Compression garment selection, fitting

and monitoring education resource

Component 1: Self guided learning package

Version 5.0 June 2014

Compression garment selection, fitting and monitoring education resource
Component 1: Self guided learning package
Published by the State of Queensland (Queensland Health),
Version Draft 5.0 June 2014

This document is licensed under a Creative Commons Attribution 3.0 Australia licence.
To view a copy of this licence, visit creativecommons.org/licenses/by/3.0/au
© State of Queensland (Queensland Health) 2014
You are free to copy, communicate and adapt the work, as long as you attribute the
State of Queensland (Queensland Health).
For more information contact:
Allied Health Professions,
Office of Queensland, Department of Health,
GPO Box 2368, Fortitude Valley QLD 4006,
tel (+61) 07 3328 9298email Allied_Health_Advisory@health.qld.gov.au

An electronic version of this document is available at

http://www.health.qld.gov.au/ahwac/docs/self-guided-learn.pdf

Disclaimer:
The content presented in this publication is distributed by the Queensland Government as an information source only.
The State of Queensland makes no statements, representations or warranties about the accuracy, completeness or
reliability of any information contained in this publication. The State of Queensland disclaims all responsibility and all
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on such information.

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Contents
1. Introduction ................................................................................................ 1
1.1 Background ................................................................................................ 1
1.2 Aims ........................................................................................................... 1
1.3 Pre-requisites ............................................................................................. 1
2. Education resource components................................................................ 2
2.1 Component 1 .............................................................................................. 2
2.2 Component 2 .............................................................................................. 2
3. Education resource scope ......................................................................... 3
4. Component 1: Self guided learning package ............................................. 4
5. Instructions for use of the self guided learning package ............................ 4
6. Using mind-mapping as a learning tool ...................................................... 5
7. Module 1: Overview of the lymphatic system and lymphoedema............... 6
7.1 Intended learning outcomes........................................................................ 6
7.2 Capabilities ................................................................................................. 6
8. Self guided learning ................................................................................... 7
8.1 Mind mapping- What I know about lymphoedema ...................................... 7
8.1.1 The lymphatic system - review........................................................... 7
8.1.2 What is lymphoedema and how does it develop? .............................. 8
8.1.3 Stages of lymphoedema .................................................................... 9
8.1.4 Psychosocial impact of lymphoedema ............................................... 9
8.1.5 Summary ......................................................................................... 10
9. Module 2: Assessment of lymphoedema ................................................. 11
9.1 Intended learning outcomes...................................................................... 11
9.2 Capabilities ............................................................................................... 11
9.3 Self guided learning .................................................................................. 12
9.3.1 Diagnosis of lymphoedema ............................................................. 12
9.3.2 Assessing and monitoring stable lymphoedema .............................. 12
9.3.3 When to refer to a lymphoedema therapist? .................................... 14
10. Case study 1: Henry ................................................................................ 15
11. Module 3: Management of lymphoedema ................................................ 16
11.1 Intended learning outcomes...................................................................... 16
11.2 Capabilities ............................................................................................... 16
11.3 Self guided learning .................................................................................. 17
11.3.1 What is ‘full scope lymphoedema management’? ........................ 17
11.3.2 Facilitating long-term management of stable lymphoedema ........ 18
11.3.3 Compression garments: contraindications and cautions .............. 18
11.3.4 Lymphoedema education ............................................................ 19
11.3.5 Risk reduction for lymphoedema exacerbation ............................ 19
11.3.6 Exercise/ Movement .................................................................... 20
11.3.7 Skin care advice .......................................................................... 21
12. Module 4: Compression therapy and garments ....................................... 22

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 12.1 Intended learning outcomes...................................................................... 22
12.2 Capabilities ............................................................................................... 22
12.3 Self guided learning .................................................................................. 23
12.3.1 Role of compression garments in lymphoedema ......................... 23
12.3.2 Compression garment characteristics.......................................... 23
12.3.3 Compression garment styles ....................................................... 25
12.3.4 Garment fixation .......................................................................... 27
12.3.5 Choosing a compression garment ............................................... 27
12.3.6 Ordering compression garments ................................................. 28
12.3.7 Fitting a compression garment .................................................... 30
12.3.8 Wearing regimen ......................................................................... 31
12.3.9 Care instructions ......................................................................... 31
12.3.10 Application and removal of garments (donning/doffing) ............. 32
12.3.11 Patient education....................................................................... 33
12.3.12 Garment evaluation ................................................................... 33
12.3.13 Review schedules ..................................................................... 34
13. Case studies ............................................................................................ 35
13.1 Case study: Helen .................................................................................... 36
13.2 Case study: Joyce .................................................................................... 37
13.3 Case study: Jack ...................................................................................... 38
14. Case studies ............................................................................................ 39
14.1 Case 1 ...................................................................................................... 39
14.2 Case 2 ...................................................................................................... 40
14.3 Case 3 ...................................................................................................... 41
15. Appendices .............................................................................................. 42
16. Compression garment .............................................................................. 53
16.1 Instructions ............................................................................................... 53
16.2 Precautions .............................................................................................. 53
16.3 Care instructions....................................................................................... 54
17. Glossary ................................................................................................... 59
18. References............................................................................................... 62

Tables
Table 1 Staging of lymphoedema4 ........................................................................... 9
Table 2 Lower limb compression garment styles ................................................... 25
Table 3 Upper limb compression garment styles ................................................... 26
Table 4 Compression garments on SOA QH742 ................................................... 29
Table 5 Compression garment accessories on SOA QH742 ................................. 32

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1. Introduction

1.1 Background
This education resource has been developed to support the implementation of the
Queensland Health guideline:
# QH-HSDGDL-030-1:2013, Guideline for Compression Garments for Adults with
Malignancy Related Lymphoedema: Eligibility, Supply and Costing.
In addition the Queensland Health Lymphoedema Clinical Practice Guideline 2014
(CPG) provides practical, evidence based recommendations for the use of
compression therapy to treat adult lymphoedema.

1.2 Aims
The target population for this resource is therapists working in urban, rural and/or
remote areas who have a generalist case load which includes patients/consumers with
stable malignancy-related lymphoedema.
This compression garment education resource aims to:
 Provide sustainable, accessible, capability-based education for generalist
Occupational Therapists and Physiotherapists implementing the Guideline for
Compression Garments for Adults with Malignancy-related Lymphoedema.
 Consolidate generalist therapist knowledge and skill base in compression garment
selection, fitting and monitoring for patients with uncomplicated (established)
malignancy-related lymphoedema.
 Increase support of generalist therapists by lymphoedema therapists through
a supported practice framework via Telehealth.

1.3 Pre-requisites
The following are pre-requisites for the completion of this educational program.
Participants must:
 Have a Bachelor degree in Occupational Therapy or Physiotherapy or equivalent
entry level qualification in Occupational Therapy or Physiotherapy.
 Be registered with the Australian Health Practitioners Regulation Agency.
 Have access to an occupational therapist or physiotherapist who has completed
lymphoedema training and will act as a mentor or coach.
 Have support from their line manager to:
– complete the self guided learning package;
– engage with a mentor or coach for the duration of the program;
– provide compression garments to patient/consumers with malignancy-related
lymphoedema as part of usual service delivery.

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2. Education resource components
This education resource is comprised of 2 main components:
– Component 1: Self guided learning package
– Component 2: Supported Practice Period

2.1 Component 1
Component 1 is a self guided learning package that is completed independently and
provides background knowledge about key topics related to lymphoedema and
compression garments. This component consists of:
 A self guided learning package with web links to learning resources. The internet is
required to access some learning resources and some web links may need a
Queensland Health computer to access the resource.
 Accompanying PowerPoint slideshows and audio recordings to be used with the
package.
 A work book for recording reflections and responses to activities in the education
package. This workbook will also be used to guide and inform the coaching
component of the education resource.

2.2 Component 2
Component 2 consists of a period of supported practice where the therapist
undertaking the education package enters into a coaching relationship with a
lymphoedema therapist. Interactions between the therapists can take place via
Telehealth or face to face. This component has a two tiered approach and consists of:
 A review of the components of the self-paced workbook including the identification
of any areas that require clarification or elaboration.
 A process of practice, demonstration and evaluation of clinical skills via telehealth or
face to face coaching sessions. These will involve:
– Demonstration of practical skills (e.g. measuring, fitting) with a volunteer prior to a
patient/consumer consultation.
– Coaching support provided to the generalist therapist by a lymphoedema
therapist during a patient/consumer consultation. Three supported sessions with
patients/consumers are recommended depending on variation and complexity of
patient/consumer presentation.
– Ongoing coaching support and review of patients/consumers where there are
concerns or variations in patient /consumer presentation.
Further details of the coaching component can be found in the accompanying
Supported Practice Period Framework.

