index (ABPI) is recommended if there is any doubt about the patient's peripheral arterial status (International Society of Lymphology [131]). If the patient has a history of diabetes or cardiac failure, a medical assessment should also be completed prior to the commencement of treatment and there should be close supervision during its progress to prevent complications caused by fluid shift exacerbating cardiac failure or risk of damage to the skin in a diabetic patient (International Society of Lymphology [131]).
- Physical assessment: to determine the extent of the oedema and palpation of oedema to identify if it is pitting, non‐pitting or fibrosed and to assess the skin condition and limb shape, the patient's disease status and the presence of any pain or altered sensations within the limb (Bianchi et al. [15], Quéré and Sneddon [231]). The patient's ability to follow a treatment plan, including compression therapy, should also be assessed. The patient should be observed putting on and removing their garment to ensure they can safely do so; consider appliance aids if necessary (see Table 27.10). Weight should be recorded and monitored as obesity increases the risk of developing lymphoedema (Milne [173]). Figure 27.12a is an example of mild, uncomplicated lymphoedema of the arm and Figure 27.13 is an example of severe, uncomplicated lymphoedema of the arm. Figure 27.14 is an example of moderate uncomplicated lymphoedema of the leg.
- Psychosocial assessment: to determine the influence of the swelling upon the patient's life. This includes the influence upon limb function and mobility, employment, hobbies, activities and personal roles, and also includes the patient's thoughts on wearing compression garments (Cooper [53], Woods [290]).
Table 27.10 Examples of application aids
| Aid | Description | Supplier |
|---|---|---|
| Acti glide | An application to allow open or closed toe compression stockings to glide onto leg
| L&R: www.activahealthcare.co.uk |
| Easy pad | A rectangular piece of non‐slip foam to assist with the application of compression garments | Juzo: www.juzo.com |
| Easy‐slide | A limb‐shaped slide sheet designed to ensure easy application of the garment with the right amount of pressure
| Credenhill: www.credenhill.co.uk |
| Easy‐slide Magnide | A limb‐shaped slide sheet with magnets to ease application for closed toe garments
| Credenhill: www.credenhill.co.uk |
| Ezy‐As | A rigid ‘C’ shaped plastic structure designed to assist with fitting of compression garments
| Ezy‐as: www.ezyasabc.com |
| Foot slide | A shaped piece of silky material to assist with the application of open toe compression garments over the foot | Supplied with most compression stockings |
| Medi Butler | A specially designed metal frame that holds the garment in place so that the foot or hand can slide into it. The frame has handles that are used to pull the garment up the limb
| medi: medi: www.mediuk.co.uk |
| Mediven 2 in 1 | A limb‐shaped slide sheet that assists with the putting on and taking off of garments
| medi: medi: www.mediuk.co.uk |
| Rubber gloves | Cotton‐lined rubber gloves to provide a better grip on garments to assist in donning and doffing | Widely available in retail shops and also through Haddenham Healthcare: www.hadhealth.com |
| Sleeve on | A metal applicator with a suction pad to secure the applicator to a firm surface during the application and removal of garments | Haddenham Healthcare: www.hadhealth.com |
| Slide On Stocking (SOS) | Metal frame designed to hold the garment in place so that the foot can slide into it | Sigvaris: www.sigvaris.com/global/en |
| Rolly | A flexible plastic band that rolls compression garments on to the limb
| Sigvaris www.sigvaris.com/global/en |
Figure 27.12 Mild uncomplicated arm lymphoedema.
Figure 27.13 Severe uncomplicated lymphoedema of the arm. Source: Dougherty and Lister ([90]).
Figure 27.14 Moderate uncomplicated lymphoedema of the leg.
Assessment should also include the following:
- Planning: to improve problems and utilize patient strengths. The healthcare professional should work in partnership with the patient to enable them to take appropriate action to manage their lymphoedema and work towards long‐term control. Planning should focus on the patient's objectives so that immediate problems can be addressed. Long‐ and short‐term goals can then be identified and agreed with the patient.
