Measuring change in limb volume to evaluate lymphoedema treatment outcome

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Maria Mills
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adrid Spain EWMA n GNEAUPP 2014 Submitted to EWMA Journal, based on a presentation given at a free paper session (Free paper session: Quality of life) at the EWMA - GNEAUPP 2014, Madrid Measuring

Aim This paper provides an overview of the practical approaches to assessing limb and calculating changes in limb after treatments in patients with unilateral lymphoedema.

A compression bandaging system comprised of a foam roll and cohesive, inelastic bandages was applied to 9 patients with unilateral lymphoedema on 6 occasions over a 12-day treatment period.

1 adrid Spain EWMA n GNEAUPP 2014 Submitted to EWMA Journal, based on a presentation given at a free paper session (Free paper session: Quality of life) at the EWMA - GNEAUPP 2014, Madrid Measuring change in limb to evaluate lymphoedema treatment outcome ABSTRACT The accurate, non-invasive measurement of limb in patients with lymphoedema is important in the clinical and research setting. Aim This paper provides an overview of the practical approaches to assessing limb and calculating changes in limb after treatments in patients with unilateral lymphoedema. Methods Techniques for assessing limb are described, and a case study example is presented. A compression bandaging system comprised of a foam roll and cohesive, inelastic bandages was applied to 9 patients with unilateral lymphoedema on 6 occasions over a 12-day treatment period. Two parameters for measuring the changes in limb after the course of treatment were used to evaluate treatment outcomes. n Parameter 1: percentage change in excess limb over time. n Parameter 2: percentage change in absolute limb over time. Results In 9 patients, the mean percentage change in excess limb at Day 12 was 35%, and the mean percentage change in absolute limb was 8%. Conclusions The two parameters for calculating changes in limb are not interchangeable. Parameter 1 is only suitable for patients with unilateral lymphoedema, but provides the information on the reduction of lymphoedema (excess). Parameter 2 can be used for patients with bilateral lymphoedema, where no comparator or unaffected limb is available. Both parameters should be reported in research, and both limbs should be measured, if possible. However, Parameter 2 should be used with caution, as the percentage change is based on the whole limb, rather than the more accurate excess limb as a measure of lymphoedema. INTRODUCTION A key characteristic of lymphoedema is increased limb. The accurate, non-invasive measurement of limb is essential in the clinical and research setting. The change in limb is an important treatment outcome in determining the effect of decongestive treatments, such as compression bandaging. This manuscript provides an overview of the practical approaches for assessing limb and describes two parameters for calculating the changes in limb over time. Nine patients with unilateral lymphoedema participated in an audit of a lymphoedema bandaging system comprised of a foam roll and cohesive inelastic bandages (Fig. 1). This bandaging system was applied on 6 occasions over a 12-day treatment period. WHY MEASURE LIMB VOLUME? Measuring limb can be a useful tool in establishing the extent and stage of lymphoedema and identifying the treatment outcomes 1,2. In patients with unilateral lymphoedema, the difference between the affected and unaffected limb is expressed as the excess limb, which is often reported as a percentage of the of the unaffected limb (Table 1). A grading system for unilateral lymphoedema based on the excess limb has been established 2 : n <20% = mild lymphoedema n 20 40% = moderate lymphoedema n >40% = severe lymphoedema In patients with bilateral lymphoedema, monitoring the of each limb can provide information on the treatment and self-management outcomes over time, thus enabling both patients and practitioners to recognise any change in individual limb size. However, as there is no unaf- Science, Practice and Education Anne F. Williams PhD, MSc, RN, DN, Dip Nurse Ed Lecturer in Nursing Queen Margaret University Edinburgh EH21 6UU Scotland Justine Whitaker MSc, RN Director and Lymphoedema Nurse Consultant, Northern Lymphology Ltd, Senior Lecturer, University of Central Lancashire, UK Correspondence: anne@esklymphology. co.uk Financial support was provided from Activa Healthcare for the bandaging audit and the original presentation at EWMA This manuscript is based on the original presentation. EWMA Journal 2015 vol 15 no 1 27