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3. Education resource scope
This education package has been developed as part of a response to address service
gaps in the provision of compression garments to people with stable (uncomplicated
malignancy related) lymphoedema who live in urban, rural and remote locations.
The completion of a recognised lymphoedema training course is a basic requirement
for health professionals providing the full scope of lymphoedema assessment and
treatment. Lymphoedema training provides health professionals with knowledge about
the pathophysiology of lymphatic function and disorders, and training in manual
techniques and compression bandaging principles, along with other components of
intensive treatment.
While best practice guidelines from the UK-based British Lymphology Association1, the
US-based National Lymphoedema Network2; the Australian-based Australasian
Lymphology Association3 and the Queensland Health Lymphoedema Clinical Practice
Guideline 2014 support the need for specialist lymphoedema training, this model of
service delivery is not easily maintained in urban, rural and remote areas.
The Compression Garment Selection, Fitting and Monitoring Redesign Trial is
designed to promote a different model of care to patient/consumers with malignancy
related lymphoedema who live in urban, rural and remote locations. The trial provides
scope for generalist therapists in urban, rural and remote areas to offer
patients/consumers with stable lymphoedema compression garment, selection, fitting
and monitoring services.
This education package is designed to consolidate generalist knowledge and skills in
this one aspect of lymphoedema management. Australian and International Guidelines
recommend that other aspects of lymphoedema management such as manual
lymphatic drainage, providing advice on self lymphatic drainage and providing
lymphoedema compression bandaging should only be carried out by therapists with
lymphoedema training. 1,2,3
Information about recognised Australian-based training courses is available from the
Australasian Lymphology Association.
Completion of this educational package will enable generalist allied health
professionals, with the support where needed from lymphoedema trained therapists to:
Provide information about lymphoedema, including risk reduction guidelines
Educate patients/consumers in aspects of self management including advice on
positioning, elevation and movement and care of the skin including prevention and
management of cellulitis
Select, fit and monitor compression garments for stable lymphoedema
Direct patient/consumers to the most appropriate lymphoedema services (with
lymphoedema-trained health professionals) when required.

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4. Component 1: Self guided learning package
The self guided learning package has been developed to provide foundation theoretical
knowledge about lymphoedema and its assessment and treatment. The self guided
learning package is presented as four discrete modules:
 Module 1: Overview of the lymphatic system and lymphoedema
 Module 2: Assessment of lymphoedema
 Module 3: Management of lymphoedema
 Module 4: Compression therapy and garments

Each module has:

 Readings and other resources, often with links embedded in the text.
 PowerPoint and supporting audio.
 Workbook activities in the accompanying wordbook.
These resources will assist you to get the most value from each module.

5. Instructions for use of the self guided

learning package
The self guided learning package is designed to be used in the following way:
1. Work though each module with the accompanying PowerPoint and audio
presentation.
2. Complete the workbook activities for the module.
The following symbols are used throughout the modules:

This symbol indicates there is a writing activity to complete.

This symbol indicates points where you should listen to the audio and go
through the PowerPoint presentation.

This symbol indicates there is information for you to watch or read (usually
from the internet).

Each module will require approximately 1. 5 hours to complete.

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6. Using mind-mapping as a learning tool
Throughout this learning package you will be encouraged to use mind maps for your
written activities. This will assist to maximise your learning as:
‘The most important single factor influencing learning is what the learner already knows
– ascertain this and teach him accordingly’ (David Ausbel).
Meaningful learning is about assisting individuals to relate new knowledge to relevant
existing knowledge they already have. Mind maps are an attempt to ascertain what the
learner knows and bring this to the forefront. New knowledge is then provided and
organisation of new knowledge into the learners existing knowledge is facilitated. The
mind map provides a visual road map of how each person organizes their knowledge.

The following process is recommended if you wish to use mind-mapping to assist your
learning:
1. At the start of each module take an initial brief look at the presentation, readings
and/or resources.
Do not review the material in depth, and then put it away.
Now start your mapping task.
For each topic:
 Brainstorm anything you know about the topic. Write these down without worrying
about order or category.
 Once you have exhausted the information decide which items can be grouped
together in some logical manner. You may like to place them in categories and
number them category 1, category 2 etc.
 Next label these groups with a heading which describes the category and transfer
them to a new page with groupings according to their relationship to each other. In
the context of lymphoedema they may be aetiology, signs and symptoms etc.
 If a clear hierarchy exists then place groupings from top to bottom.
 Finish by drawing arrows between the groups to depict the relationship between the
groupings – they may be uni-directional or bi-directional arrows.

2. Once you have completed this task it is time to listen to the audio with the
PowerPoint and read the readings.
3. After you have finished the module construct a second mind map which illustrates
the integration of the new information into your existing knowledge on that topic.
Mind maps have been around in many forms from the 1970s. Early exponents were
Tony Buzan and Edward de Bono and we acknowledge their work.
There is free software available at http://mindmapfree.com/ to assist you in developing
your mind map. More information and an example are provided in the Workbook.

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7. Module 1: Overview of the lymphatic system
and lymphoedema

7.1 Intended learning outcomes

At the end of this module, you will be able to:
describe the basic anatomy and physiology of the lymphatic system
identify risk factors for malignancy related lymphoedema and the grade of
lymphoedema
identify the functional and psychosocial impact of malignancy related
lymphoedema.

7.2 Capabilities
The table below identifies the knowledge (Knowing WHAT), skills (Knowing HOW) and
therapeutic approach that this module addresses.

Knowing WHAT Knowing HOW Therapeutic APPROACH

Basic workings of the Identify signs of Provide clear explanations

lymphatic system lymphoedema to patient/consumer to
assist their understanding
Risk factors for malignancy Apply lymphoedema
of lymphoedema
related lymphoedema grading system
Functional and
psychosocial impact of
having lymphoedema

This module is estimated to take approximately 1.5 hours to complete.

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8. Self guided learning

8.1 Mind mapping- What I know about lymphoedema

Activity 1: Draw a mind map to illustrate what you know about the lymphatic
system and lymphoedema.
Mind mapping (or concept mapping) involves writing down a central idea and thinking
up new and related ideas which radiate out from the centre. Mapping information in this
way helps to identify key ideas and connections between these ideas. Mind maps are
tools to assist in understanding and remembering information. Click on this link to find
out further information about how to do a Mind Map:
Mind Mapping Resource Link
Further information on Mind Maps can be found in your workbook.

8.1.1 The lymphatic system - review

Listen to the accompanying audio presentation for slides 1–18 of the

PowerPoint presentation.

Click here: Oxford Textbook of Medicine and accept the conditions

Type in the search bar: Chronic peripheral oedema and lymphoedema.

Read the following sections:

 Essentials
 Introduction
 Pathophysiology
 Aetiology

Activity 2: Following your review of the above information, write down a

summary of key information that you have identified about the lymphatic
system. You can use your mind map to do this.

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8.1.2 What is lymphoedema and how does it develop?
Damage to or impairment of the lymphatic system can result in the development of
lymphoedema.

Listen to the accompanying audio presentation for slides 19-end of the

PowerPoint presentation.

Click here and watch: Ups and Downs: Life with lymphoedema (Link TBA)
Watch: 0-5.45minutes:

Click here and read: What is lymphoedema? The Australasian Lymphology

Association.

Activity 3: Consider the following scenario.

You are a generalist therapist working in a small rural town. The local CWA are going
to have a ‘Biggest Morning Tea’ event and have invited you to come and speak. They
have asked that you specifically talk about what lymphoedema is, what causes it and
how people can tell if they are developing lymphoedema.
Plan the main points of your talk either using a mind map or by writing a summary of
the main points you will include in your talk.

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8.1.3 Stages of lymphoedema
The progression of lymphoedema is commonly described using a staging system as
shown in Table 1.1. Individual severity determinations may also be affected by factors
such as4:
 extensiveness
 presence of cellulitis attacks
 inflammation
 quality of life issues (social, emotional, physical disabilities, etc.)

4
Table 1 Staging of lymphoedema
Stage Description

Stage 0: Swelling is not yet evident despite impaired lymph transport, subtle
Latent or sub- changes in tissue fluid/composition, and changes in subjective
clinical symptoms. This stage may be present for months or years before
condition overt lymphoedema occurs

Stage I: Early Early accumulation of fluid relatively high in protein content which
accumulation subsides with limb elevation. Pitting may occur. An increase in various
proliferating cells may also be seen.

Stage II Limb elevation alone rarely reduces tissue swelling and pitting is
present.

Late Stage II: the tissue in the limb may or may not be pitting as
excess fat and fibrosis take over.

Stage III Encompasses lymphostatic elephantiasis where pitting can be absent

and trophic skin changes such as acanthosis, further deposition of fat
and fibrosis, and warty overgrowths have developed.

Within each Stage, a limited but nonetheless functional severity assessment has
utilized simple volume differences assessed as minimal (<20% increase in limb
volume), moderate (20-40% increase), or severe (>40% increase).

8.1.4 Psychosocial impact of lymphoedema

The presence of lymphoedema is associated with psychosocial challenges. Negative
perceptions related to body image, appearance, sexuality, and social barriers have
been reported.5 Previous research has consistently described a negative psychological
impact (negative self-identity, emotional disturbance, and psychological distress) and
negative social impact (marginalization, financial burden, perceived diminished
sexuality, social isolation, perceived social abandonment, public insensitivity, and non-
supportive work environment) for people with lymphoedema.5 Health Professionals
providing long term interventions such as compression garment provision can play an
important role in the provision of supportive psychosocial care for this population.

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 Click on the following link and read the section on ‘Everyday Life’ (pages 24-
33).
Link: Lymphoedema Stories: The Untold Truth
(NOTE: you can make the print bigger using the sliding button on the top of the
screen.)

Activity 4: From your reading, what are some of the main issues that people
with lymphoedema have to deal with on a day to day basis?

In your own practice, what have patients/consumers told you about living with
lymphoedema?

