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Lymphoedema is a chronic and progressive condition, which leads to excessive accumulation

of lymph fluid in the superficial tissues. This is due to lymphatic failure, related to either congenital abnormality or damage to the lymphatic system (Lymphoedema Framework, 2006). It is estimated that one in 6,000 to one in 10,000 within the UK are affected by primary lymphoedema caused by intrinsic factors in the development of the lymphatic system (Table 1). This compares to secondary lymphoedema, which is estimated to affect 63,000–100,000, and is caused by extrinsic factors that damage the lymphatic system (Moffatt et al, 2003; Rockson and Rivera, 2008; Macmillan, 2013) (Table 1). However the above is acknowledged as an underestimation of the condition (Moffatt et al, 2003; Cooper, 2012; 2013).

To ensure appropriate management methods are instigated, a diagnosis needs to be made as well as excluding other causes (Table 2) (Lymphoedema Framework, 2006). Additional investigations such as

An overview of lymphoedema for community nurses

blood tests or ultrasound scans may identify undiagnosed conditions, for example, heart failure (Lymphoedema Framework, 2006). A patient may present with a number of physical signs and symptoms, which will help the community nurse arrive at a diagnosis

Garry Cooper, Macmillan lymphoedema nurse specialist, Worcestershire Health and Care NHS Trust

This article provides an overview of lymphoedema and its management. It includes information on the definition of lymphoedema, anatomy (lymphatics), lymphoedema staging, complications and the psychosocial impact. This leads onto a discussion of the management methods that can be delivered by community staff and practice nurses who have received appropriate training. Involving patients and their family/carers in all aspects of the management plan can help them to cope with this lifelong condition and promote concordance with treatment.

KEYWORDS:Lymphoedema Complications Management Compression

Garry Cooper

THE SCIENCE — LYMPHATIC SYSTEMThis one-way system comprises a superficial and deep system, associated with multiple organs, such as the thymus and spleen, and lymph nodes (Waugh and Grant, 2001). Its main responsibilities are immunity, fluid/waste product transportation and absorption of fats. The term ‘lymph’ is applied once interstitial fluid has entered the lymphatics in the superficial lymphatics (Waugh and Grant, 2001). It is suggested that 100% of fluid is

absorbed by the initial/superficial lymphatics, with further research yet to be completed on their role within the deeper tissues. The exceptions relate to changes in fluid exchange between the lymphatic/circulatory microvascular system — located within the intestines — and the lymph nodes and kidneys for example (Levick and Michel, 2010). This differs to the original understanding in which 10% was absorbed by the lymphatics (Waugh and Grant, 2001). Lymph fluid passes through several lymph nodes that contain white cells (T, B lymphocytes, macrophages) (Waugh and Grant, 2001). The role of lymph nodes is to purify lymph and resolve antigen presence before returning lymph to the heart via the thoracic duct, internal jugular, and sub-clavian veins (Waugh and Grant, 2001). It is estimated that a person may have 700 lymph nodes, but this varies between individuals (Waugh and Grant, 2001; Wigg, 2010).

of lymphoedema (Table 3). These signs and symptoms can also assist in the staging of lymphoedema within the International Society of Lymphology (ISL, 2013) staging system (Table 4).

Patients with multiple conditions and contributory factors are often seen by district nurses.

COMPLICATIONS

Lymphoedema has a number of complications associated with the progression of the condition, which affect the patient’s psychosocial and physical health (Cooper, 2012). The two main physical complications that are often seen within primary and secondary care are the development of cellulitis and lymphorrhoea (Lymphoedema Framework, 2006).

CellulitisCellulitis is estimated to cost the NHS £96 million and leads to 400,000 bed

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Doublebase™ Gel Isopropyl myristate 15% w/w, liquid paraffin 15% w/w. Uses: Highly moisturising and protective hydrating gel for dry skin conditions. Directions: Adults, children and the elderly: Apply direct to dry skin as often as required. Doublebase Dayleve™ Gel Isopropyl myristate 15% w/w, liquid paraffin 15% w/w. Uses: Long lasting, highly moisturising and protective hydrating gel for dry skin conditions. Directions: Adults, children and the elderly: Apply direct to dry skin morning and night, or more often if necessary.Contra-indications, warnings, side effects etc: Please refer to SPC for full details before prescribing. Do not use if sensitive to any of the ingredients. In the rare event of a reaction stop treatment. Package quantities, NHS prices and MA numbers:Doublebase Gel: 100g tube £2.65, 500g pump dispenser £5.83, PL00173/0183.Doublebase Dayleve Gel: 100g tube £2.65, 500g pump dispenser £6.29, PL00173/0199.