- Implementation: to determine the appropriateness of interventions and modify them where required. An individualized, holistic approach will incorporate education and support, particularly if personal changes are required to minimize the risk of complications developing. Success will be achieved when the patient possesses positive motivational factors and is an active participant in the management of their lymphoedema (Cooper [53]).
- Evaluation: to assess progress, modify and stop the intervention if necessary. To evaluate the outcome of a plan of treatment, suitable outcome indicators are required (Frisby [107]). No standardized method of evaluating the outcome of a plan of treatment has been determined but the measurement of limb volume using surface measurement is the most frequently used means of assessing response to treatment in lymphoedema management (Williams and Whitaker [286]). The effect of treatment on the patient's psychological and psychosocial well‐being should, however, also be monitored, and this is frequently achieved in a more subjective manner where the patient's views are sought (Keeley et al. [138]).
Methods of measuring limb size, shape and volume
The measurement of both limbs assists in determining the presence of early lymphoedema in a limb. When swelling is present, limb measurements can objectively identify the degree of swelling to assist in making decisions concerning appropriate treatment. Repeated limb measurements over time can evaluate response to treatment and facilitate motivation with self‐management (Williams and Whitaker [286]). Simple measurements of a limb assist in the choice of the correct size of compression garment.
Simple surface measurements of a limb
A frequently used method of establishing alterations in limb size and shape is the circumferential measurement of limb size (Williams and Whitaker [286]). This can be established by recording and comparing measurements taken of both limbs with a tape measure positioned at fixed points on a limb, usually the wrist and 10 cm above and below the point of the elbow (olecranon process) or 15 cm above and below the superior pole of the patella (Piller [225]). Although this method is easy and quick to complete, its use is primarily to track only broad changes in limb circumference. The method is prone to error if the tape measure is not positioned in the same place on each consecutive occasion.
Limb volume measurements of a limb
A more accurate method of assessing response to treatment is the measurement of limb volume (Figure 27.15). Multiple circumferential measurements of both limbs at 4 cm intervals, applied to the formula for the volume of a cylinder, provide a reliable method of determining the size of the limb and a useful, objective means of determining response to treatment. This is the most widely used method of establishing limb volume (Williams and Whitaker [286]). Reproducibility is accurate if care is taken with the procedure and a standard format for the recording of the measurements is used (Ng and Munnoch [192]).
Figure 27.15 Measurement of limb volume. Source: Dougherty and Lister ([90]).
Pre‐procedural considerations
The sequential circumferential measurement of a limb for the calculation of limb volume should not be confused with simple limb measurements used in the choice of compression garment for a patient. These are recorded at set points on the limb and used to guide the therapist in choosing the correct size garment for the patient.
The principles in Table 27.12 and points in Table 27.13 should be considered when using sequential circumferential measurements to calculate limb volume (Williams and Whitaker [286]).
Procedure guideline 27.10
Compression therapy limb volume calculation: lower limb
Procedure guideline 27.11
Compression therapy limb volume calculation: upper limb
| Problem | Cause | Prevention | Action |
|---|---|---|---|
| The tape measure will not lie evenly on the surface of the skin because of the shape of the limb and development of deepened skin folds. | The effect of the lymphoedema on the tissues and the distribution of swelling. | The limb shape can be artificially corrected. | Wrap the limb in cling film to create a more cylindrical shape. Mark the cling film and measure at these points. |
| Loose areas of skin, making it difficult to place the tape measure smoothly around the limb. | Age‐related loss of skin turgor or weight loss causing excess skin. | The limb shape can be artificially corrected. | Elevation of the limb distributes the excess skin and a more accurate measurement of the limb can be obtained. |
| Limited range of movement of upper limb, making limb positioning difficult. | Brachial plexopathy. | Work within the patient's ability. | Position the limb comfortably and seek assistance if necessary to support the limb. |