8.1.5 Summary
This module has reviewed the lymphatic system and the risk factors, types and
progression of lymphoedema as well as the functional and psychosocial impacts of
lymphoedema.

To consolidate your learning you should read the first chapter of the
Queensland Health Lymphoedema Clinical Practice Guideline 2014.

Activity 5: The following activities will assist you to consolidate your

knowledge.

Draw a mind map for each of the following questions:

 What is the lymphatic system and how does it work?
 What are the types, risk factors and stages of lymphoedema?
 How does having lymphoedema impact on everyday life?

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9. Module 2: Assessment of lymphoedema

9.1 Intended learning outcomes

At the end of this module, you will be able to:
 Describe the components of a comprehensive assessment of a client with
lymphoedema.
 Outline the roles of the generalist and lymphoedema therapists within the
assessment process.
 Identify signs of the clinical presentation of lymphoedema.
 Classify the clinical presentation of lymphoedema into stages/grades.
 Measure and monitor stable malignancy related lymphoedema.

9.2 Capabilities
The table below identifies the knowledge (Knowing WHAT), skills (Knowing HOW) and
therapeutic approach that this module addresses.

Knowing WHAT Knowing HOW Therapeutic APPROACH

Causes of and contributors Accurately conduct Provide a thorough

to malignancy-related circumferential assessment of the status of
lymphoedema measurements and pitting the patient/consumer with
test stable lymphoedema.
Knowledge of differential
diagnosis including Complete a thorough and Identify when the patient/
metastasis accurate lymphoedema consumer requires
assessment intervention from a
Contraindications for
lymphoedema therapist.
compression Evaluate history to
determine suitability for
compression
Identify a suitable referral
pathway to tertiary
services

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9.3 Self guided learning

Activity 1: Draw a mind map to illustrate what you know about diagnosis,
assessment and monitoring of lymphoedema.

9.3.1 Diagnosis of lymphoedema

This education package has been developed to support the implementation of the
Guideline for Compression Garments for Adults with Malignancy Related
Lymphoedema: Eligibility, Supply and Costing. Following the completion of the
education package and with appropriate support from a lymphoedema therapist, it is
anticipated that a generalist therapist will provide support to patients/consumers with
stable malignancy related lymphoedema. Oedema is a symptom of many conditions
including lymphoedema. It is important to be aware of these other conditions as their
presence may alter the required treatment and/or the expected lymphoedema
treatment outcomes.

Listen to the accompanying audio presentation for Module 2 slides 1–8 of the
PowerPoint presentation.

Click here and read: How to recognise lymphoedema The Lymphoedema

Support Network.
Further reading on differential diagnosis of Lymphoedema can be found at the following
link: Differential diagnosis BMJ Best Practice Lymphoedema

9.3.2 Assessing and monitoring stable lymphoedema

Activity 2: Consider the following scenario:

You have been referred a patient/consumer who has been in a large
metropolitan health service for cancer treatment. She has returned to her home town in
a rural area and has stabilised lymphoedema of her (L) arm.
 In your workbook, outline the main topics/areas that you will cover in your initial
appointment with her. You can use a mind map for this activity.
Now look at the Lymphoedema Assessment form found in Appendix 1. What are the
similarities and differences between this form and your assessment plan? Are there
areas not included on the form that you will include in your assessment? Are there any
areas that you have missed that are included in the form?

Read the following information and listen to the accompanying audio

presentation for Module 2 slides 9-19 of the PowerPoint presentation.

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Palpation
The texture of lymphoedema can be examined using palpation. Textures are described
using the staging system in Table 1.1 (e.g. soft, pitting, fatty, fibrotic). Pitting indicates
the presence of excess interstitial fluid. A pitting test is conducted by pressing firmly on
the area being examined with a finger or thumb for a count of at least 10 seconds. 6, 7 If
an indentation remains when pressure is removed, then pitting is present. The depth of
the indentation reflects the severity of the lymphoedema. Pitting results may be
described using the measurement of the depth of any resulting indentation, the
duration until the indentation resolves or the time taken to create an indentation.
Results of a pitting assessment can be documented on the lymphoedema assessment
form (see Appendix 1).

 Palpation is also used to examine a patient/consumer for signs of circulatory

impairment:
– Skin temperature changes. 8
Cold indicates limited perfusion
– Warm temperature indicates well/over perfused tissue.
 Capillary refill limitations
– Push on the tip of the great toe or nail bed until blanching occurs
– Release and note the amount of time for red colour to return
– >2-3 seconds is considered indicative of arterial insufficiency

Read the following information and listen to the accompanying audio

presentation for Module 2 slides 20-26 of the PowerPoint presentation.

Limb volume or circumferential measurements

Limb volume and circumferential measurements are considered to be de facto gold
standard measurements for lymphoedema. Limb volume and circumference are
interchangeable and therefore lymphoedema can be reliably assessed using either
measure.9 Circumferential measurements are the most commonly used lymphoedema
assessment performed by generalist Health Professionals in Queensland Health.

Circumferential measurements should be performed at each review to monitor a

patient’s progress over time. Measurements can be compared to previous
measurements and to the unaffected contralateral limb (in the case of unilateral
lymphoedema). Weight should be recorded in combination with circumferential
measurements as weight change will affect limb size.

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 Click here: Measuring guidelines Australasian Lymphology Association
Click here: Measuring standards Australasian Lymphology Association

Activity 3: With a colleague, perform circumferential measurements as

described in the ALA Measuring standards document. Use the circumferential
measurement form in Appendix 2 to record your measurements.
Repeat the set of measurements three times to determine your accuracy.

9.3.3 When to refer to a lymphoedema therapist?

Generalist therapists that have completed or are completing the Compression Garment
Prescription Fitting and Monitoring program will be involved in the provision of
compression garments for people with stable lymphoedema. Stable lymphoedema is
uncomplicated malignancy related lymphoedema with swelling which is:
“… affecting a limb(s) which has been present for over 3 months and is not relieved by
bed rest or elevation. Subcutaneous tissues are soft and normal shape of the limb
preserved. Swelling does not affect the head and neck, trunk or genital regions of the
body.” 1:8
Stable lymphoedema has the following characteristics1:
 The lymphoedema is confined to one or two limbs and does not extend to the
proximal root of the limb
 The subcutaneous tissue is predominantly soft and/or pits on pressure in a small
and localised area
 The affected limb has maintained a normal shape
 The skin on the affected limb is healthy and intact
 There is no arterial insufficiency
 There is no known malignancy in the quadrant of the trunk which is adjacent to the
affected limb
Renal, cardiac, liver and thyroid problems have been excluded as contributing factors
or if present, these conditions are well controlled
If your assessment of a patient/consumer identifies they do not meet the above criteria,
referral to or consultation with a lymphoedema therapist is indicated. The following
resources will assist you to identify an appropriate practitioner.

Click here: National Lymphoedema Practitioners Register Australasian

Lymphology Association

Click here: Treatment Facilities and Resources Directory Lymphoedema

Association of Queensland

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 Activity 4: Plan the referral pathway that you will use if you need to refer onto
a lymphoedema therapist. Consider the following aspects:
 Who are the lymphoedema therapists in your local area?
 Where is your closest tertiary lymphoedema centre?
 How you will make the referral (what format will you use)?
 What information will be required for the referral?
 Are there any specific forms or requirements at a local level?

Can you develop a flow chart that reflects this in your workbook?

10. Case study 1: Henry

Henry is a 72 y.o. male, who lives at home in a small rural town. He lives alone.
He was admitted to the local hospital with lower limb recurrent cellulitis.

Past Medical Hx:

 hypertension, osteoporosis, type II DM, hypercholesterolaemia
 Past Surgical Hx:
 # L) NOF 2007, melanoma left leg 2008, inguinal lymph node dissection 2009,
CABG x 3 2005, MVA 2001 with # R) tibia

Medications: Lipitor, Cardaprin, Diuretics

He presents with thickened but low volume left leg swelling. He has not had any
previous odemea management.

Consider:
 What risk factors does Henry have for the development of oedema?
 What risk factors does Henry have for the development of lymphoedema?
 What steps would you take to determine the cause of Henrys’ oedema? Include the
resources you might need and the members of the health team you would involve.

Write you answers in your workbook.

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11. Module 3: Management of lymphoedema

11.1 Intended learning outcomes

At the end of this module, you will be able to:
 Describe the full scope of malignancy related lymphoedema management
 Outline the scope of practice for generalist therapists in the management of
malignancy related lymphoedema
 Identify contraindications and precautions to compression therapy
 Develop appropriate self-management plans with clients with malignancy related
lymphedema, including the use of compression garments, risk reduction strategies,
skin care and exercise advice.

11.2 Capabilities
The table below identifies the knowledge (Knowing WHAT), skills (Knowing HOW) and
therapeutic approach that this module addresses.
Knowing WHAT Knowing HOW Therapeutic APPROACH

Overview of the full scope Determine the Partner with patients/

of management of appropriateness of consumers in the
malignancy related compression therapy for an development and
lymphoedema. individual monitoring of
patient/consumer. individualised self -
Role of generalist management plans.
therapists in management Provide individualised
of malignancy related information relating to use
lymphoedema. of compression garments,
risk reduction strategies,
Contraindications and skin care and exercise
precautions to compression advice.
therapy.

This module is estimated to take approximately 1.5 hours to complete.