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References: 1. Whitefield M. Clinical evaluation of Doublebase. A multi-centre GP study of 78 patients with dry skin conditions. (Data on File). 2. Wynne A. et al. An effective, cosmetically acceptable, novel hydro-gel emollient for the management of dry skin conditions. Journal of Dermatological Treatment No 2 June 2002; 13: 61-66. 3. Aslam A. Children’s preference in selecting an emollient of their choice. British Journal of Dermatology 2009; 161 (Suppl. 1):116. 4. Gallagher J., Rosher P., Sykes K., Walker J. & Hart V. Are all emollients equally effective in hydrating dry skin? A single centre, double-blind, bi-lateral comparison of two commercially available emollient products in the UK. Poster presented at the 21st EADV Congress in September 2012, Prague. 5. Gallagher J., Rosher P., Walker J. & Hart V.A. An in vivo comparison of two commercially available topical emollients in the UK, DELP gel and DIPC cream. Poster presented at the 70th AAD Annual Meeting, March 2012, San Diego, USA.

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Table 1: Primary and secondary lymphoedema (Lymphoedema Framework, 2006)

Primary SecondaryMilroy’s Trauma or tissue damage

Turner’s syndrome Malignant disease

Meige lymphoedema Venous disease

Praecox (cause unknown) 2–35 years old Infection

Tarda (cause unknown) 35 years and over Inflammation

Endocrine

Dependency or immobility

Table 2: Differential diagnosis

Unilateral limb swelling Symmetrical swellingAcute deep vein thrombosis (DVT) Congestive heart failure

Post-thrombotic syndrome Chronic venous insufficiency (CVI)

Arthritis Dependency oedema

Baker’s cyst Renal dysfunction

Presence/reoccurrence of carcinoma Hepatic dysfunction

Hypoproteinaemia

Hypothyroidism/myxoedema

Drug-induced (e.g. calcium channel blockers, steroids)

Lipoedema

Table 3: Signs and symptoms (Lymphoedema Framework, 2006)

Limb swelling

Complaints of heaviness

Tingling sensation

Skin tight and shiny

Skin changes (hyperkeratosis, papillomatosis)

Repeated infection

Table 4: ISL (2013) lymphoedema staging

Stage 0 A subclinical state where swelling is not evident despite impaired lymph transport. This stage may exist for months or years before oedema becomes evident

Stage 1 This represents early onset of the condition where there is accumulation of tissue fluid that subsides with limb elevation. The oedema may be pitting

Stage II Limb elevation alone rarely reduces swelling as pitting is manifest

Late stage II There may or may not be pitting as tissue fibrosis is more evident

Stage III The tissue is hard (fibrotic) and pitting is absent. Skin changes such as thickening, hyperpigmentation, increased skin folds, fat depositis and warty overgrowths develop

stays (per year) (Levell et al, 2011). This is a preventable condition that can be reduced or resolved through prompt diagnosis and management in conjunction with patient education (Lymphoedema Framework, 2006; Cooper 2012). The British Lymphology Society (BLS, 2013) has created a consensus document for management that includes antibiotic guidance for patients with lymphoedema, which covers acute episodes and prophylactic treatment.

Acute episodesAntibiotics should be continued until all signs of acute inflammation have resolved. This may mean taking antibiotics for 1–2 months for no less than 14 days from the time a definite clinical response is observed (BLS, 2013), e.g: Oral amoxicillin 500mg, eight-

hourly is the treatment of choice Flucloxacillin 500mg, six-hourly

(Streptococcus and Staphylococcus infections)

Patients who are allergic to penicillin should be prescribed erythromycin 500mg, six-hourly or clarithromycin 500mg, 12-hourly

If there is no, or a poor response to oral amoxicillin after 48 hours, clindamycin 300mg, six-hourly should be prescribed.

Prophylactic antibioticsAntibiotic prophylaxis should be considered in patients who experience two or more attacks of cellulitis per year (BLS, 2013), e.g: Penicillin V 250mg twice daily

(500mg twice daily if the person has a body mass index [BMI] of 33). The dose may be reduced to 250mg daily after one year of

successful prophylaxis Patients allergic to penicillin can

be prescribed erythromycin 250mg twice daily. If this is not tolerated, clarithromycin 250mg daily is an alternative.

