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Effectiveness of a multidisciplinary treatment programme applied in patients with lower limb lymphoedema and the predictive variables for a good response on the treatment.

The International Society of Lymphology[1], the Dutch Guideline for lymphedema[2] and the International Lymphedema framework[3] state that decongestive lymphatic therapy (DLT) is the first choice of treatment for lymphedema. It consists of two phases: in the first phase (intensive phase) multilayer bandages are applied together with skin care, exercises and manual lymph drainage. In the second phase (maintenance phase) skin care and exercises are continued while the bandages are replaced by compression stockings to maintain the results obtained in phase 1. Manual lymph drainage can be continued as needed.[1-3] These components can be provided by a physiotherapist. However, a multidisciplinary approach is required.[2,4] Since lymphedema is a chronic condition5 self-management support should also be included in the context of the chronic care model.[2,6] Patients with lymphedema at the arm after breast cancer state that lack of education is one of the main barriers to apply self-management.[7] Therefore, education should also be a part of the treatment[2]. In the study of Pamela et al. they also saw psychological and psychosocial factors as barriers for an effective lymphedema self-management.[7] Since lymphedema has also a negative impact on quality of life,[8,9] psychosocial support should also be part of a holistic treatment.[10] Obesity and weight fluctuation after breast cancer treatment are risk factors for developing lymphedema.[11] Hence, professional advice from a dietician is recommended.[2] To make this holistic, conservative and multidisciplinary treatment realistic and financially feasible, ‘Rijksinstituut voor ziekte- en invaliditetsverzekering’ (RIZIV) established one specialized center in the Walloon and one in the Flemish region of Belgium. Since May 2018, lymphedema patients are treated in such a multidisciplinary treatment program in the center for lymphedema at Campus Pellenberg in UZ Leuven. Here patients are guided by physicians, nurses, compression specialists, physical therapists, dieticians, social workers and psychologists specialized in treating patients with lymphedema. However, since this is a new project it is important to know what the effectiveness of such an intensive multidisciplinary treatment program is on different clinical parameters and which variables predict a good result on the long term. Many studies have been executed to investigate the effect of decongestive lymphatic therapy and its predictive factors, but only a few studies looked at the result of a multidisciplinary approach.[12] Moreover, studies about the predictive factors of a good response of DLT are mainly performed in patients with upper limb lymphedema[13,14,15,16,17] and only a few studies in lower limb lymphedema. However, these studies had either a rather small sample size[18] or potential important factors like BMI were not included[19] or only included primary unilateral lymphedema and did only investigate the predictors of volume reduction after intensive phase and not at the maintenance phase.[20] For this reason, the first aim of this PhD would be to investigate the effectiveness of a multidisciplinary treatment program and the variables that predict a good response at the end of the intensive phase and at 6 months follow-up in patients with lower limb lymphedema. However, we first need to know which lymphedema characteristics we have to evaluate to investigate the effectiveness of such a program and which measurement tools are capable of detecting clinically important change in these characteristics in a reliable way. Studies about the measurement properties of existing evaluation tools in lower limb lymphedema are lacking. Therefore, the second aim of this PhD is to look at the reliability, validity and responsiveness of different evaluations tools (perometry, bioimpedance spectroscopy and bioimpedance analysis, lymphofluoroscopy, MoistureMeter D, SkinFibroMeter, circumferential measurements and questionnaires) in lower limb lymphedema. A third aim is to determine the costs of DLT, since this is the firsts choice of treatment. References 1. ISL. The Diagnosis and Treatment of Peripheral Lymphedema: 2020 Consensus Document of the International Society of Lymphology. Lymphology 2020; 53(1):3-19. 