Figure 1: Application of the bandaging system, which was comprised of the spiral application of a foam roll* and the figure-of-eight application of the cohesive, inelastic bandages** * Rosidal Soft,

2 Figure 1: Application of the bandaging system, which was comprised of the spiral application of a foam roll* and the figure-of-eight application of the cohesive, inelastic bandages** * Rosidal Soft, Lohmann & Rauscher, Rengsdorf, Germany ** Actico, Activa Healthcare, Staffordshire, United Kingdom fected control limb, the actual (excess) of lymphoedema cannot be accurately established in someone with bilateral swelling. Similarly, no fully validated and reliable method exists for establishing the lymphoedema in patients with swelling in the head, neck, genitalia, and trunk 2. TECHNIQUES FOR MEASURING LIMB VOLUME Various techniques for measuring limb have been reported in the literature. n Tape measure n Water displacement n Perometer TAPE MEASURE This is the most practical and portable technique in the therapeutic setting. Most commonly, the limb is marked and measured at 4-cm intervals 1. Circumferential measurements are recorded (Table 1), and measurements can be compared over time for each point, thereby 28 Table 1: Recording circumferential measurements in Patient A (a woman with lower limb lymphoedema). The cylinder equation is used. Before treatment After treatment Right limb Left limb Right limb Left limb affected unaffected (cm) affected (cm) unaffected (cm) (cm) DISTAL Distal limb 0 (ml)0 2,904 4,524 2,856 3,651 Excess (ml)0 1, % excess0 56% - 28% - PROXIMAL Proximal limb0 (ml)0 6,145 7,045 6,182 6,609 Excess (ml) % excess0 15% - 7% - Total limb 0 (ml)0 9,050 11,569 9,038 10,260 Excess (ml)0 2,519-1,222 - % excess0 28% - 14% - EWMA Journal 2015 vol 15 no 1

3 Science, Practice and Education Table 2: Two equations for calculating limb Volume of a cylinder: the limb is viewed as a series of cylinder-shaped segments. Volume of each segment = C²/π C is the circumference at the midpoint of a segment with a length of 4 cm. Therefore, the starting point for the first measurement is 2 cm above the wrist or ankle. Total limb is determined by the sum of the segment s. Volume of a truncated cone: the limb is viewed as a series of truncated cone or frustrum-shaped segments. Volume of each segment = L/12π (C1² + C1 C2 + C2²) C1 and C2 are the circumferences at either end of a segment length (L). The starting point for the measurement is at the wrist or ankle, which represents the first point of the distal truncated cone. Total limb is determined by the sum of the segment s. Table 3: Limb calculations before treatment in Patient A Total limb The calculation of total limb (ml): Right leg: 9,050 Left leg: 11,569 Excess limb comparing affected and unaffected limbs The difference between the limb of the affected and unaffected limbs in a patient with unilateral lymphoedema (ml): 11,569 9,050 = 2,519 Percentage difference in excess The excess limb is expressed as a percentage of the unaffected limb. This indicates how much larger the affected limb is compared to the unaffected limb. 2,519 x 100 = 28% 9,050 Volume of different segments of the limb The limb is divided into the distal and proximal segments, and the total, excess, and percentage excess are reported for each segment. This is particularly useful if the swelling is not evenly distributed (for example, below the knee only). Distal segment s (ml) Affected distal segment: 4,524 Unaffected distal segment: 2,904 Excess of distal segment: 1,620 % excess of distal segment: 1,620 x 100 = 56% 2,904 Proximal segment s (ml) Affected proximal segment: 7,045 Unaffected proximal segment: 6,145 Excess of proximal segment: 899 % excess of proximal segment: 899 x 100 = 15% 6,145 giving precise information on the distribution of swelling and changes in limb circumference. Any change in limb circumference may indicate an increased or reduced fluid. These changes may also be influenced by the alterations in muscle mass, fat tissue, and tissue fibrosis. As such, an unaffected limb should always be measured as the control, as symmetrical change can be expected in response to factors, including exercise and weight loss. Circumferential measurements can be entered into computer software programmes or pre-programmed calculators to calculate limb and, in unilateral swelling, excess limb. Most commonly, two formulae are used to calculate the (Table 2), although the limb is rarely shaped like a true cylinder or truncated cone (frustrum). The calculation of the limb, excess, and percentage excess can be established for the whole limb, distal segments, and proximal segments, thus providing specific information on the distribution of oedema within the limb (Table 1). In the example shown in Table 1, the excess s before treatment at the distal and proximal sections of the limbs are very different (56% and 15%, respectively). This indicates an uneven distribution of swelling, which is not evident in the whole limb excess figure of 28%. When the measurement method is precise and standardised, evidence indicates that circumferential methods are valid and reliable 3,4,5 (Table 4). The actual limb achieved will depend on the size and shape of each limb segment and the method of calculation 6-8. The formulae (cylinder or truncated EWMA Journal 2015 vol 15 no 1 29