Lymphorrhoea‘Lymphorrhoea or ‘leaking legs’, is the leaking of lymph fluid from the skin’s surface, which can be extremely distressing to patients, and challenging for nurses to manage (Lymphoedema Framework, 2006; Cooper, 2012). The cause of lymphorrhoea needs to be established, as this may involve cellulitis, chronic oedema/lymphoedema, or be the result of comorbidities, such as heart or kidney failure (Lymphoedema Framework, 2006). If lymphorrhoea is due to existing comorbidities, medical intervention and possible hospital admission for symptom control may be needed (Lymphoedema Framework, 2006).

If lymphorrhoea is related to cellulitis, a suitable antibiotic regimen should be prescribed, plus

Red Flag Cellulitis

Cellulitis is an acute spreading inflammation of the skin and subcutaneous tissues caused by bacterial infections that are either group A Streptococcus or Staphylococcus.

Signs/symptoms: pain, warmth, swelling and erythema. Some episodes are accompanied by severe systemic upset, with high fever and rigors.

Source: British Lymphology Society (BLS), 2013

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appropriate dressings for fluid control, e.g. foams, padding and bandaging (Lymphoedema Framework, 2006). Once the cellulitis has resolved, patients should resume or be provided with appropriate compression hosiery. However, if lymphorrhoea occurs due to complications with the patient’s existing chronic oedema/ lymphoedema, due to increases in limb volume/size or trauma to the skin and protrusions, for example, papillomatosis, a different approach is needed (Lymphoedema Framework, 2006). This involves the application of compression bandaging to reduce the fluid content within the limb, followed by measuring and application of suitable compression hosiery (Lymphoedema Framework, 2006; Cooper, 2012).

Psychosocial The impact of lymphoedema extends beyond the physical properties of the condition. Community nurses need to have an awareness of the psychosocial impact of the condition. This may lead to screening, monitoring, signposting or referral to relevant psychological and social services (Cooper, 2012). A recent meta-analysis by Fu et al (2012) identified psychological themes across a number of studies, including depression, helplessness and altered body image. Each of these studies also identified social themes such as marginalisation, social abandonment and an unsupportive work environment (Fu et al, 2012). Other studies have identified similar themes (Fu, 2008; Murray et al, 2010). This illustrates the impact that lymphoedema has upon patients, and the need to place importance not only on the physical complication, but also the psychosocial.

MANAGEMENT

Lymphoedema management requires a multifaceted approach to devise a patient care plan and the setting of realistic goals (Lymphoedema Framework, 2006; Cooper, 2012). There are two management phases: Phase 1: intensive management

(2–6 weeks), involving: skin care remedial exercise manual lymphatic

drainage (MLD)

multilayer lymphoedema bandaging (MLLB)

Phase 2: maintenance, involving: skin care regular exercise compression garments

(Lymphoedema Framework, 2006; Clinical Resource Efficiency Support Team [CREST], 2008)

Although, in the author’s clinical experience, only three management methods are usually initiated by community and practice nurses who are not lymphoedema specialists, namely skin care, exercise and compression therapy, with specialist guidance and the completion of agreed competencies, community nurses may become involved in more advanced care, such as the teaching of simple lymphatic drainage (SLD).

Skin careSkin care regimens aim to maintain or re-establish the skin’s main function as a barrier (Lymphoedema Framework, 2006; CREST, 2008; International Lymphoedema Framework [ILF], 2010). As discussed, complications of lymphoedema involve cellulitis and lymphorrhoea. A daily skin care routine ensures that the skin’s integrity is maintained and reduces the potential for bacteria to enter an already compromised system (Cooper, 2010).

Devising a skin care regimen through appropriate emollient selection depends on any existing conditions, for example, eczema and known allergies or sensitisers (Lymphoedema Framework, 2006; Cooper, 2010). Community nurses should also work with patients so that they understand the self-management techniques that can protect their skin, such as managing the nails and preventing fungal infections. Table 5 shows an example of a skin care regimen.

However, other skin care guidelines have been produced, such as the British Dermatological Nursing Group’s (BDNG) (Penzer, 2012). This type of guidance can be used for the care of patients with or without lymphoedema.

