Effect of an Enhanced Self-Care Protocol on Lymphedema Status among People Affected by Moderate to Severe Lower-Limb Lymphedema in Bangladesh, a Cluster Randomized Controlled Trial

Abstract

Background: Lymphatic filariasis (LF) is a major cause of lymphedema, affecting over 16 million people globally. A daily, hygiene-centered self-care protocol is recommended and effective in reducing acute attacks caused by secondary infections. It may also reverse lymphedema status in early stages, but less so as lymphedema advances. Lymphatic stimulating activities such as self-massage and deep-breathing have proven beneficial for cancer-related lymphedema, but have not been tested in LF-settings. Therefore, an enhanced self-care protocol was trialed among people affected by moderate to severe LF-related lymphedema in northern Bangladesh. Methods: Cluster randomization was used to allocate participants to either standard- or enhanced-self-care groups. Lymphedema status was determined by lymphedema stage, mid-calf circumference, and mid-calf tissue compressibility. Results: There were 71 patients in each group and at 24 weeks, both groups had experienced significant improvement in lymphedema status and reduction in acute attacks. There was a significant and clinically relevant between-group difference in mid-calf tissue compressibility with the biggest change observed on legs affected by severe lymphedema in the enhanced self-care group (∆ 21.5%, −0.68 (−0.91, −0.45), p < 0.001). Conclusion: This study offers the first evidence for including lymphatic stimulating activities in recommended self-care for people affected by moderate and severe LF-related lymphedema.

Addition of Lymphatic Stimulating Self-Care Practices Reduces Acute Attacks among People Affected by Moderate and Severe Lower-Limb Lymphedema in Ethiopia, a Cluster Randomized Controlled Trial

“…Primary outcome measures on lymphedema status in Ethiopia echoed the results reported on the Bangladesh arm of the study [21] which showed a greater change in connective tissue composition in the enhanced self-care group. Results on secondary outcomes in Ethiopia present further between-group differences favouring the intervention which were not observed in the Bangladesh cohort.…”

“…Detailed data collection methods have been published [ 21 , 28 , 34 ]. The primary outcome was change in lymphedema status as determined by a combination of; (1) lymphedema stage [ 33 ], (2) mid-calf circumference, and (3) mid-calf tissue compressibility quantified by tissue tonometry using the Indurometer [ 35 ].…”

“…Current MMDP guidelines for lymphedema self-care include only calf-pump exercises (rising up and down on the toes) to support lymph flow, but research on other lymphedema populations suggests that clearing proximal lymph pathways through diaphragmatic breathing and proximal muscle pump exercises [ 14 , 15 , 16 , 17 ], and more directly stimulating the lymphatic system through massage [ 18 ], may improve outcomes and even prevent lymphedema from forming in those at risk [ 19 , 20 ]. Few lymphatic stimulating practices are offered to people affected by LF- and podoconiosis-related lymphedema but could be added to current recommendations without additional financial burden [ 19 ], and may increase the benefits that people derive from adherence to their daily self-care efforts [ 21 , 22 ].…”

The development of a capacity-strengthening program to promote self-care practices among people with lymphatic filariasis-related lymphedema in the Upper West Region of Ghana

“…Patients suffering from the consequences of LF are poorly served in most endemic areas. They frequently suffer from stigmatization and discrimination, and live in poverty [ 15 , 15 ]. This study also found that local beliefs about the causes of these conditions were common, often leading patients to rely on traditional healers as the first choice of care providers.…”

Infrared Thermal Imaging as a Novel Non-Invasive Point-Of-Care Tool to Assess Filarial Lymphoedema

“…Participant information included age, sex, marital, education and employment status. All participants were provided with information on LF and training on an enhanced self-care protocol for lymphoedema management after the survey [ 31 , 33 ].…”