Indian Journal of Physiotherapy and Occupational Therapy. Assessment of inelastic sleeves in patients with upper limb lymphoedema

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1 Indian Journal of Physiotherapy and Occupational Therapy All Medical Journals Issues Contents Editorial Board & Information Assessment of inelastic sleeves in patients with upper limb lymphoedema Author(s): José Maria Pereira de Godoy, MD, PhD, Maria de Fátima Guerreiro Godoy, OT, PhD Vol. 1, No. 4 ( ) Print-ISSN: , Electronic - ISSN: José Maria Pereira de Godoy, MD, PhD*, Maria de Fátima Guerreiro Godoy, OT, PhD** * Livre Docente of the Vascular Service of the Medicine School in São José do Rio Preto (FAMERP), Brazil and CNPq researcher ** Occupational Therapist, Professor of the Lato Sensu Postgraduation Course in Lymphovenous Rehabilitation of FAMERP ABSTRACT Lymphoedema patients need mechanical help to complete removal of lymph from the tissues. The objectives of this study were to adapt and evaluate a fabric which would fill the basic requirements of compression, tolerability, easy to find and of a low cost. A new inelastic sleeve made from a type of polyester fabric called gorgurão was evaluated in six female patients with lymphoedema of the upper limbs. The sleeves always need to be well adjusted so that they act as a compartment limitation during exercises. A method to measure the pressure using a modified pressure apparatus was developed. This new fabric was compared with conventional dressings. The pressure variations during the flexion and extension of arm fluctuated from 20 to 60 mmhg with the sleeve dressings. The sleeves were very tolerable and reduced the measurement of the circumferences of the affected limbs 2 to 4 cms in three weeks of use. In conclusion, the sleeves made from this fabric with low elasticity are effective to reduce the circumferences of upper limbs with lymphoedema. Key words: lymphoedema, development, inelastic sleeves. INTRODUCTION Lymphoedema patients need mechanical help to complete removal of lymph from the tissues. Mastectomy is the most common genesis of lymphoedema of the upper limbs, and is due to aggression to the lymphatic system caused by the removal of the lymph nodes and radiotherapy. 1,2 Compression associated with lymph drainage represents one of the principal treatments for this disease. The objective of compressive therapy is to prevent the formation of edema and to help to remove the excess of

2 accumulated lymph. 3,5 External pressure exerted on the tissue favors the mobilization of the fluids and during muscular contraction it is possible to increase the pressure thereby improving pumping of the lymphs. 6 Dressings can be categorized in four groups depending on the extensibility: inelastic; low (<70% elasticity); moderate (between 70 to 140%) and high (>140%) elasticity. The difference between elastic and inelastic dressings is important. An elastic dressing exerts an unnatural pressure on the limb whereas a inelastic dressing merely acts as a limiting boundry and so enhances the natural pumping effect of the muscles during exercise. 7 One of the main difficulties experienced is to find the correct dressing for the treatment. The cost is another factor to be considered especially in impoverished countries where adaptations are often necessary to comply with the economic reality of those places in order to make the treatment viable. 8 The aim of this study was to select a textile for the manufacture of a sleeve and evaluate its effectiveness during treatment of lymphoedema. The basic requisites were good compression and tolerability, ease of availability of the material and of fabrication of the sleeve, and a low cost. MATERIAL Six female patients suffering from grade II lymphoedema of upper limbs with ages varying from 60 to 72 years (mean 66 years) were evaluated. A fabric, which in Brazil is commercially known as Gorgurão, and which filled the recommended prerequisites for dressings of low extensibility was assessed. This material is made of 62% cotton and 32% polyester and satisfied the pre-condition: inelastic but permits a limited extension in both the transversal and longitudinal directions. Using this material, sleeves were made in a way that the extension of the fabric in the transversal direction is less than the extension in the longitude direction. This is an important point as it permits a better mobility of the limb whilst acting as an external limiting restraint around the limb. The design followed existing standards of this type of sleeve leaving a space for the elbow joint as is shown in Figure 1A, B and C. Fastening was achieved using Velcro which permits adjustment of the external pressure necessary after reduction of the measurement of the circumference of the limb. It is important that it fits tightly so that it acts as an external compartment restraint; similar in principle to what occurs naturally with the bone-aponeurotic physological compartments. During exercise, due to expansion of the muscles in a limited space, other structures within the compartment are compressed and a natural pumping effect is seen. A method was created to measure the pressure exerted during movement by modifying a pressure apparatus to study variations of pressure as is shown in figure 2. Use of the sleeves was compared with inelastic dressings evaluating pressure variations during flexion and extension of the arm. The tollerability of the dressings and the acceptability by the patients were also assessed. Measurements of the circumference of the limbs at five-centimeter intervals were made before using the sleeve and after three weeks of use. RESULTS The sleeves permitted a pressure variation, varying from 20 to 60 mm Hg during flexion and extension of the arm similar to what was observed with inelastic dressings. In five of the six patients who used the sleeves a reduction of the measurements of the circumference of the limb of from 2 to 4 centimeters was observed. It was observed that the more the limb was exercised, the higher the reduction was. These reductions were lost soon after the patient stopped to use the sleeve. DISCUSSION