The choice of skin care products may be restricted to what has been

Table 5: General skin care principles (Lymphoedema Framework, 2006)

Wash daily, whenever possible, using pH neutral soap, natural soap or a soap substitute and dry thoroughly

Ensure skin folds, if present, are clean and dry

Monitor affected and unaffected skin for cuts, abrasions or insect bites, paying particular attention to any areas affected by sensory neuropathy

Apply emollients

Avoid scented products

Particularly in hot climates, vegetable-based products are preferable to those containing petrolatum or mineral oils

agreed on your local formulary; however, the most appropriate type of emollients should always be selected. Ointments, for example 50/50, are one of the most effective, but are greasy and can stain clothing/bedding, thus making them more appropriate while the patient is undergoing bandaging. Once bandaging is complete, a cream-based emollient can be used (such as Doublebase® [Dermal Laboratories]), which are less effective but do not cause the issues raised above. Soap substitutes can also be selected, which increase emollient usage during the patient’s normal bathing/cleansing routine. It is always important to consider the patient’s own sensitivities and whether the product has any known irritants, while also ensuring that the patient is educated on how the emollients are used/applied.

ExerciseThe ability of exercise to improve the condition of patients with lymphoedema is underestimated (Lymphoedema Framework, 2006; Cooper, 2012). The benefits of exercise include an increase in blood velocity via muscle pump action, lymphatic stimulation, muscle strength, increased joint flexibility and improved psychological wellbeing (Cooper, 2012). A number of exercises are considered suitable, such as yoga and swimming. However, some patients may not be able to complete these activities, and thus need tailored regimens.

The patient’s ability to mobilise and participate in activities will be affected by their existing co-

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A simple and effective alternative to bandaging and stockings*

fp10@hadhealth.com 01844 208842 www.hadhealth.com* Lawrence S. "Use of a Velcro® wrap system in the management of lower limb lymphoedema/chronic oedema." J Lymphoedema 2008:3(2). P 65-70.

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morbidities (i.e. arthritis) and psychosocial status (e.g. depression; isolation) (Lymphoedema Framework, 2006). This may mean introducing activities that are simple to complete, such as foot and leg exercises. These can easily be undertaken each hour, or while watching television. Also, patients can be encouraged to mobilise more frequently, such as walking to the kitchen on an hourly basis. However, to reduce the risk of falls/infections, it is advisable to discuss/support the patient or carer in obtaining appropriate fitting footwear.

The use of exercise is determined by the patient’s willingness and ability to engage in the activity. However, community nurses can encourage patients to take an active role in the self-management of their condition, through appropriate education and support (Department of Health [DH], 2012).

Compression therapyCompression therapy is the mainstay of lymphoedema management and compromises multilayer lymphoedema bandaging (MLLB) and/or compression hosiery/wraps (Cooper, 2012) (Figures 1–3). Today, there are a number of variations in style and colour that may appeal to patients and thus help with concordance. Before applying compression, a patient’s arterial status must be assessed. This should involve a physical assessment and the possible completion of a doppler assessment, for example, ankle brachial pressure index (ABPI) or toe brachial pressure index (TBPI) (Lymphoedema Framework, 2006) (Table 6).

MLLB is used to reduce limb size and reshape the limbs within a planned period, or to resolve an acute episode, for example, lymphorrhoea (Cooper, 2010). The two main methods of MLLB are (inelastic) short-stretch bandages, or two-layer systems (ILF, 2012a) (i.e. KTwo; Urgo Medical). These are applied either on a daily basis or alternative days within a set number of weeks, depending on the bandaging system selected and the health of the patient (Lymphoedema Framework, 2006). Each is applied

compression hosiery (Lymphoedema Framework, 2006).

There are a number of companies producing compression garments with variations in style and colour (Cooper, 2010). However, they are either circular or flat-knit, owing to their construction and clinical indications for use (Lymphoedema Framework, 2006). Circular-knit hosiery is constructed through the knitting of material on a cylinder and is shaped by varying stitch height and tension. These garments offer a more cosmetically acceptable appearance, but are not suitable for all patients (Lymphoedema Framework, 2006). Flat-knit hosiery is firmer and thicker in construction, and is sewn together creating a seam (Bianchi et al, 2012).

Circular-knit is offered by most hosiery brands and comes as either custom-fit or ready-to-wear garments, which may be finer in construction or more rigid (Lymphoedema Framework, 2006; Cooper, 2010). Choosing a brand of circular-knit hosiery depends on the patient’s condition, organisational restrictions and clinician knowledge. Company representatives (from companies such as Activa Healthcare, BSN Medical, medi UK and Sigvaris) can help by providing education about different products and offering training and support.