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11.3 Self guided learning

Activity 1: Draw a mind map to illustrate what you know about the
management of lymphoedema.

Read the following information and listen to the accompanying audio

presentation for Module 3 slides 1-8 of the PowerPoint presentation.

11.3.1 What is ‘full scope lymphoedema management’?

There are many treatments provided for lymphoedema. Full scope of lymphoedema
treatment is taught via lymphoedema training courses and may involve the following
treatment modalities3:
 Manual lymphatic drainage
 Lymphoedema compression bandaging
 Active exercises including breathing exercises
 Skin care
 Laser therapy
 Hydrotherapy
 Drug therapy
 Surgical treatment
 Intermittent pneumatic compression pumps
 Hyperbaric treatment
 Lymphoedema taping
 Lymphoedema compression garment therapy

A broad understanding of the full scope of lymphoedema treatment is necessary for

health professionals to understand the treatment trajectory for their patients.

Click here and read: Lymphoedema Management Australasian Lymphology

Association

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11.3.2 Facilitating long-term management of stable
lymphoedema
Generalist health professionals perform an important role in supporting people in the
long term management of lymphoedema. A key role they play is in supporting people
with stable lymphoedema in the continued self management of their condition. Aspects
of this role can include:
 Providing and monitoring compression garments
 Providing information about lymphoedema risk and exacerbation
 Providing education about skin care
 Providing education about exercise/ movement

Each of these aspects of the generalist role are discussed below.

11.3.3 Compression garments: contraindications and cautions

Compression garments are used across the treatment trajectory in lymphoedema.10
The use of compression garments is one type of compression therapy. Other forms of
compression therapy, such as compression bandaging and intermittent pneumatic
compression, may be used during intensive stages of management. Compression
garments are usually used for long term management once swelling is stabilised.11
During the long term management phase, patients should be stable with their self-
management regime, but will require provision of replacement compression garments
every 6-12 months. The long term management phase is the phase targeted by the
Compression Garment Selection, Fitting and Monitoring Statewide Service Redesign
Trial.

The next module will provide detailed information about the provision of compression
garments however it is essential that when undertaking a lymphoedema assessment,
the therapist gives consideration to potential contraindications and precautions for
compression therapy.

Listen to the accompanying audio presentation for Module 3 slides 9-14 of the
PowerPoint presentation.

Click here and read: Queensland Health Lymphoedema Clinical Practice

Guideline.

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Read the following sections:
 Section 3.5 Contraindications
 Section 3.6 Precautions
 Section 3.8 Compression garment use in lymphoedema treatment

Click here and read: Oxford Textbook of Medicine and accept the conditions

Type in the search bar or click: Peripheral arterial disease

Read section 16.14.2 Peripheral arterial disease
 Essentials
 Introduction
 Aetiology and epidemiology
 Clinical features of leg ischaemia
 Investigation of the patient with leg ischaemia

Activity 2: Based on the information above, complete the following activity in

your workbook.

List the absolute contraindications and precautions for compression and the possible
implications of applying compression in the presence of these conditions.

11.3.4 Lymphoedema education

The provision of ongoing education about the lymphatic system, lymphoedema and its
treatment is an essential role for all health professionals.

Click here: Lymphoedema- what you need to know. Cancer Australia.

This resource is available for multiple cultural groups including Greek, Arabic, Italian,
Vietnamese, Chinese, Aboriginal and Torres Strait Islanders.

11.3.5 Risk reduction for lymphoedema exacerbation

Those at risk of lymphoedema and those who have developed lymphoedema, are
advised to reduce the demand on their lymphatic system. Increase load on the
lymphatic system may overwhelm its capacity and result in the development or
exacerbation of lymphoedema. A list of risk reduction practices has been developed to
guide patients and health professionals in activities to reduce demand on the lymphatic
system.

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The lymphoedema risk reduction guidelines are based on anatomical and physiological
principles but the strength of the research evidence for each recommendation is mixed.
Stronger evidence exists for the recommendations about body weight and exercise.
Research has shown a consistent association between the development of
lymphoedema and increased body weight.12-18 Many studies have found that exercise
does not cause or increase lymphoedema and carefully controlled exercise may
improve lymphoedema.19,20

Listen to the accompanying audio presentation for Module 3 slides 15-27 of

the PowerPoint presentation.

Click here and read: Risk Reduction Practices and Risk Reduction Summary
from the National Lymphoedema Network

Activity 3: Consider the following scenario and write your response in your
workbook.

 You have a long standing client who has stable lymphoedema and wears a
compression garment as part of her long term management. She reports she is
intending to travel to see family in Canada, and will also be traveling throughout
Alaska on a holiday. She has asked you to provide a written list of ways she can
best manage her lymphoedema while traveling.
 Compile instructions for her for her holdiay to reduce the risk of exaccerbating her
lyphoedema while she is traveling and away from home.
 How would your advice differ if it was her upper limb rather than her lower limb?

11.3.6 Exercise/ Movement

Exercise is not contraindicated in patients with lymphoedema and may improve the
condition.19 Exercise has the dual benefit of increasing lymph flow and maintaining a
healthy body weight. Slowly progressive exercise of varying modalities is not
associated with the development or exacerbation of lymphoedema and can be safely
recommended with proper supervision.21 Specific lymphoedema exercises may be
provided by lymphoedema therapists. All health professionals can encourage people
with lymphoedema to participate in general exercise and movement and to monitor the
impact of exercise on lymphoedema.

Click here and watch 0–9.27 minutes of: Exercise and lymphoedema risk
reduction Memorial Sloan Kettering Cancer Centre

Activity 4: Write answers to the following questions in your workbook:

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 A client with stable lymphoedema wants to start exercising. They ask you for advice
about the benefits of exercising and if there are any types of exercise that are better
than others for lymphoedema. What advice do you give?
 They ask if they should wear their compression garment when exercising? What
advice do you give?

11.3.7 Skin care advice

Advice about skin care is important to maintain skin integrity in order to prevent
infection. People using compression garments also need education about the
interaction between their compression garment regimen and skin care regimen.

Click here and watch the section on Skin Care Treatment Advice (6.54–11.50
minutes): Lymphoedema Arm Australasian Lymphology Association

Click here and read the section on Skin Care and Cellulitis p24-27: Practice
for the Management of Lymphoedema.

Further reading can be found here: Management of Cellulitis in Lymphoedema

Australasian Lymphology Association

Activity 5: Answer the following questions in your workbook:

 What skin care advice would you provide for a person with lymphoedema?
 How would you explain cellulitis to a patient/consumer?
 What signs should you or a patient/consumer look for if they thought they may have
cellulitis?
 What advice would you give to that person if you thought they may be developing
cellulitis?

Activity 6: Slides 28–35 of the PowerPoint presentation have been

reproduced in your workbook. Match the skin features on the slides to the
conditions listed.

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12. Module 4: Compression therapy and
garments

12.1 Intended learning outcomes

At the end of this module, you will be able to:
 Explain the purpose of compression therapy
 Describe, compare and contrast the range and characteristics of compression
garments available
 Apply knowledge to select and order a compression garment for a patient with
malignancy-related lymphoedema
 Evaluate the fit of a compression garment
 Decide on appropriate donning and doffing methods and equipment and use of
other accessories
 Develop an education and follow up plan for use, care and replacement of
compression therapy garments

12.2 Capabilities
The table below identifies the knowledge (Knowing WHAT), skills (Knowing HOW) and
therapeutic approach that this module addresses.
Knowing WHAT Knowing HOW Therapeutic APPROACH

Principles of compression Determine appropriate Using a patient centred

therapy. compression garment approach the clinician will
prescription based on support the individual
Range and characteristics assessment outcomes. patient/consumer in the
of compression garments long term self-
including: Correct fitting Fit and evaluate the management of stable
principles and compression garment lymphoedema.
consequences of poor fit; prescribed.
donning/ doffing strategies;
garment care and wearing Provide a regime for
precautions. wearing, care instructions
and precautions for
compression garments.

Apply professional
reasoning to emergent
problems with compression
garment wear and identify
appropriate resolution
strategies.

This module is estimated to take approximately 1.5–2 hours to complete.

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12.3 Self guided learning
Activity 1: Draw a mind map to illustrate what you know about compression
therapy and compression garments.

Read the following information and listen to the accompanying audio

presentation for Module 4 slides 1-6 of the PowerPoint presentation.

12.3.1 Role of compression garments in lymphoedema

The use of compression garments is a primary treatment for people with
lymphoedema.4
Click on the link and read the following resource: Australasian Lymphology
Association: The use of compression garments in the management of
lymphoedema
Click on the link and read the following sections: Queensland Health
Lymphoedema Clinical Practice Guideline
Sections 3.1-3.6
 Mechanism of action
 Common indications
 Effectiveness
 Contraindications
 Cautions

Activity 2: Write down your response to the following situation in your

workbook.
You are seeing a client with stable lymphoedema who is due for replacement of his
compression garments. He asks you why they have to be so tight. How would you
answer him?

12.3.2 Compression garment characteristics

There is a wide range of compression garments available for the treatment of
lymphoedema. Health professionals must develop an understanding of the
characteristics of different garments to ensure garment selection is individualised for
each patient.

Listen to the accompanying audio presentation for slides 7-14 of the

PowerPoint presentation.

Methods used to manufacture lymphoedema garments include circular knit, flat knit
and cut and sew. The manufacturing method and fabric used will determine the
characteristics of the garment produced.