3 This type of sleeve achieved the same results as were seen using inelastic dressings. Several Advantages can be seen when the sleeve is compared with the traditional inelastic dressings. First is the cost which is less than one third of the price of dressings. Second is the acceptability of the patient as the sleeve can be removed and replaced by the patient himself whereas dressings normally require the assistance of a family member. Finally, and most importantly, is that it is simple to exert a uniform pressure when using the sleeve which is not always the case with a dressing. Adaptation is simple and at a low cost. It is easy to acquire the fabric and to instruct a professional to produce the sleeve. Tolerance on the part of the patients was good. The sleeve should be used continuously until a satisfactory reduction of the lymphoedema is achieved. The size loss was notable during the first two weeks and reduced significantly after this period. This is probably due to the greater loss of liquids during the initial period. It is important that during the use of the sleeve, it must be tight so that it acts as an external compartment restraint, if not, it will not fulfill its objective. This external limiting should minimize the volume of the anatomic compartment thereby limiting muscle expansion during movement. This pressure on the lymphatic and venous systems improves the natural pumping effect. In this case a new limiting compartment involving the subcutaneous tissue is used. These sleeves assist in the treatment of lymphoedema, however the patients who use them should be aware that this is a chronic disease where lifelong care is necessary. The non-use of the sleeves means a rapid return to the initial measurements of the circumference of the limb; however continuation permits a continued reduction. CONCLUSION The sleeves made from this fabric with low elasticity are effective to reduce the circumferences of upper limbs with lymphoedema. Fig 1A, B and C Observe the model of a inelastic sleeve of polyester type material known as Gorgurão.

4 Fig. 2 Observe the pressure apparatus adapted for this research. REFERENCES 1. Casley-Smith JR. Casley-Smith J. Lymphaticovenous insufficiency and its conservative treatment. Phlebolymphology 1994; 6:9-15.

5 2. Földi M, Foldi E. Lymphoedema. Methods of Treatment and Control. English Translation Andrew C Newell. New York: Caring and Sharing, Godoy JMP, Silva HS. Prevalence of cellulitis and erysipelas in post-mastectomy patients after breast cancer. Arch Med Sci Leduc A, Leduc O. Association of several therapeutic modalities in the treatment of edema. In: Progr. XVI Congress of Lymphology, Washington, Nieto S. Método diagnóstico. In: Nieto S. Linfedema Trat. Médico. Argentina, Belczack CED, Fracchia BCA. Compressão. Grupo Internacional de la Compresión. Buenos Aires, Hafner J, Botonakis I, Burg G. A Comparison of Multilayer Bandage Systems During Rest, Exercise, and over 2 Days of Wear Time. Archives of Dermatology 2000; 136: Godoy JMP, Godoy MFG, Godoy MF, Braile DM. Drenagem Linfática e Bandagem Co-Adesiva em Pacientes com Linfedema de Membros Inferiores. Cirurgia Vascular & Angiologia 2000; 16(6): Address for correspondence: Prof. Dr. José Maria Pereira de Godoy Rua: Floriano Peixoto, São José do Rio Preto São Paulo-Brazil Zipe code: godoyjmp(at)riopreto.com.br