Flat-knit hosiery is mostly custom-fit, which means you choose the style and accessories, but the colour selection varies between brands. Some only offer beige or black, while others have at least five to ten colours from which to choose.

differently, requiring appropriate training and supervision. However, the use of elastic bandaging similar to that used within leg ulceration, is not commonly used within the care of patients with lymphoedema/chronic oedema, or who have a distorted limb shape (Lymphoedema Framework, 2006).

Patient tolerance and concordance should also be considered when choosing the most appropriate bandaging option. For example, some patients are more active and wish to wear their own clothes and shoes without the restriction of bulky bandages, and so a two-layer or velcro wrap-based system may be more appropriate, e.g. FarrowWrap (Haddenham Healthcare) and Juxta-Fit/Cure (medi UK). The benefits of these systems are similar to compression bandages, but they help to promote self-management, as the patient and/or their carer are able to apply them (ILF, 2012b).

However, some patients will need more comprehensive bandaging in the form of short-stretch bandages, because this represents the most efficient and effective way of managing their condition due to the greater concordance/tolerance required as a result of variations in pressure. These variations alter between high working and low resting pressures, and are associated with increased lymphatic/vascular stimulation (ILF, 2012b).

Once bandaging has been successful, the patient will require long-term management and maintenance through the use of

Table 6: Doppler assessment: readings and meanings

Ankle brachial pressure index (ABPI)ABPI <0.5 Referral to vascular specialist (compression therapy contraindicated)

ABPI 0.5–0.8 Intermittent claudication indicating arterial disease (compression therapy contraindicated)

ABPI 0.8–1 Mild peripheral arterial disease (apply compression therapy with caution)

ABPI 1–1.3 Normal (apply compression therapy)

ABPI >1.3 Toe pressures are recommended

Toe brachial pressure index (TBPI)TBPI <0.64 Abnormal indicating arterial disease

TBPI 0.64–0.7 Borderline

TBPI >0.7 Normal, indicating no arterial disease

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Any hosiery should ideally extend beyond the level of the oedema to ensure that fluid does not accumulate in uncompressed areas, and to ensure that fluid is efficiently returned to the lymphatic system (Bianchi et al, 2012; Cooper 2012). However, the patient’s tolerance, acceptance and ability to apply and remove the garment will affect implementation. Variations in compression classes can also be confusing owing to the availability of British, German (RAL) and French classes (Lymphoedema Framework, 2006; Bianchi et al, 2012). RAL compression hosiery has been accepted as the standard for individuals with lymphoedema, although this may alter according to diagnosis, for example palliative diagnosis/pain threshold, or presentation (Lymphoedema Framework, 2006).

Once a type of hosiery has been agreed upon, it is important that it is correctly fitted by a nurse,

both to ensure suitability, and to demonstrate application and removal techniques to the patient. Verbal and written advice on circulatory warning signs, wear time, laundering and how often the garment will need to be renewed should also be given (Lymphoedema Framework, 2006; Cooper, 2010; Bianchi et al, 2012).

There are application and removal aids available to help with the successful implementation and continuation of compression therapy, however, patients with reduced dexterity may need assistance from carers or relatives (Lymphoedema Framework, 2006; Cooper, 2010).

RESOURCES

Table 7 details further guidance. Alternatively, advice and support can be sourced from existing lymphoedema services or specialists. However, there is now an increased focus upon the creation of link workers within lymphoedema to increase patients’ access to lymphoedema care through increasing the knowledge and skills of nurses and other healthcare professionals in the delivery of management methods. This is especially important with current austerity measures and recent reports, which indicate that there is a shortage of lymphoedema specialists within existing lymphoedema services (Cooper, 2012; 2013). These challenges may lead to changes within service delivery and patient access to specialist services.

CONCLUSION

Lymphoedema is a progressive condition related to multiple causes that are either intrinsic or

extrinsic. Its development can result in complications that are both physical (cellulitis) and psychosocial (depression/isolation). As it is an irreversible condition, it is important that steps are put in place to reduce its impact on the patient’s quality of life, including appropriate compression therapy, skin care and an exercise regimen.

The involvement of the patient/carer in self-management will heklp to improve the patient’s concordance, and, thereby, their quality of life.