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 Circular Knit Flat Knit Cut and Sew

Compression garments can be made with pre-determined sizing as a ready-to-wear

garment (RTW) or custom made to the patient’s exact measurements. Due to their
lower cost and faster delivery times, RTW garments should be investigated as a first
option. Where clinical indications or limb size fall outside the RTW range provided,
custom made garments may be required.

Compression garments are made with different compression levels as required for the
different stages of lymphoedema. Compression levels can be referred to using their
Compression Class (Ccl1, 2, 3, 4) and more specifically by the amount of pressure at
the ankle (millimetres of mercury - mmHg).

Measurement for compression garments should be undertaken when lymphoedema is

at its lowest volume. This may be after a period of intensive treatment, early in the
morning or after a period of elevation.
Click on the link and read the following sections of the Queensland Health
Lymphoedema Clinical Practice Guideline.
Sections 3.7-3.14: Compression garment characteristics
 Compression garment use in lymphoedema treatment
 Determining compression garment levels for garments
 Garment prescription
 Comorbidities
 Garment measuring
 Garment wearing regimen
Click here and read pages 39-42 of the Best Practice for Management of
Lymphoedema from the International Lymphoedema Framework about
compression garment measurements for ready-to-wear or custom made
garments

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12.3.3 Compression garment styles
Multiple compression garment styles are available to suit each patient’s lymphoedema
presentation. Common styles for lower limb and upper limb garments are described
below in Tables 2 and 3.

Table 2 Lower limb compression garment styles

Lower Limb Styles Indications Image
Toe glove  For use when there is consistent or
fluctuating lymphoedema in the toes.
 Might not be tolerated all day, every day

Knee High  For use with ankle/lower leg

lymphoedema

Thigh High  For use with lymphoedema up to

distal/mid thigh
 This garment is best fit for thighs without
excessive proximal adipose tissue

Thigh high with waist  For use with lymphoedema up to

attachment distal/mid thigh – as for thigh high
 Attachment piece has no compression
 Waistband provides a gentle/ gradual
end-point to the garment for thighs with
excessive proximal adipose tissue
Waist high  For use with bilateral LL lymphoedema
including lymphoedema over the hip
region
 Panty section has reduced or no
compression

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Table 3 Upper limb compression garment styles

Upper Limb Styles Indications Image

Gauntlet  For use with very minimal hand
lymphoedema
 Not for use in the presence of finger
lymphoedema

Glove  For use with hand and/or finger

lymphoedema

Sleeve (wrist - axilla)  For use with arm lymphoedema

 Can be used in isolation or in
combination with a hand piece if mild
hand swelling is present

Sleeve (hand – axilla)  Attached hand pieces are used when

there is excessive hand lymphoedema
present that is obstructed by the layering
of a separate sleeve and handpiece
 These garments can be more challenging
to don than separates
Sleeve with bra strap  Reduces the pressure at the proximal
attachment edge of the garment
 May cause bra strap to slip off
 No compression in shoulder piece

Sleeve with body strap  Reduces the pressure at the proximal

edge of the garment
 Strap may be visible under clothing or
may rub on chest
 No compression in shoulder piece

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12.3.4 Garment fixation
Some people have challenges maintaining the position of their
compression garment. Fixation options may assist with positioning
and include the following:
 Attachment pieces (e.g., thigh high with waist attachment)
 Silicone bands at the proximal end of the garment provide a non-
slip point to resist garment movement. Silicone irritation can occur,
particularly in hot and humid climates due to the interaction of
perspiration and silicone. Although it is rare, a more severe silicone
allergy may also occur.
 Garment glue is a water-based substance applied to the skin prior
to the application of a garment to assist with positioning. Most
compression garment manufacturers produce their own garment
glue. Jobst It Stays garment glue available via SOA QH742.

12.3.5 Choosing a compression garment

There are many factors discussed above to consider when choosing a compression
garment for your patient. The decision tree below outlines the key factors to consider.

Figure 4.1 Compression Garment Decision Tree

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12.3.6 Ordering compression garments
Eligible patients are able to receive Queensland Health funded compression garments
under the Queensland Health Guideline, Guideline for Compression Garments for
Adults with Malignancy Related Lymphoedema: Eligibility, Supply and Costing.

Queensland Health has a Standing Offer Arrangement (SOA) which guides the
purchase of compression garments by the organisation. An SOA is a formal agreement
between Queensland Health and suppliers to supply products at an agreed price for an
agreed period, as a result of a competitive offer process. The purpose of an SOA is to
obtain value for money (most suitable clinical product for the best price). An SOA is,

“...mandatory for use by all Queensland Health facilities under the control of hospital
and health services throughout Queensland”22

SOA QH742 lists compression garments and related products available for order by
Queensland Health, Health professionals. The contact information for each
compression garment distributor is located on the second page of the SOA. These
suppliers can provide additional information about the garments they distribute. A
summary of the compression garments listed on SOA QH742 is provided in Table 3.1

Read: Standing Offer Arrangement QH742. Queensland Health. Contact your

Clinical Product Advisory Committee (CPAQ) representative or see the
website if you cannot find a suitable compression garment on the SOA or if you wish to
lodge a complaint about a product on the SOA or alternatively see the CPAQ website.

Activity 3: Your resource kit contains measurement forms and fabric

swatches to provide additional information about all garments available on
SOA742.

Use the compression garment guides in your resource kit to identify:

 A circular knit class 2 below knee garment from Sigvaris
 A flat knit class 2 below knee garment from Smith and Nephew

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Table 4 Compression garments on SOA QH742
Supplier Brand Country of Product Description
Manufacture
Lower limb garments
Biomet Venosan Switzerland - Custom Venosan 6000
- RTW Venosan 5000
Venosan 4000
Venosan 7000
Medical Stockings Therafirm USA - RTW Therafirm Women
Therafirm Men
Therafirm Unisex
Morris Medical Sigvaris Switzerland - Custom Cotton (CM, CX)
- RTW Comfort (CF)
Magic (MG)
Top fine (TF)
Traditional (503/4/5)
Orthopaedic OFA Germany - RTW OFA Bamberg
Appliances Bamberg
Prius Healthcare Ellipsis Taiwan - RTW Ellipsis Pro
Solutions Ellipsis Therapy
Reis Orthopaedic Medi Germany - Custom Duomed
and Surgical - RTW Mediven Plus
Mediven Forte
Mediven Ulcer
Smith and Nephew Jobskin Australia - Custom Jobskin
Jobst Elvarex Germany - RTW Jobst Elvarex
Jobst Germany Jobst Ulcer care
USA Jobst Ultrasheer
Jobst for Men
Jobst Relief
Upper limb garments
Biomet Venosan Switzerland - Custom Venosan 4000
- RTW Venosan 7000
Venosan 2000
Morris Medical Sigvaris Switzerland - RTW Advance
Traditional
Reis Orthopaedic Medi Germany - Custom Medi Harmony
and Surgical - RTW Mediven Esprit
Smith and Nephew Jobskin Australia - Custom Jobskin
Jobst Elvarex Germany - RTW Jobst Elvarex
Jobst USA Jobst Bella lite

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 Activity 4: Write responses to the following questions in your workbook

1. Describe the primary aim of compression garment use for a person with stable
lymphoedema.
2. During which phase of lymphoedema management are compression garments
most commonly used as the primary treatment modality?
3. Under what circumstances is it appropriate to use compression garments during
the initial management phase?
4. Describe the characteristics of a limb suitable for fitting with a compression
garment.
5. When is the best time to measure for a compression garment in terms of
lymphoedema volume, time of day and stability of lymphoedema?
6. When considering if a person will successfully use a prescribed compression
garment what aspects do you need to consider?
7. Do all class 2 compression garments have the same compression value
(mmHg)? Why/ why not?
8. Compare the recommended levels of compression for upper and lower limbs.
What differences do you see? What are the reasons for different levels of
compression between upper and lower limbs?
9. Populate the table in your work book with the appropriate manufacturing
technique. When complete, each column in the table should have cut and sew,
circle knit and flat knit listed.

12.3.7 Fitting a compression garment

Compression garments should ideally be fitted when lymphoedema volume is similar to
the volume at the time of compression garment selection. All new compression
garments should be examined for their fit on the patient.

Listen to the accompanying audio presentation for slides 15-37 of the

PowerPoint presentation.

Click here and read: The Role of Hosiery in Lower Limb Lymphoedema p19.

 Fitting and Evaluation

 Problem solving

Click here and read: Best Practice for Management of Lymphoedema.

International Lymphoedema Framework p43-46.
Familiarise yourself with the Lymphoedema compression garment provision
record form (Appendix 3).

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12.3.8 Wearing regimen
People with lymphoedema most commonly wear garments during the day. Garments
are most commonly applied after waking and removed just before sleep. Patients
should be prescribed an individually designed wearing regimen depending on their
clinical needs.

Click here and read Queensland Health Lymphoedema Clinical Practice

Guideline. Section 3.14.1 p40: Application/Frequency

12.3.9 Care instructions

Regular laundering of garments is essential for two reasons:
1. Hygiene of the compression garment – compression garments will become soiled
during wear. Irritants may build up in the garment causing damage to skin (e.g.
sweat under a silicon band).
2. Re-tensioning of the compression garment – compression garments stretch with
wear, particular at joint articulation points. Laundering garments will re-tension
the fabric and remove the creases that have developed. This will assist to
maintain the fit and sizing of the garment.
Patients should be educated about the above rationale to encourage regular
laundering.
Each manufacturer has slightly different instructions about the appropriate care of their
garments.