| Skin lesions, open wounds, pain or tenderness resulting in the omission of some measuring points and inaccurate calculation of limb volume. | Measurements cannot be taken where there is a breach of skin integrity or pain. | Carefully examine the skin for breaks in skin integrity prior to measuring and check that the patient is comfortable so that action can be taken if necessary. | Cover any open wounds with cling film to ensure measurements can be taken in the required place. Avoid pulling the measuring tape tightly to avoid trauma to the area. |
Table 27.12 Using sequential circumferential measurements to measure limb volume
| Indications | Contraindications |
|---|---|
| To determine the total excess volume of the swollen limb compared with the patient's contralateral normal limb | In palliative care, the tracking of limb volume changes in a limb may not be appropriate and simple circumferential limb measurements can provide an alternative means of assessment |
| To establish the distribution of the swelling along the limb | In the presence of infection or open wounds |
| To provide information to assist in the choice of compression therapy | To detect early lymphoedema. Consideration should be given to other symptoms including patterns of transient swelling and any sensation changes (Finlay et al. [103]) |
To provide an objective method of determining response to treatment by indicating:
|
Table 27.13 Points for consideration when recording sequential circumferential measurements to calculate limb volume
| Principle | Rationale |
|---|---|
| Ensure that the same position is used for the same patient each time the limb is measured | The position of the limb will affect the measurements taken because the degree to which muscles are flexed or relaxed will influence the shape and size of the limb |
| The limb should be marked afresh on each measuring occasion with a washable ink, even when measuring on consecutive days | Any increase or decrease in limb volume will influence the position of the marks on the limb |
| Tension should not be exerted on the tape measure during measuring | If tension is applied it will vary between measurers and recordings will not be consistent |
| The tape measure should be positioned so that it is horizontal around the limb, taking care to ensure that it is not pulled tightly | To minimize inaccuracies in measurement |
| The same number of measurements should be taken on both limbs each time measurements are taken | The normal limb acts as a control in patients with unilateral swelling |
| The starting point for the taking of measurements should be clearly identified by measuring and clearly recording the distance from the tip of the middle finger to the wrist or base of heel to point above ankle where the tape measure lies flat | This starting point on the wrist/ankle should be used each time |
| A standard format for the recording of measurements should be adopted | To ensure that key points can be referred to |
Post‐procedural considerations
Once a sequential circumference measurement of both limbs has been recorded, a few formulas may be used to calculate the limb volume of each limb (Williams and Whitaker [286]).
The formula for the volume of a cylinder (Box 27.8) considers the limb as a series of cylinders, each with a height of 4 cm.
Box 27.8
Procedure for calculating volume from circumferences
The formula for calculating the volume of a cylinder is 
. The formula must be applied to each circumference measurement (circ1, circ2, …, circn) in order to calculate the volume of each segment; the volumes are then totalled to give the total limb volume.
 |
Using a programmable calculator to calculate the volume of a cylinder will speed up the process of calculation.
To calculate the volume of the limb, each measurement needs to be converted into a volume for that segment of the cylinder and then totalled. This is illustrated in Table 27.14.
Table 27.14 Example calculation of the total volume of a limb using the formula in Box 27.8
| Circumference measurement (cm) | C 2/π (3.14) | Volume of each cylinder (mL) |
|---|---|---|
| 18.4 | = | 107.7 |
| 19.1 | = | 116.1 |
| 21 | = | 140.3 |
| 23.2 | = | 171.3 |
| 24.9 | = | 197.3 |
| 25.7 | = | 210.2 |
| 26.6 | = | 225.2 |
| 29.6 | = | 278.8 |
| 30.3 | = | 292.2 |
| 31.7 | = | 319.8 |
| 32.7 | = | 340.3 |
| 33.5 | = | 357.2 |
| Total volume | = | 2757 |
The volume difference between the limbs is then usually expressed as a percentage. The calculation for this is shown in Table 27.15.
Table 27.15 Calculating the volume difference between the limbs as a percentage
| Formula for calculation | ||
| Divide 100 by unaffected limb volume and multiply by the volume difference between the limbs | ||
| Worked example | ||
| Swollen limb volume | Unaffected limb volume | Difference between the limbs |
| 2757 | Minus 2459 | Equals 298 |
| 100 divided by 2459 (unaffected limb volume) | Multiplied by 298 (volume difference between the limbs) | Equals 12.11 |
| The swollen limb is 12% bigger than the normal limb | ||