4 Table 4: Tips for achieving accuracy using the tape measure method Consistent limb position Consistent tape type, width, and tension: some practitioners use a pre-tensioned tape to standardise Accurate and consistent marking of the starting and subsequent measurement points throughout the limb: for example, marking the starting point as a consistent distance from the base of the nail bed of the middle finger Standardisation of the measurement as below and above the marked point Consistent number of measurement points used Measurements by the same operator at the same time each day Table 5: Using two outcome parameters to calculate changes in limb after treatment in Patient A Parameter 1: Parameter 2 Pre-treatment excess : 2,519 ml Pre-treatment absolute of the affected leg: 11,569 ml Post treatment excess : 1,222 ml Change in excess : Post-treatment absolute of the affected leg: 10,260 ml % change in excess : 2,519 1,222 = 1,297 ml 1,297 x 100 = 52% 2,519 Change in absolute of the affected leg: 11,596 10,260 = 1,336 ml % change in absolute : 1,336 x 100 = 15.5% 11,596 cone) must be used consistently and are not interchangeable 5,7. The hand or foot is not included in the calculation of limb, although approaches to measuring the hand have been explored 9. WATER DISPLACEMENT METHOD This method is often viewed as the gold standard 2 and is mainly used in research. It relies on measuring the amount of water that is displaced from a container when the limb or part of the limb is submerged. This provides information on the of the whole limb, including the hand or foot, and can be used to accurately measure the hand or foot alone 7. The total of each limb can be used to calculate the excess and percentage excess of the whole limb, hand, or foot. This is generally not practical for clinical use. Circumferential measurements have been shown to correlate well with water displacement 3,5,10,11, although the reported s from water displacement are often slightly lower than those from the circumferential measurements4. Therefore, the methods are not interchangeable. 30 PEROMETER METHOD (OPTOELECTRONIC PLETHYSMOGRAPHY) This device uses infra-red sensors to measure the limb 7, 12. The limb is placed within a frame that does not touch the limb but is moved along the length of the limb. The method has some disadvantages, as it is expensive, is only suitable for the clinical setting, and relies on the patient being able to hold the limb steady in a specific position: for example, the arm is generally abducted. The machine provides various readings, including limb, and produces a visual representation of the limb, which may be particularly useful for patient education. Tan et al. 13 examined the agreement between a vertically orientated perometer and the tape measure method in volunteer legs. He concluded that the methods were reliable but not interchangeable, as the tape measure overestimated the limb in comparison to the Perometer. CALCULATIONS OF LIMB VOLUME Details of limb, excess limb, and percentage excess of the limb, as well as sections of the EWMA Journal 2015 vol 15 no 1