Click here and read Queensland Health Lymphoedema Clinical Practice

Guideline. Section 3.14.4 p42: Care of Garments.

A manufacturer care instruction card is included with all garments and should be
provided to patients.

Familiarise yourself with the Lymphoedema compression garment patient

information handout (Appendix 4).

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12.3.10 Application and removal of garments
(donning/doffing)
The patient’s ability to don (apply) or doff (remove) a garment is critical to the safety
and success of the garment. Consequences of improper garment donning/doffing can
include skin damage or impaired circulation, and even damage to the garment. A
patients’ application/removal technique should be observed and assessed before a
garment is provided. The don/doff capacity of a patient should also be monitored over
time.11

Many people will require training, modifications or assistive devices to successfully

manage their garments. The provision of an assistive device does incur a cost
however this device may be the difference between the success and failure of a
garment. It may also be the difference between the requirement for a custom made or
ready-to-wear garment.

Local procedures should be investigated for funding of assistive devices. The

Queensland Health SOA QH742 contains information about assistive devices for
donning/doffing of garments. A summary of these assistive devices is listed in Table 5

Donning and doffing aids available on SOA QH742. Information is available

via QHEPS. All supplier contact information is located on the second page of
the SOA.

Table 5 Compression garment accessories on SOA QH742

Product Brand Supplier

description
Donning Easy slide Arion Morris Medical
devices

Export Butler Medi Reis

Easy As applicator Easy As Sutherland Medical

Stocking frame Venosan Biomet

applicator

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 Donning gloves Therafirm Medical Stockings

Rubber gloves Sigvaris Morris Medical

Doffing Butler off Medi Reis

devices

12.3.11 Patient education

Patients/consumers require written and verbal education about all of the above
compression garment instructions. This is particularly important if patients are new to
the use of compression garments.
Patients/consumers should be advised to monitor their swelling and their skin under the
compression garment. They should be provided with contact details for their therapist
to report any significant changes in swelling or skin condition.

Familiarise yourself with the Lymphoedema compression garment patient

information handout (Appendix 4).

12.3.12 Garment evaluation

Although compression garments are effective, patient compliance is often poor
because garments may be uncomfortable and cause social morbidity.10 Due to
potential changes in a patient’s condition or circumstances, garments require regular
re-evaluation. Each garment evaluation should examine the following factors at a
minimum:
 Does the compression garment maintain the lymphoedema when worn?
 The primary indicator of effective compression is the maintenance of lymphoedema
reduction/stabilisation.
– Effective compression = stable lymphoedema volume and indicates the garment
is appropriate for the patient

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 – If the volume of lymphoedema is unstable troubleshooting is required. The
garment selection should be reviewed to consider whether the fabric, level of
compression, style and size require modification.
 Has the garment caused any skin damage/irritation?
 Has the patient been concordant with the wearing regimen and garment care
instructions?
 Does the patient have any concerns about their garment wear, donning or doffing?
Have they experienced any lifestyle or psychosocial issues associated with wearing the
compression garment?

Familiarise yourself with the Compression Garment Evaluation Form

(Appendix 5).

12.3.13 Review schedules

Patients should be reviewed four to six weeks after initial fitting of the compression
garment and then after three to six months if the response is satisfactory. 11 All patients
should be provided with contact details for the prescribing therapist to facilitate contact
if problems arise with the fit or management of their compression garment between
appointments.
The need for replacement garments should be reviewed every three to six months, or
when the garments start to lose their elasticity. 11 The patient should be reassessed at
each garment renewal point.11
Garment replacement rates will vary between individuals. People who are hard wearing
with their garments may require replacement more frequently than others. For
example, people who are very active, obese, or are wearing garments in a humid
environment. Garments which are worn infrequently also have a limited lifespan. The
common shelf-life for a garment is three years. The shelf life time is indicated on the
compression garment packaging.

Click here and read the Queensland Health Lymphoedema Clinical Practice
Guideline Section 3.14.5 p42: Garment replacement

Activity 5: Write responses to the following questions in your workbook

 You have placed an order for a compression garment and the patient/consumer
asks you to post it out to them when it arrives. What response do you give to their
request?
 A patient/consumer asks why it is necessary to wash the garments so regularly.
What is your response?
 You have just provided a compression garment to a new patient/consumer with
stable lymphoedema.
– What are the key points you will take note of at the initial fitting?

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 – What are the key factors you will go through about the use of their new garment?
– What is your follow up plan (frequency/mode) for this person?
– What key questions are you going to ask them when you contact them for follow
up?
– If they are wearing their garment daily, what timeframe should they consider for
garment replacement?
 When you see this person again in 6 months, they have had a significant increase in
lymphoedema even though they are wearing their garment daily. What
strategies/plan of action do you consider?

13. Case studies

The following case studies are designed to provide you with the opportunity to apply
and consolidate the information presented in this learning package. They can also be
used as the basis for discussion/clarification during the Supported Practice meetings.

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13.1 Case study: Helen
Helen is 55 years old and works part time in a child care centre in a fairly large regional
town. She lives with her husband Ben and has 2 adult children, the youngest living at
home.

Medical History
 5 years ago Helen was diagnosed with breast cancer and underwent axillary lymph
node dissection and radiotherapy.
 She developed malignancy related (L) upper limb (non-dominant) lymphoedema
which has been stable for the past 3 years.
 She reports that her (L) arm aches and feels heavy most days.

Assessment information
 Sum of arm circumference (SOAC) – L > R 12.5 cm
 Texture: Non-pitting soft swelling throughout upper arm with small area of pitting
proximal forearm
 Lymphoedema stage classification - ISL Stage 2
 BMI 35 (Obesity classification)

Questions for discussion:

1. What are the characteristics of Stage 2 lymphoedema?
2. What is Helen’ self management plan likely to involve?
3. Provide details of the type of compression garment you might consider
appropriate for Helen.
 Type of fabric?
 Style of garment?
 Level of compression?

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13.2 Case study: Joyce
Joyce is a 68 year old widow who lives in a small rural town about a 1 hour drive from a
larger regional centre. She has lived in this town for a number of years and has a
strong social network. She is a pensioner and has family (a son) who lives close by and
helps keep her yard and garden in order. Joyce is able to manage all of her self-care
and household tasks. She drives to access her many social events.

Medical History
 Left dominant and left sided breast cancer with axillary lymph node dissection about
2 years ago.

Current presentation
 Swelling present past 18 months
 Responds completely to elevation overnight then re-accumulates throughout the day
to feel heavy and aching
 Location: hand, forearm
 Texture: Soft, fluctuant, non-pitting oedema
 SOAC L>R 6cm
 ISL stage: 1

Questions for discussion:

1. What are the characteristics for Stage 1 lymphoedema?
2. Provide details of the type of compression garment you might consider
appropriate for Joyce.
 Type of fabric?
 Style of garment?
 Level of compression?

3. What other intervention are you going to provide to Joyce?

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13.3 Case study: Jack
Jack is a 60 year old man who recently retired having worked for most of his life
running his own business. He lives with his wife Rona in a large regional city. They
spend much of the winter traveling with their caravan around Australia but usually
spend the summer months at home near their family.
Medical History
 Melanoma left calf with inguinal lymph node dissection and radiotherapy 3 years ago

Current presentation
 Malignancy-related lymphoedema past 2 years
– Heavy, aching leg
– Limits mobility
– Texture: Mild thickening, adipose proliferation
– ISL Stage: 2
 Wears compression garment some days but finds it uncomfortable

Questions for discussion:

1. What are the characteristics for Stage 2 lymphoedema?

2. Provide details of the type of compression garment you might consider

appropriate for Jack.
 Type of fabric?
 Style of garment?
 Level of compression?
GARMENT SELECTION

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14. Case studies
Which garments would suit these patients?