2. Damstra, Robert J, et al. The Dutch Lymphedema Guidelines Based on the International Classification of Functioning, Disability, and Health and the Chronic Care Model. Journal of Vascular Surgery. Venous and Lymphatic Disorders (New York, NY), vol. 5, no. 5, 2017, pp. 756–765. 3. Lymphoedema Framework. Best practice for the management of lymphedema. International Consensus. London: MEP Ltd,2006. 4. Morrell, Rosalyn M, et al. Breast Cancer-Related Lymphedema. Mayo Clinic Proceedings, vol. 80, no. 11, 2005, pp. 1480–1484. 5. Földi M, Kubik S, eds. Lehrbuch der Lymphologie für Mediziner, Masseure und Physiotherapeuten, 5th ed. Munich-Jena: Urban & Fisher, 2002. 6. Wagner, Edward H, et al. Improving Chronic Illness Care: Translating Evidence Into Action. Health Affairs, vol. 20, no. 6, 2001, pp. 64–78. 7. Ostby, Pamela L, et al. Patient Perceptions of Barriers to Self-Management of Breast Cancer–Related Lymphedema. Western Journal of Nursing Research, vol. 40, no. 12, 2018, pp. 1800–1817. 8. Carter, Jeanne, et al. GOG 244 - The Lymphedema and Gynecologic Cancer (LeG) Study: The Impact of Lower-Extremity Lymphedema on Quality of Life, Psychological Adjustment, Physical Disability, and Function. Gynecologic Oncology, vol. 160, no. 1, 2021, pp. 244–251. 9. Bojinovic-Rodic, Dragana, et al. Upper Extremity Function and Quality of Life in Patients with Breast Cancer Related Lymphedema. Vojnosanitetski Pregled, vol. 73, no. 9, 2016, pp. 825–830. 10. Fu, Mei R, et al. Psychosocial Impact of Lymphedema: a Systematic Review of Literature from 2004 to 2011. Psycho-Oncology (Chichester, England), vol. 22, no. 7, 2013, pp. 1466–1484. 11. Jammallo, Lauren S, et al. Impact of Body Mass Index and Weight Fluctuation on Lymphedema Risk in Patients Treated for Breast Cancer. Breast Cancer Research and Treatment, vol. 142, no. 1, 2013, pp. 59–67. 12. Papadopoulou, Maria-Christina, et al. Multidisciplinary Lymphedema Treatment Program. International Journal of Lower Extremity Wounds, vol. 11, no. 1, 2012, pp. 20–27. 13. Vignes, Stéphane, et al. Predictive Factors of Response to Intensive Decongestive Physiotherapy in Upper Limb Lymphedema After Breast Cancer Treatment: a Cohort Study. Breast Cancer Research and Treatment, vol. 98, no. 1, 2006, pp. 1–6. 14. Liao, Su-Fen, et al. The Efficacy of Complex Decongestive Physiotherapy (CDP) and Predictive Factors of Lymphedema Severity and Response to CDP in Breast Cancer-Related Lymphedema (BCRL). Breast (Edinburgh), vol. 22, no. 5, 2013, pp. 703–706. 15. Forner-Cordero, Isabel, et al. Predictive Factors of Response to Decongestive Therapy in Patients with Breast-Cancer-Related Lymphedema. Annals of Surgical Oncology, vol. 17, no. 3, 2010, pp. 744–751. 16. Keskin, Dilek, et al. The Results of the Intensive Phase of Complete Decongestive Therapy and the Determination of Predictive Factors for Response to Treatment in Patients with Breast Cancer Related‐Lymphedema. Cancer Reports, vol. 3, no. 2, 2020, pp. e1225-n/a. 17. Duyur Cakıt, Burcu, et al. Complex Decongestive Therapy in Breast Cancer-Related Lymphedema: Does Obesity Affect the Outcome Negatively? Lymphatic Research and Biology, vol. 17, no. 1, 2019, pp. 45–50. 18. Carmeli, Eli, and Bartoletti, Roberto. Retrospective Trial of Complete Decongestive Physical Therapy for Lower Extremity Secondary Lymphedema in Melanoma Patients. Supportive Care in Cancer, vol. 19, no. 1, 2011, pp. 141–147. 19. Liao, Su-Fen, et al. The Efficacy of Complex Decongestive Physiotherapy (CDP) and Predictive Factors of Response to CDP in Lower Limb Lymphedema (LLL) after Pelvic Cancer Treatment. Gynecologic Oncology, vol. 125, no. 3, 2012, pp. 712–715. 20. Vignes, Stéphane, et al. Clinical and Scintigraphic Predictors of Primary Lower Limb Lymphedema-Volume Reduction During Complete Decongestive Physical Therapy. Physical Therapy, vol. 100, no. 5, 2020, pp. 766–772.

Date:10 Sep 2021 →  Today
Keywords:Lymphoedema, Lymphedema
Project type:PhD project