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Chapter 24
Alternative Assessment and Measurement Tools
Neil B. Piller
The stage and status of any lymphedematous limb (or other part of the body) and
the impact of treatment on it can be measured objectively and accurately,1 yet,
very few health professionals (and even fewer patients) ever make any attempt to
make even the most basic measurements to obtain a complete assessment of the
limb, few bother to compare the at-risk or affected limb with the contralateral one,
and even fewer have the opportunity to measure a high-risk limb prior to an
intervention.
Why is this so? Time is certainly an issue, but is not an excuse because a good
understanding of the limb and its current presentation should help target and
sequence treatment and thus gain a better outcome for the patient (and a better
reputation for the treating clinician or therapist). The lack of enthusiasm for measuring is also another issue. This is often perceived as another chore, which can be
bad news for the practitioner. Accurate information will certainly help the patient,
but it can also help protect the practitioner should a legal claim be made against
him or her.
A number of simple and easily used alternate tools and strategies can detect
early changes in the tissues before the clinician or the patient might otherwise
notice them (as a change in the size of a limb) and indicate how the treatment is
progressing.
I strongly believe that we must all make every attempt to detect lymphedema
before it manifests clinically; this means easier treatment, a greater chance of patient
involvement, better outcomes, and, from the perspective of the health care system,
a better cost-benefit analysis.
The alternative tools and techniques that are available to help us better understand and react to changes in limb structure (fibrotic tissue build-up) and function
(shown as changes in levels of extracellular fluids) will be described.
N.B. Piller
Lymphoedema Assessment Clinic, Department of Surgery, School of Medicine,
Flinders University and Medical Centre, Bedford Park, SA, Australia
B.-B. Lee et al. (eds.), Lymphedema,
DOI 10.1007/978-0-85729-567-5_24, © Springer-Verlag London Limited 2011
199
200 N.B. Piller
Measurement of Fibrotic Induration
Perhaps one of the first noticeable sequelae of surgery and radiotherapy is the formation of local or diffuse fibrous tissue. This is part of the tissue repair process, but also
can be associated with a wound infection. Scarring associated with the surgical or
radiotherapeutical sites at the root of the extremity may significantly reduce the ability of new lymph capillaries and collectors to grow or existing ones to regenerate.
In addition, as lymphedema progresses, so too does the extent and distribution of
fibrotic tissue, with fluids being replaced by fatty and then fibrous tissues. The rate
of this progression varies greatly. Tonometry, which measures the resistance of the
tissues to compression, is an indicator of the extent of underlying fibrosis.2 It has
been used since 1976 and, when used over the major lymphatic territories or at the
watersheds, can indicate the extent of induration and of the impact of treatment.
Tonometry is quickly and easily performed and can be used by individuals with
minimal training. It does not measure the actual amount of fibrous tissues but, rather,
the tissue resistance to compression by measuring the depth of compression of the
tissues when a standard weight is placed on them. With current tonometers (made
by BME at Flinders Medical Centre) accuracy to 1 mm is possible.
Variations in fibrotic tissue can be cross-confirmed with ultrasound (or CT if necessary initially) when this is performed at the same site as tonometry. When fibrotic
induration is detected, strategies such as low-level laser or frictional massage or special
MLD can be used to target it. There are perhaps more accurate ways of measuring scarring and its location (e.g., ultrasound, MRI), but they take longer and are expensive.
Measurement of Fluid Content
One of the early signs of a failure of the lymphatic system is the accumulation of
small amounts of extra-cellular fluids in the affected lymphatic territory or the whole
limb. Fluid accumulation is a sign that, regionally, the lymphatic system is failing.