5 Science, Practice and Education Table 6: Use of Parameter 2 to calculate the percentage change in absolute limb Example 1: Example 2: Limb before treatment: 10,000 ml Limb after treatment: 8,000 ml Reduction in limb : 2,000 ml Expressed as a percentage of the starting treatment : 2,000 x 100 = 20% 10,000 Limb before treatment: 16,000 ml Limb after treatment: 14,000 ml Reduction in limb : 2,000 ml Expressed as a percentage of the starting treatment : 2,000 x 100 = 12.5% 16,000 Table 7: Measuring limb change in nine patients with unilateral lymphoedema during a 12-day course of lymphoedema bandaging Parameter 1: Change in excess limb Parameter 2: Change in absolute of the affected limb Excess (ml) at Day 1 (pretreatmenttreatment) Excess (ml) at Day 12 (post- Change in excess % change in excess Before treatments: affected limb After treatments : affected limb Change in limb (ml) % change in limb (ml) (ml) (ml) ID1 1,788 1, ,709 7, ID2 1, ,995 11, ID3 3,501 2, ,021 10, ID4 1,446 1, ,396 10, ID5 1, , ,631 7,394-1, ID6 3,485 2, ,135 8, ID7 4,182 3, ,376 12, ID8 4,760 2,295-2, ,399 10,931-2, ID9 5,650 4, ,039 16, Mean 3,145 2, ,522 10, limb such as the distal and proximal segments, can be calculated (Tables 1 and 3). Practitioners must understand the implications of any data which are obtained through software packages or calculators. This ensures that (1) circumferential measurements are taken at the correct intervals with a precise starting point, (2) data are correctly entered, and (3) any feedback that is given to patients or recorded for the clinic or research purposes is accurate. The formula for a cylinder requires the first circumferential measurement to be taken at 2 cm above the wrists or ankle (midpoint of the cylinder). The frustrum formula requires measurements at the end of each segment, so the first circumference is taken directly at the wrist or ankle. ESTABLISHING THE CHANGE IN LIMB VOLUME AFTER TREATMENT In a patient with unilateral lymphoedema, reporting excess s before and after treatments also enables a calculation of absolute and percentage change in excess limb in relation to the pre-treatment excess (Table 5). This is the most accurate representation of the actual change in the amount of lymphoedema in the affected limb and is particularly useful for research and audit purposes. When a patient has bilateral lymphoedema, the excess cannot be calculated. Instead, the reduction in absolute limb may be expressed as a percentage of the pre-treatment total limb in each affected limb. However, this does not provide precise details of the lymphoedema or change in the lymphoedematous component of the limb. As shown in Table 5, two outcome parameters were used to calculate the changes in the affected limb of a patient with unilateral lymphoedema. The two methods produced very different results. Although Parameter 1 relied on the unaffected leg as a control, the result from Parameter 2 was influenced by the initial of the limb.this is further illustrated in the examples given in Table 6 where two limbs have each reduced by 2000mls, although the calculation of percentage change, based on the initial limb s of 10,000mls and 16,000mls, are very different. Importantly, it is impossible to know how much of an initial limb is due to lymphoedema in a patient with bilateral swelling. EWMA Journal 2015 vol 15 no 1 31