14.1 Case 1
 50 year old female
 R) WLE and ALND 0/7 +’ve and XRT to breast 1 year ago
 Subjective- heaviness in upper arm, ache in forearm
 Objective- mild soft oedema distal upper arm and proximal forearm, No finger/hand
oedema
 Left handed
 BMI 24

Left Right

MCP 19.0 19.4

Mid P 19.0 19.7

0 15.8 16.0

10 20.4 19.7

20 24.9 25.0

30 25.1 25.5

40 30.1 32.0

SOAC 154.3 157.3

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14.2 Case 2
 55 year old female
 BMI 28; Right handed
 Melanoma right upper trapezius
 WLE right arm and ALND 1/32
 XRT 48 Gy 20# to R axilla
 History of bilateral frozen shoulders
 Soft non-pitting oedema right forearm and hand

Left Right

MCP 22.9 21.7

Mid P 19.0 18.5

0 19.2 17.6

10 24.3 22.0

20 30.4 28.2

30 37.2 36.5

40 40.1 40.3

SOAC 193.1 184.8

Length 43cm

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14.3 Case 3
 Myxoid Sarcoma 2007
 Radiation L) thigh 2008 30# 60Gy
 Occupation: Chef
 Other: on feet long hours, allergic to silicone
 Oedema presentation: oedema calf and ankle when working, nil oedema upper leg

left right

MTP 23.2 23.1

TMT 24.5 24.5

DAC 33.0 32.3

10 27.1 25.6

20 28.9 27.5

30 40.9 38.6

40 33.5 33.5

50 36.1 37.5

60 39.5 41.7

70 47.0 47.3

Sum 333.7 331.6

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15. Appendices

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 Appendix 1 Assessment
For Stable Established Malignancy-Related Lymphoedema

(Affix patient identification label here)

URN:
Family name:
Assessment for Stable Established Malignancy- Given name(s):
Related Lymphoedema
Date of birth:

Sex: M F

Date of referral: Date of initial assessment:

Referring Practitioner General Practitioner

Name: Name:
Clinic: Clinic:
Phone: Phone:
Social History
Occupation

Social history/
Family supports

Medical History
Cancer Diagnosis

 Surgery Type:
Date:

Lymph node dissection

Date:
Site:
Nodes positive/ removed
Post operative complications:
 Radiotherapy Date:
Details:
Complications:
 Chemotherapy Date:
Details:
Complications:
 Other cancer
therapy

Other medical /
surgical history

Subjective lymphoedema report

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Details of onset
(date, possible
trigger)
Affected area

Increasing factors

Reducing factors

Lymphoedema  Fluctuating  Persistent  Reduces overnight

Sensations  Tightness  Aching  Stiffness

 Heaviness  P&N/Numb  Other
History of
infection/ cellulitis
Pain  Pain (when/ where/ when doing what/ severity - rate out of 10):

Psychosocial
impact
Functional
limitations  ADL/ IADL (including community services):

 Community/ medical access:

 Home environment:

 ROM/ Strength/ sensory limitations:

Treatment Previous Current

 Massage

 Bandaging

 Garments

 Exercise

 Other

Objective assessment

Skin issues  Intact  Fragile  Dry

 Shiny / Taut  Discoloured  Lymphorrhoea/
 Blisters/ ulcers  Fungal signs leaking

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  Wounds
 Scarring
Venous impairment  Nil venous signs  Varicose veins  Haemosiderin staining
Telangectasia  Purple colour  Warm temperature
Arterial impairment  Nil identified  Cold temperature  Claudication with
 Ischemic rest pain  Pale colour exertion
 ABPI required yes/
no/ previous
score………….
Presentation of
lymphoedema

Therapist Assessment

Compression severe arterial insufficiency

Contraindications uncontrolled heart failure
severe peripheral neuropathy
Record on diagram:
Compression Cautions extreme limb shape distortion complex regional painoedema
 Soft syndrome
very deep skin folds  Firm oedema
malignant lymphoedema
extensive ulceration.  Pitting (10+ seconds)
acute cellulitis/erysipelas
an ABPI <0.8 or >1.2  Fibrosis
diabetes mellitus
high arterial blood pressure paralysis  Adipose
cardiac arrhythmia or cardiac stenosis sensory deficit
controlled heart failure fragile or damaged skin
scleroderma lymphorrhoea or other weeping skin
chronic polyarthritis conditions

Lymphoedema staging  Stage 0 (latency – no objective signs)

 Stage 1 (reversible with elevation, may be pitting)
 Stage 2 - early (irreversible with elevation, pitting, adipose proliferation)
 Stage 2 - late (pitting may be absent, fibrosis more evident)
 Stage 3 (non-pitting, fibrotic tissue, trophic skin changes)

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Summary of findings …………………………………………………………………………………………………

…..

…………………………………………………………………………………………………

…..

…………………………………………………………………………………………………

…..

…………………………………………………………………………………………………

…..

…………………………………………………………………………………………………

…..

Treatment provided …………………………………………………………………………………………………

…..

…………………………………………………………………………………………………

…..

…………………………………………………………………………………………………

…..

…………………………………………………………………………………………………

…..

…………………………………………………………………………………………………

…..

…………………………………………………………………………………………………

…..

Treatment plan …………………………………………………………………………………………………

…..

…………………………………………………………………………………………………

…..

…………………………………………………………………………………………………

…..

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 …………………………………………………………………………………………………

…..

…………………………………………………………………………………………………

…..

Follow up plan/ next …………………………………………………………………………………………………

review appointment
…..

…………………………………………………………………………………………………

…..

Therapist’s signature: ………………………………...........................................................................................…

Therapist’s name (print): ……………………………… Date: ………………………………………………………..

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 Appendix 2 Circumferential measurement forms
(Affix identification label here)
URN:
CIRCUMFERENTIAL UPPER LIMB MEASUREMENTS Family name:
Given name(s):
Address:
Date of birth: Sex: M F

Position of patient: Sitting Variations: Abd. 90 Variations:

rd
Board levels: Right Tip 3 finger: Mid point MCP: Mid point MCP radial: Mid ulna styloid:
rd
Left Tip 3 finger: Mid point MCP: Mid point MCP radial: Mid ulna styloid:
Dominance: Right Left Ambidextrous
DATE
Weight/ Height/ BMI
Side
MCP
Mid palm
Ulna styloid
10cm
20cm
30cm
40cm
50cm
60cm
Sum

Difference

Fingers 1.
2.
3.
4.
5.
Therapist and time of day

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 (Affix identification label here)
URN:
CIRCUMFERENTIAL LOWER LIMB MEASUREMENTS Family name:
Given name(s):
Address:
Date of birth: Sex: M F

Position of patient: Supine Variations:

Board levels: Right MTP med: lat: TMT med: lat: Mid-point malleoli med: lat:
Left MTP med: lat: TMT med: lat: Mid-point
Mid-point malleoli
malleoli med:
med: lat
lat:
Dominance: Right Left Ambidextrous Mid-point malleoli med: lat

DATE
Weight/height/BMI
Side
MTP
TMT
DAC
10cm
20cm
30cm
40cm
50cm
60cm
70cm
80cm
Sum
Difference
Toes 1.
2.
3.
4.
5.

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Therapist and time of day

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 Appendix 3 Lymphoedema compression garment provision record

(Affix patient identification label here)

URN:

Family Name:
LYMPHOEDEMA Garment Log Given Names:

Date of Birth: Sex: M F

Date Qty Manufacturer Style and details Size mmHg Wearing regimen Comments/ Issues Therapist details

Name:………………………….……
Signature: …………………….…..
Designation: ………………..……..
Date: ………………………..………

Name:………………………….……
Signature: …………………….…..
Designation: ………………..……..
Date: ………………………..………

Name:………………………….……
Signature: …………………….…..
Designation: ………………..……..
Date: ………………………..………

Name:………………………….……
Signature: …………………….…..
Designation: ………………..……..
Date: ………………………..………

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Appendix 4 Lymphoedema compression
garment patient information
handout

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16. Compression garment

16.1 Instructions
You have been fitted with a compression garment to assist in managing your
lymphoedema. For the best results it is important that you wear your garment as
instructed by your therapist.

Wearing regime
Your compression garment is to be worn:
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………

Applying your garment

Your therapist will show you the best way to apply your garment. Remember that your
garment is supposed to be firm, so may take a little time to get on and off each day.

Some tips for applying your garment:

 Ensure you skin is free from moisturizer / creams / moisture when you apply the
garment
 Use rubber gloves to get a good grip and prevent tearing the garment
 If needed, try a small amount of powder to help the garment slide
 Use an aid to assist (your therapist can show you these)
 If the garment seems too long, do not fold over the top or bottom of the garment.
Use your rubber gloves to redistribute the fabric.
 Look for wrinkles in the garment and smooth these out of the garment.

16.2 Precautions
Observe your limb for the following symptoms:
 New onset or increase in swelling / puffiness
 Pins and needles
 Cold / blueness
 Rash or skin changes
 Pain or discomfort
 Skin indentations – when you remove your garment it is normal to see indentations
in your skin where the garment has been fitting firmly. However, if a mark persists

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 longer than one hour after removing the garment or if the skin becomes
inflamed/broken, this may indicate a problem.

If you observe any of the above symptoms, discontinue use of the garment and contact
your lymphoedema therapist as soon as possible

16.3 Care instructions

 Wash your garments after each wear. This helps to re-tension the garment to
improve its fit
 Handwash your garment or wash in a hosiery bag or pillow case on a gentle cycle
using cold or warm water (no hot water).
 Use a mild pure liquid laundry detergent and rinse the garment out well. Do not use
powder, wool mix or hand soap.
 Roll or place the garment in between two towels to remove excess water (don’t
wring)
 Dry the garment flat in the shade. Do NOT tumble dry or dry near direct heat or in
the sun

For further information contact:

Name: …………………………………………………………………………………………….

Location: ………………………………………………………………………………………..

Contact hours: …………………………………………………………………………………

Contact details: ………………………………………………………………………………

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Appendix 5 Garment evaluation form

Site Location
Therapist Initials:
Date:

This evaluation should be administered by phone by your therapist one week

after fitting of a new garment and at your face to face review.

1. Since you started wearing your new garment have you experienced any new and/or
different pain, sensation or discomfort?

No Yes – If yes, please describe………………………………………..

2. Since you started wearing your new garment have you experienced any reduction
in circulation (i.e. fingers/toes change colour, pins and needles/numbness)?

No Yes – If yes, please describe………………………………………..

3. Have you experienced any increase in swelling since you started wearing your new
garment?

No Yes– If yes, please describe………………………………………..

If yes, do you think the increase in swelling is related to the new garment?