The patient or clinician may not be able to detect or measure this subtle indication
of lymphatic system failure. As there is no detectable increase in limb volume or
circumference when measured by the more traditional techniques of tape measurement, the early detection of fluids is possible using multi-frequency bio-impedance.3
Current equipment is claimed to detect differences and changes in limb extra-cellular fluids as small as 5 mL. There is a large range of bio-impedance devices available at the moment, but not all have been clinically tested. At this time, the SFB7 is
best suited for office use (Impedimed Queensland); for larger, more complex clinical care settings, Multi frequency (which measures the whole body composition)
Inbody Bio-space (South Korea) will be useful for multipurpose applications. There
is also a radio frequency-based unit that can detect local area fluids, marketed under
the name of Bio-impedance and Radio-frequency (Delfin, Finland). Alone or in
combination with tonometry, these devices can provide valuable information about
24 Alternative Assessment and Measurement Tools
subtle changes in the latent phase (non-clinically manifest) of lymphedema and of
the impact of treatment on the lymphedema once it becomes clinically apparent.
Importantly, these techniques facilitate early treatment, presumably reducing the
risk and severity of clinically manifest stage 1 (ISL classification) lymphedema.
201
Measurement of Limb Volume and Circumference
While limb volume and circumference are often seen as traditional measures of
limb change, often their full value is not exploited, nor their accuracy utilized.
There are a number of ways to measure these variables. Perometry4 is suited to
larger clinics, while water displacement and/or determination of segmental or whole
limb volume by calculation following the use of a tape measure5 is often easier for
smaller ones. All can be equally accurate and reliable, but accuracy is dependent on
their correct use.
Perometry, for instance, can discriminate at 1 mm for circumferences and to the
nearest 10 mL for volume. Similar accuracy is possible with water displacement. Both
can be used to assess segmental changes in limb volumes, but water displacement needs
additional circumference measurements to be made, which facilitate cross-checking.
When tape measurement at specified positions is used, care must be taken to
minimize errors in the tension on the tape, the placement of the tape, the distance
between measurement sites, and the side of measurement. Excel or other statistical
programs can be used to calculate volume. Tape measurement is able to discriminate to 1 mm, but due to the variables identified, 5 mm is more realistic. The
Australasian Lymphology Association has defined a program to ensure accuracy
and repeatability in measurement (www.lymphology.asn.au). Such strategies can be
used to add accuracy to the measurement for garment selection (in addition to manufacturers’ recommendations regarding intervals and limb position for measurement) and can reduce the rate of patient rejection of garments, reduce the potential
for a tourniquet effect of garments and improve patient compliance.
Measurement of Functional Status of the Lymphatic System
While lymphoscintigraphy might also be regarded as a traditional technique, it is
often used inappropriately or inaccurately.
While initially expensive, in reality it can be a cost-effective technique for determining lymphatic system status. It is best used in patients in whom the treatment
outcome has been poor because of case complexity. The initial cost can be worthwhile in terms of the range of information it can provide, including the functional
status of the lymphatic system, the location of functional (and dysfunctional collectors), relationships between the deep and superficial lymphatics and areas of dermal
202 N.B. Piller
backflow. Importantly, the information can be used to help the health professional
direct flow to functional pathways.
6,7
There are quantitative aspects to lymphoscintigraphy, in the interpretation of the location of the radiotracer and its density and
distribution, but also quantitative aspects in terms of the rate and time of arrival at
specified regions of interest, such as the groin or axilla. Graphs of these events can
help determine functional status and repeat measures can show the effect of any
intervention. Accuracy is possible at the level of millimeters per minute of travel of
the tracer, although most often graphs are compared for slope and tracer counts at
specific times within a region of interest.
Measurement of the Structural Status of the Lymphatic System and of the Limb
If the “gold standard” of structural information is sought, the most effective method
would seem to be ultrasound and, perhaps, its fractal analysis. Ultrasound is useful
for informing us about changes in the thickness of the deep and superficial fascias,
and of the thickness of fibrotic or other changes in the epifascial compartment. Again
there are qualitative and quantitative aspects to these analyses, with the measurement of thicknesses and depths able to be undertaken to an accuracy of 1 mm. Even
if this is only done once (at tonometry points described above), for reassessments,
only tonometry will need to be undertaken. Of course MRI and other, similar techniques offer greater accuracy and discrimination, but cost often precludes their use.
