Crowds turn out for Wounds Australia professional learning
Monday, 26 February 2024
Thanks to everyone – more than 330 people! – who joined us online on Thursday 29 February for our webinar with Dr Stephanie Lam. 

In a fascinating session, Dr Lam – an expert from Macquarie University’s Australian Lymphoedema Education, Research and Treatment (ALERT) program – explored the topic of lower limb swelling and the role of the lymphatic system in oedemas. 

Because the webinar covered such a broad subject in just one hour, Dr Lam agreed to answer participant questions after the webinar ended. 

And here they are! Also included are a series of reference materials mentioned in the presentation or relating to its contents.

Thanks to all who attended and asked questions. We appreciate your commitment to ongoing professional development, particularly on the eve of Lymphoedema Awareness Week. And a very special thank you to Dr Lam for so generously sharing her time and expertise. Find out more about the ALERT program.

Watch the recording

If you’re a Wounds Australia member and you missed it, you can catch up on-demand. Simply navigate to the webinar library in your member profile and you will find it in the ‘Feet/legs’ directory.

DISCLAIMER: Please note that the advice that follows is appropriate only for medical professionals.

Q&A with Dr Stephanie Lam, March 2024

Q1. Is it ok for left-sided heart failure to receive lymphoedema compression? 
It is more common for right-sided heart failure to cause peripheral oedema, and for left-sided heart failure to cause pulmonary oedema.

However, in congestive heart failure in general, the severity of heart failure should be taken into account. 

A clinical clue may be to see whether your patient is already requiring use of diuretics to manage their heart failure. This is often an indication of difficulty managing fluid homeostasis.

Congestive cardiac failure is a precaution to using compression, and is contraindicated in unstable or decompensated heart failure. If unsure, I would recommend you and your patient speak to their primary care physician or cardiologist before commencing any compression therapy. The therapists that I work with will often enquire with me if they are unsure if it is safe to start compression. 

Q2. Do the effects of Taxol decrease with time after cessation of treatment, or is it permanent? 
Oedema is a side-effect of Taxol-based chemotherapy agents whilst the person is on treatment. Study results have been variable as to whether it is an independent risk factor for lymphoedema, but when I take a clinical history, if a patient has had adjuvant or neoadjuvant chemotherapy (e.g. in breast cancer treatment) I do consider it as one of the possible additional risk factors for lymphoedema. Once a patient has been diagnosed with lymphoedema, at this stage this is still considered a chronic condition.

As for duration of time after cessation of treatment, I am unsure if Taxol-only therapy has been studied in this case, as it is more common for Taxol to be an adjuvant or neoadjuvant treatment.

As a side note, we have seen cases, particularly in breast cancer, where patients have presented with a late presentation of lymphoedema, years down the track. In these cases, we suspect that there had been lymphatic system changes, but the lymphatics had been able to adequately compensate, to continue to maintain interstitial fluid homeostasis. However, whether it be ageing, injury, infection or other triggers, this may later decompensate the lymphatic system, with patients presenting later.

Q3. Can lymphoedema affect blood pressure or can it cause orthostatic hypotension? 
Great question! As lymphoedema is usually insidious, rather than an acute change, people’s blood pressure systems tend to adapt over time. However in situations where a person with lymphoedema is anticipated to temporarily swell more, e.g. long-haul flights, we do advise that they maintain hydration to avoid dehydration and orthostatic hypotension. 

Q4. When a person is referred with known CCF, what investigations would you conduct prior to commencement of compression? 
I would usually conduct some information gathering, including: request of previous cardiologist letters and transthoracic echo (TTE) results, current medication list and a review of other comorbidities, and pathology tests, including renal function and liver function. The cardiologist’s letter and TTE usually gives an indication of severity of CCF.

Based on this information I will make recommendations to the therapist. Sometimes we may start conservatively with low-pressure compression only, e.g. Class 1 compression, and reassess. I may also advise the patient to increase their diuretics if required. 

If you feel this is outside of your scope of professional practice, I would strongly advise for medical input. If there is concern of pulmonary oedema, then an urgent CXR is helpful to assess this. At our lymphoedema clinic, the lymphoedema therapists will ask me to see patients to determine if compression can commence, if they are unsure.

Q5. Is ICG or lymphoscintigraphy recommended for diagnosis for all patients with lymphoedema? 
Lymphoedema is still more commonly clinically diagnosed. Sometimes it is very evident and patients do not require an imaging scan. When diagnosis is in doubt, that is when imaging is helpful. 