REFERENCES

Bianchi J, Vowden K, Whitaker J (2012) Chronic oedema made easy. Wounds UK 8(2): 1–4

British Lymphology Society (2013) Consensus Cocument on the Management of Cellulitis in

Table 7: GuidelinesLymphoedema Framework (2006) Best Practice for the Management of Lymphoedema. Medical Education Partnership, London

Clinical Resource Efficiency Support Team (2008) Guidelines for the Diagnosis, Assessment and Management of Lymphoedema. CREST, Belfast

Skills for Practice (2009) Management of chronic oedema in the community. Wounds UK, Aberdeen

International Lymphoedema Framework (2010) The Management of Lymphoedema in Advanced Cancer and Oedema at the End of Life. Medical Education Partnership, London

International Lymphoedema Framework (ILF) (2012b) Best Practice for the management of lymphoedema: Compression Therapy: A Position document on compression bandaging. ILF, London

Figure 1.At assessment, before treatment.

Figure 2.After treatment with compression bandaging.

Figure 3.After bandaging and now in flat-knit compression hosiery.

JCN

Red Flag Compression hosiery

Circular-knit: Mild/moderate oedemaMinimal limb distortionNo or minimal risk of curling, twist or tourniquetLimb fits into size chart.

Flat-knit: Moderate/severe oedemaDistorted limbsReduce curl, twist or tourniquetReduce rebound of oedemaRequires custom-fit.

Source: Lymphoedema Framework, 2006; Keeley, 2009

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Partnership LtdILF. (2012a) Compression Therapy: A position

document on compression bandaging. London: Medical Education Partnership Ltd

ILF (2012b) Best practice for the management of lymphoedema. 2nd edn. Compression therapy: a position document on compression bandaging. Available online at: http://bit.ly/TysYGb (accessed 6 September 2014)

International Society of Lymphology. (2013) The diagnosis and treatment of peripheral lymphoedema: 2013 consensus document of the International Society of Lymphology. Lymphology 46(1): 1–11

Keeley V (2009) Chronic oedema of the lower limb: causes, presentation and management priorities. In: Pauline Beldon, ed. Skills for Practice. Management of Chronic Oedema in the Community. Wounds UK, Aberdeen: 4–9

Levell N, Wingfield C, Garioch J (2011) Severe lower limb cellulitis is best diagnosed by dermatologists and managed with shared care between primary and secondary care. Br J Dermatol 164(6): 1326–28

Levick R, Michel C (2010) Microvascular fluid exchange and the revised Starling

principle, Spotlight Review. Cardiovascular Res 87: 198–210

Lymphoedema Framework (2006) International consensus best practice for the management of lymphoedema. London: Medical Education Partnership Ltd

Macmillan (2013) Cured — but at what cost? Long-term consequences of cancer and its treatment. Macmillan, London

Moffatt C, Franks P, Doherty D (2003) Lymphoedema: an underestimated health problem. Q J Med 96(10): 731–8

Murray M, Gallagher P, O’Carroll S (2010) Living with lymphoedema in Ireland: patient and service povider perspectives. Dublin City University and Irish Cancer Society, Dublin

Penzer R (2012) Best Practice in Emollient Therapy: A statement for healthcare professional. British Dermatological Nursing Group, London

Rockson S, Rivera K (2008) Estimating the population burden of lymphedema. Ann N Y Acad Sci 1131(1): 147–54

Waugh A, Grant A (2001) Ross and Wilson: Anatomy and Physiology in Health and Illness. 9th edn. Churchill Livingstone: London

Wigg J (2010) Medical Lymphatic Drainage and Lymphoedema Management. Leduc UK

Lymphoedema. BLS, Buckland MarshCooper G (2010) Early diagnosis of

lymphoedema helps to reduce its psychological and social impact. Nurs Times 106(49): 15–7

Cooper G (2012) Lymphoedema treatment in palliative care: a case study. Br J Nurs 21(15): 897–903

Cooper G (2013) Compression therapy in chronic oedema and lymphoedema. Nurs Residential Care 15(3): 134–9

CREST (2008) Guidelines for the Diagnosis, Assessment and Management of Lymphoedema. CREST, Belfast

DH (2012) The Mandate: A mandate from the government to the NHS Commissioning Board: April 2013 to March 2015. DH, London

Fu M (2008) Women at work with breast cancer-related lymphoedema. J Lymphoedema 3(1): 20–5

Fu M, Ridner H, Hu S, Stewart B, Cormier J, Armer J (2012) Psychosocial impact of lymphedema: a systematic review of literature from 2004 to 2011. Psyco-Oncology 22(7): 1466–84

ILF. (2010) The management of lymphoedema in advanced cancer and oedema at the end of life. London: Medical Education

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