Measurement of the Status of the Vascular System
It is clear that there are often significant changes to the vascular inflow and outflow
patterns. Laser Doppler and other strategies such as fractal ultrasound allow these
changes to be determined and interventions to be undertaken. Recent studies indicate that we should be paying more attention to changes in the vascular system
inflow and outflow loads8 and patterns, as well as to the lymphatic pumping mechanisms,9 not only in a limb with lymphedema, but also limbs at risk.
Measurement of the Subjective Parameters
Lymphedema is more than just a swelling of the tissues.
the early stages, include heaviness, tension, aches and pains, significant impacts on
quality of life and on the ability to undertake the activities of daily living. For some
patients it is these that are important, even more so than the size of the limb or its
range of movement.
10,11
Its symptoms, even in
24 Alternative Assessment and Measurement Tools
203
If we are going to help a patient deal with his problem from a holistic perspective, then we must also undertake measurement of these variables and other subjective parameters, using visual analog and other scales. There is a range of simple and
validated test instruments, some specific, such as the LBCQ, and others more general, such as the SF –12 or −36.
Treatment Outcomes
Often, in lymphedema, treatment impacts how the limb feels, followed by softening
and then, perhaps, by subtle changes in the volume of extracellular fluids, and,
finally, by a change in volume or circumference. Detection and response to these
changes can not only help the health professional to determine the impact of treatment, but can also be used to indicate to the patient that change is occurring and that
the treatment from the professional is working or that the patient’s self-management
strategies are effective. Patients often suffer treatment fatigue and so it is important
to give them continuing feedback. Some or all of the described alternate assessment
and measurement methods would seem to provide effective opportunities to accomplish this goal.
References
1. Hayes S et al. Comparison of the methods to diagnose lymphoedema among breast cancer
survivors: 6 month follow-up. Breast Cancer Res Treat. 2005;89:221.
2. Bates D et al. Quantification of the rate and depth of pitting in human oedema using an elec-
tronic tonometer. Lymphology. 1994;27(4):159.
3. Cornish BH, Chapman M, Hirst C, et al. Early diagnosis of lymphedema using multifrequency
bioimpedance. Lymphology. 2001;34(1):2-11.
4. Stanton A et al. Validation of an optoelectronic limb volumeter (perometer). Lymphology.
1997;30(2):77.
5. Meijer RS et al. Validity and intra/inter observer reliability of an indirect volume measurement
in upper limb lymphoedema. Lymphology. 2004;37(3):127.
6. Brautigam R et al. Analysis of lymphatic drainage in leg lymphoedema using two compart-
ment lymphoscintigraphy. Lymphology. 1998;31(2):43.
7. Piller NB, Goodear M, Peter D. Lymphoscintigraphic evidence supports the evidence of axillo-
inguinal anastomotic pathways in a patient with chronic secondary lymphoedema. Eur J
Lymphol. 1998;6(24):97-100.
8. Dennis R. Haemodynamics of lymphoedema. J Lymphoedema. 2008;3(2):45-49.
9. Modi S, Stanton AWB, Svensson W, Peters A, Mortimer P, Levick J. Human lymphatic pump-
ing measured in healthy and lymphoedematous arms by lymphatic congestion lymphoscintigraphy. J Physiol. 2007;583:271-285.
10. Amer M, Ramati A. Post traumatic symptoms, emotional distress and quality of life in long
term survivors of breast cancer. J Anxiety Disord. 2002;16:195-206.
11. Amer MA, Stewart R. A comparison of 4 diagnostic criteria for lymphoedema in a post breast
cancer population. Lymphat Res Biol. 2005;3(4):208-217.
Part VI
Infection
Chapter 25
Infection
Waldemar L. Olszewski
General Overview
Infections and inflammation of the skin and soft tissues of the lower and upper
limbs are more common than those of other cutaneous regions because of exposure to the environment. The hands and feet have direct contact with surrounding matter, which is covered in micro-organisms and chemical substances.