Lymphoscintigram is more commonly and widely available than ICG. It is also Medicare-rebatable, therefore it may be more easily accessed. It is used to confirm a diagnosis of lymphoedema. Lymphoscintigrams are done at nuclear medicine imaging centres. 

ICG is not used for all of our patients, but is helpful when diagnosis is difficult or unclear, or when therapists are finding progress has plateaued and require more information to treat their patients. The ICG offers real-time data which means we can provide additional information to optimise conservative management and also determine if a patient may be a suitable surgical candidate for some of our microsurgeries offered. 

Q6. Are ICG or lymphoscintigraphy readily available across Australia? Including regional areas? 
Please see earlier. 

Q7. Is there a place for therapeutic massage in lymphoedema? 
Lymphatic massage is referred to as ‘Manual Lymphatic Drainage’ (MLD). At ALERT, we have been fortunate to have the ICG to assess the impact of MLD on lymphatic flow. 

Normal functioning superficial lymphatic collector vessels will flow on their own, but we do see light massage is adequate to help them along. 

In Lymphoedema, where we see dermal backflow (i.e. the body needing to use the very small lymphatic capillaries to move lymph fluid along due to disruption of the lymphatic collector vessels), we can see on ICG that firm and slow pressure is required to move this lymph fluid. Light and fast pressure does not appear to be effective. Additionally, our ICG results, called ‘lymphatic mapping’, are used by therapists to then individualise their MLD for patients. We also use lymphatic mapping to then teach patients how to do self-MLD, where possible. This is usually more easily done for the head and neck, chest, arm and genital region. The legs can be difficult to self-MLD. 

Q8. What to do when you have an oedemic leg, but unable to compress due to arterial disease?
As mentioned in my presentation, assessment is important in these situations. The extent of oedema vs. extent of arterial disease should be determined.

If unsure, please seek advice from the patient’s primary care physician or vascular surgeon. In mixed wounds and mixed disease, an MDT approach is very important. 

In mild arterial disease, the vascular surgeon may still be accepting of a trial of light compression, e.g. Class 1 compression to start with. The skin and wound should be monitored closely.

In moderate arterial disease, again, exercise caution and consult the patient’s vascular surgeon for an opinion. They may accept a trial of Class 1 compression with regular monitoring of the skin and wound.

In severe arterial disease, compression is not appropriate. There are also cases of moderate-severe arterial disease where, after vascular surgery e.g. bypass or stenting, the vascular surgeon is then agreeable for compression to be used. 

Q9. If you have a client with a leaky leg, but no wounds, just lymphorrhoea, how do you address it? Compression, exercises, etc., but do you also need to dress it like a wound? Like, wrap the leg in a big dressing?
Great suggestions. It should be a combination of all of the above. Lymphorrhoea is an indication of significant oedema with nowhere else for the lymph fluid to go. In these cases, a compression bandaging program can be helpful to very rapidly reduce the volume of the limb. If this program is not feasible or accessible for the patient, compression garments or wraps can also be helpful, but will take longer. Please also ensure adequate dressings/absorption to reduce risk of skin maceration, as cellulitis remains a risk if there is skin breakdown.  Adjuncts like the pneumatic pump can also be helpful if a patient is not able to tolerate a compression bandaging program but can wear garments. I often encourage patients to walk or exercise with their compression garments on where possible to have an additional pressure effect on their veins and lymphatics.

Exercise is also recommended, and if one can exercise whilst wearing compression, particularly flat knit compression or wraps, then this is a bonus. 

Q10. Who can size/prescribe farrow wraps? 
These are usually prescribed by lymphoedema therapists who had training on how to assess, measure and prescribe the garment. However, the company reps can also provide some training and advice on prescribing. 

Reference materials:

Lymphoedema: A guide for clinical services: NSW Agency for Clinical Innovation (Chatswood; 2018)

The Journal of Wound Care, Chronic Oedema document, 2021 [link not supplied]

Wounds In Chronic Leg Oedema. Burian EA, Karlsmark T, Nørregaard S, Kirketerp-Møller K, Kirsner RS, Franks PJ, Quéré I, Moffatt CJ. Int Wound J. 2022 Feb;19(2):411-425.

The use of compression therapy for peripheral oedema: considerations in people with heart failure. Wounds UK, London, 2023

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