6 APPLICATION IN AN AUDIT Nine patients with unilateral lower limb lymphoedema participated in an audit of a bandaging system incorporating the spiral application of a foam roll and the figureof-eight application of cohesive, short-stretch bandages 14. The patients were bandaged over 12 days with a total of 6 applications of the bandaging system (Fig. 1). The limb was calculated using the formula for a cylinder before and after the 12-day treatment course. Circumferential measurements were taken at 4-cm intervals along the affected and unaffected limb, starting 2 cm above the ankle. These data were entered into a spreadsheet to calculate the limb, excess, and % excess. The changes in limb in the 9 patients (Table 7) were expressed using two parameters. n Parameter 1: percentage change in excess limb over time. n Parameter 2: percentage change in absolute limb over time. RESULTS The results from the 9 patients with unilateral lymphoedema show a mean reduction in the excess limb of 35% (range 11 72%) when Parameter 1 was used (Table 7). This was similar to the mean reduction of excess of 33.5%, which was reported by Badger et al. 15 in a study of 31 patients after 18 days of bandaging. Using Parameter 2, the mean reduction in the absolute limb in the 9 patients who took part in the audit was 8% (Table 7). CONCLUSIONS The two parameters for calculating the change in limb yielded different results and were not interchangeable. Our results suggest that Parameter 1 is only suitable for patients with unilateral lymphoedema, but provides information on the reduction in lymphoedema. Parameter 2 may be used for patients with bilateral lymphoedema, where no comparator (unaffected) limb is available. Both parameters should be reported in research, and both limbs should be measured. However, Parameter 2 should be used with caution, as the percentage reduction is based on the whole limb. The accurate representation of limb reduction cannot be achieved using Parameter 2, where the extent of lymphoedema is unknown, as a comparison with the unaffected limb is not possible. However, both parameters are useful in the clinical setting to monitor changes in the limb over time. To ensure accuracy, practitioners should use standardised, valid, and reliable approaches when assessing limb change. Limb measurements should be used in conjunction with other quality of life measures and patient-reported outcomes to provide a more holistic perspective on progress and change. Future work could involve the use of a larger dataset to examine the correlations between different approaches to quantifying limb reduction. REFERENCES 1. Lymphoedema Framework. Best Practice for the Management of Lymphoedema, International consensus. London: MEP Ltd.; Available at: Wound_Guidelines/Lymphoedema_Framework_Best_ Practice_for_the_Management_of_Lymphoedema.pdf [Accessed ]. 2. International Society of Lymphology (ISL). The diagnosis and treatment of peripheral lymphoedema. Consensus document of the International Society of Lymphology. Lymphology 2013;42: Sander AP, Hajer NM, Hemenway K, Miller AC. Upper-extremity measurements in women with lymphedema: a comparison of measurements obtained via water displacement with geometrically determined. Phys Ther 2002;82: Taylor R, Jayasinghe UW, Koelmeyer L, et al. Reliability and validity of arm measurements for assessment of lymphedema. Phys Ther 2006;86: Mayrovitz HN, Macdonald J, Davey S, Olson K. & Washington E. Measurement Decisions for Clinical Assessment of Limb Volume Changes in Patients With Bilateral and Unilateral Limb Edema. Phys Ther 2007;87(10): Sitzia J. Volume measurement in lymphoedema treatment: examination of formulae. Eur J Cancer Care (Engl) 1995;4: Stanton AWB, Badger C, Sitzia J. Non-invasive assessment of the lymphedematous limb. Lymphology 2000;33: Katz-Leurer M, Bracha J. Test-retest reliability of arm measurement in women with breast cancer-related lymphoedema. J Lymphoedema 2012;7(2): Borthwick Y, Paul L, Sneddon M, McAlpine L, Miller C. Reliability and validity of the figure-of-eight method of measuring hand size in patients with breast cancer-related lymphoedema. Eur J Cancer Care 2013;22: Karges JR, Mark BE, Stikeleather SJ, Worrell,TW. Concurrent validity of upper extremity estimates: comparison of calculated derived from girth measurements and water displacement. Phys Ther 2003;83: Tewari N, Gill PG, Bochner MA, Kollias J. Comparison of displacement versus circumferential arm measurements for lymphoedema: implications for the SNAC trial. ANZ J Surg 2008;78(10): Adriaenssens N, Buyl R, Lievens P, Fontaine C, Lamote J. Comparative study between mobile infrared optoelectronic try with a Perometer and two commonly used methods for the evaluation of arm in patients with breast cancer related lymphedema of the arm. Lymphology 2013;46(3): Tan C-W, Coutts F, Bulley C. Measurement of lower limb : Agreement between the vertically orientated perometer and a tape measure method. Physiotherapy 2013;99(3): Whitaker J, Williams A, Pope D, Charles H, Muldoon J. Sub-bandages pressures and comfort in a lymphoedema bandaging system with a foam layer and cohesive short stretch bandages. Poster at Harrogate Wound Care Conference, Badger C, Peacock J, Mortimer P. A randomisedcontrolled parallel-group clinical trial comparing multi-layer bandaging followed by hosiery versus hosiery alone in the treatment of patients with lymphedema of the limb. Cancer 2000;7: EWMA Journal 2015 vol 15 no 1

Research Report. Measurement Decisions for Clinical Assessment of Limb Volume Changes in Patients With Bilateral and Unilateral Limb Edema

Research Report. Measurement Decisions for Clinical Assessment of Limb Volume Changes in Patients With Bilateral and Unilateral Limb Edema Research Report Measurement Decisions for Clinical Assessment of Limb Volume Changes in Patients With Bilateral and Unilateral Limb Edema Harvey N Mayrovitz, John Macdonald, Suzanne Davey, Kelly Olson,