Readily acquired damage to the epidermis, such as abrasions, cuts, pricks, and
closed injuries, create portals of entry for environmental bacteria.
surface, and appendices such as sweat, sebaceous glands, and hair follicles, are
inhabited by commensal bacteria, mostly Staphylococcus epidermidis and coag-
ulase-negative strains. Staphylococcus aureus and corynebacteria are also pres-
ent. In addition, the feet and calves may be colonized by pathogenic microbes
originating from the perineal region, such as Enterococcus, Enterobacter,
Acinetobacter, Proteus, Escherichia coli, and Pseudomonas. These microbes
float down from the perineum on desquamated epidermal scales.
The commensal microbes are not pathogenic as long as they remain in their
physiological niche. Once they have penetrated the epidermis the local host
defense response is initiated. This response depends on the mass of penetrating
microbes. A mass of 105 of bacteria per gram of tissue is the threshold value.
Interestingly, the skin-colonizing bacterial strains are sensitive to most
antibiotics.
1,2
The skin
W.L. Olszewski
Department of Surgical Research and Transplantology,
Medical Research Centre, Warsaw, Poland
B.-B. Lee et al. (eds.), Lymphedema,
DOI 10.1007/978-0-85729-567-5_25, © Springer-Verlag London Limited 2011
207
208 W.L. Olszewski
Primary and Secondary Infections
Primary Infections
These include lymphangitis, erysipelas, necrotizing fasciitis, and other rare conditions. The predisposing conditions are lymph stasis in the form of latent or overt
lymphedema and chronic venous insufficiency.
Lymphangitis is characterized by the occurrence of an inflammatory streak (red,
warm, and painful), the topography of which is that of the superficial lymphatic vessels. It is accompanied by fever. There is a non-inflammatory spreading lesion.
Erysipelas is a non necrotizing bacterial subdermal inflammation usually associated with streptococcal infection.
genes) is the usual etiological agent. It may sometimes be a complication of chronic
lymphedema.6 Erysipelas is often of sudden onset, marked by frank systemic signs –
fever >38° C, chills – and general malaise. Local signs develop within a few hours; a
red, warm, painful, inflammatory spreading lesion with centrifugal extension develops within a few days. Inflammatory, satellite adenopathy and lymphangitis are associated with erysipelas.
Necrotizing dermal–subdermal bacterial infection, or necrotizing fasciitis, is characterized by necrosis of the fascia and myositis, resulting in a presentation of infectious
gangrene. Diffuse, indurated edema extends beyond the margins of the erythematous
and sometimes slightly inflammatory spreading lesion. Deep necrosis may be manifest
in the initial stage solely as a cyanotic, grayish-blue, poorly demarcated swelling with
a geographical map-like presentation. Fever is a usual finding, but it can be mild or
absent. A septic syndrome (with hemodynamic signs, hypoxia, and thrombocytopenia)
subsequently develops. This should prompt emergency hospitalization of the patient.
Other acute forms of dermal–subdermal bacterial infection are caused by
Erysipelotrix rhusiopathiae (Rouget’s swine erysipelas), Haemophilus influenzae,
Pasteurella multocida, and Borrelia burgdorferi.
3-5
Group A beta-hemolytic Streptococcus (S. pyo-
Secondary Infections: Dermato-Lymphangio-Adenitis
Chronic Dermatolymphangioadenitis
Each case of lymphedema is predisposed to infections and chronic dermatolymphangioadenitis (DLA).7 This is due to impairment of bacterial elimination via lymphatics. Lymphedema is complicated by infection of the skin and deep tissues in
approximately 40% of cases, irrespective of what is the primary etiological factor for
the development of this condition. In the upper extremities after mastectomy and
local irradiation, infection of the swollen limb, expressed as acute and later as chronic
inflammation, ranges between 20% and 40%.
of DLA is higher in subjects with a long duration of edema. It is followed by a rapid
4
The recurrence rate of acute attacks