No Yes– If yes, please describe………………………………………..

4. When you remove your new garment do you have any skin irritation or redness?

No Yes– If yes, please describe………………………………………..

5. Are you able to wear the garment for the prescribed timeframe?

Yes No– If no, please describe………………………………………..

6. How does this garment compare to previous garments you have been prescribed?

The new garment is much better

The new garment is a little better
The new garment is the same as previous garments
The new garment is a little worse than previous garments
The new garment is a lot worse than previous garments
Not applicable this is the first garment prescribed

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Appendix 6 Self guided learning resource
evaluation
Site Location:
Therapist Initials:
Date:

Feedback and Evaluation form for self guided learning package.

Your feedback is important to inform the future design and implementation of this
package.

Please circle the appropriate response and write answers in spaces provided.

Learning Package
1. Overall did you find the content appropriate?
3 4 5
1 2

Not at Slightly Moderately Quite a Extremely

all bit

2. Overall did you find the content interesting?

1 2 3 4 5

Not at all Slightly Moderately Quite a Extremely

bit

3. Please comment on aspects of the learning package that worked well and
facilitated your learning.

4. Please comment on aspects of the learning package that could be improved and
did not facilitate your learning.

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Workbook Activities

5. Overall did you find the workbook activities assist your learning and knowledge
about prescription, fitting and monitoring of compression garments?

1 2 3 4 5

Not at all Slightly Moderately Quite a Extremely

bit

Content

6. Please rate the modules in terms of their relevance to your work as a generalist
therapist.
1= not at all relevant; 2= slightly relevant; 3= moderately relevant; 4 = very relevant;
5 = extremely relevant.

Module
1 2 3 4 5
Module 1: Overview of lymphatic system and
lymphoedema
Module 2: Assessment of lyphoedema

Module 3: Management of lymphoedema

Module 4: Compression therapy and garments.

7. The workload for this learning package was …….

1 2 3 4 5

Too little Just right Too much

1. Please record the time it took to complete each module

Module 1:
Module 2:
Module 3:
Module 4:

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PowerPoint Presentations

2. Overall did you find the PowerPoint presentations assist your learning and
knowledge about prescription, fitting and monitoring of compression garments?

1 2 3 4 5

Not at all Slightly Moderately Quite a Extremely

bit

10. Would having an audio of the transcript for the PowerPoint presentation be useful?

1 2 3 4 5

Not at all Slightly Moderately Quite a Extremely

bit

Please use the space below to make any other comments about the self guided
learning package.

Thank you for completing this evaluation.

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17. Glossary
Assessment for A process of subjective and objective information gathering for
compression garment the purpose of decision-making regarding the sourcing and
supply of a compression garment. The minimum components of
the assessment for a compression garment are described in
Compression Garment, Selection, Fitting and Monitoring
Education Resource, Section 1: Assessment Module. It includes
history taking with a focus on changes in signs and symptoms
since the supply of a previous garment, the presence of contra-
indications and precautions, information about the Clinical
Prescription of the garment, patient/ consumer reports of
tolerance and issues with the current garment, and on objective
assessment of the affected limb including circumferential
measurements using a standardised measurement process.
NOTE: An assessment for a compression garment is not the
same as a comprehensive lymphoedema assessment
undertaken for the purpose of diagnosis and development of a
comprehensive lymphoedema intervention plan. A
comprehensive lymphoedema assessment should form part of an
Episode of Care for malignancy-related lymphoedema.
Clinical prescription A written description of specific parameters of compression
garment style including class, fit, fabric and size for the purpose
of sourcing through a supplier / vendor. Clinical prescriptions for
compression garments should be made by appropriately trained
and experienced clinicians (including public and private sector
practitioners).
Clinical prescriptions should be for ready-to-wear garments,
unless custom-made garments are clinically indicated.
Non QH Hospital health service providers are responsible for
provision of current prescriptions.

Compression garment To examine a patient’s response to the prescribed compression

review garment following supply. This includes information collection
from the patient/consumer (supplemented by information from
carers or other members of the multi-disciplinary team). Review
differs from “re-assessment” as the purpose is primarily to gain
information on the specific response to the intervention (garment
supply), rather than more broadly gathering clinical information
for the purpose of developing or modifying a diagnosis or care
plan as part of a current episode of care.
Education To provide information that allows a patient/consumer or carer to
optimise benefit and minimise risks associated with wearing the
supplied compression garment. Education also includes
information about garment care and must include information and
practice of donning and doffing the garment including the use of
relevant aids. Education should be broadly consistent with the
Lymphoedema compression garment patient information handout
Compression Garment, Selection, Fitting and Monitoring
Education Resource, Appendix 4.
Fit / fitting An Occasion of Service provided for the purpose of supplying
and checking the fit of a compression garment.

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Generalist therapist A physiotherapist or occupational therapist who has not
completed a formal lymphoedema training program (e.g. Level 1
or 2 course), but has undertaken, or is currently undertaking the
Compression Garment, Selection, Fitting and Monitoring
Education Resource as part of the Statewide Compression
Garment Trial
Lymphoedema therapist Holders of a Level 1 Lymphoedema Training Certificate
accredited by the Australasian Lymphology Association (ALA)
and have recency of practice by demonstration of clinical
experience in compression garment prescription within the
previous two years and have completed 50 points of Continued
Professional Development in the previous two years as set out in
the ALA Lymphoedema Continuing Professional Development
Program and/or have Eligibility for Category 1 registration on the
National Lymphoedema Practitioners Register of the Australasian
Lymphology Association
Clinician who provides A health practitioner who will either be (1) a Lymphoedema
compression garment Therapist (private or public), (2) Generalist Therapist with
care supervision by a Lymphoedema Therapist, consistent with the
requirements of the supported practice period outlined in the
Compression Garment, Selection, Fitting and Monitoring
Education Resource, or (3) a Generalist Therapist who has
completed the supervised practice period of the Compression
Garment, Selection, Fitting and Monitoring Education Resource.
Malignancy-related Lymphoedema which develops as a result of damage to the
lymphoedema lymphatic system caused by cancer or its treatment.
Self guided learning Component 1 of the Compression Garment Selection, Fitting and
package Monitoring Education Resource. This component is completed
independently by the generalist therapist participating in the
Compression Garment Selection, Fitting and Monitoring
Redesign Trial.
Supported practice Component 2 of the Compression Garment Selection, Fitting and
component Monitoring Education Resource. This component consists of a
period of supported practice provided by a lymphoedema
therapist to the generalist therapist participating in the
Compression Garment Selection, Fitting and Monitoring
Redesign Trial. The Support Practice Framework uses a
coaching approach and is intended to consolidate the application
of learning from the self guided learning package. The Supported
Practice Period will primarily be provided via Telehealth.
Source For patients/consumers meeting the eligibility criteria under
Section 3 of the Guideline for Compression Garments for Adults
with Malignancy Related Lymphoedema: Eligibility, Supply and
Costing this means the health service directly sources (orders)
the garment from the supplier for the patient/consumer including
meeting the cost of the garment.
Stable lymphoedema Uncomplicated malignancy-related lymphoedema. Swelling
affecting a limb(s) which has been present for over 3
months and is not relieved by bed rest or elevation.
Subcutaneous tissues are soft and the normal shape of the
limb is preserved. Swelling does not affect the head and
neck, trunk or genital regions of the body.
The lymphoedema is confined to one or two limbs

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 and does not extend to the proximal root of the limb.
The subcutaneous tissue is predominantly soft
and/or pits on pressure in a small and localised area.
The affected limb has maintained a relatively normal
shape.
The skin on the affected limb is healthy and intact.
There is no arterial insufficiency.
There is no known malignancy in the quadrant of the
trunk which is adjacent to the affected limb.
Renal, cardiac, liver and thyroid problems have been
excluded as contributing factors or if present, these
conditions are well controlled.
The following characteristics would indicate that the
condition of the patient/consumer is not consistent with
stable lymphoedema:
New presentation of oedema/lymphoedema, not previously
assessed or treated by a lymphoedema therapist
Recurrent cellulitis in the previous twelve months
History of infection of the lymphoedematous limb requiring
antibiotics
Fluctuating and increasing circumferential measures
Secondary skin changes and lymphorrhea
Oedema extends to root of limb and affects abdomen or trunk
Other secondary complications e.g. seroma, scarring issues,
cording impacting on patient comfort or function

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18. References
1. British Lymphology Society (2013) Lymphoedema.
2. National Lymphoedema Network (2013) Position Statement of the National
Lymphoedema Network - Training of lymphoedema therapists.
3. Australasian Lymphology Association Lymphoedema Training Course Guideline.
4. The diagnosis and treatment of peripheral lymphoedema: 2013 Consensus
Document of the International Society of Lymphology. Lymphology, 2013. 46(1):
p. 1-11.
5. Stout, N.L., et al., A systematic review of care delivery models and economic
analyses in lymphoedema: health policy impact (2004-2011). Lymphology, 2013.
46(1): p. 27-41.
6. O’Sullivan, S. and T. Schmitz, eds. Physical rehabilitation: assessment and
treatment. 5 ed. 2007, F. A. Davis Company: Philadelphia. 659.
7. Hogan, M., Medical-Surgical Nursing. 2 ed. 2007, Salt Lake City: Prentice Hall.
8. Neschis, D. and M. Golden, Clinical features and diagnosis of lower extremity
peripieral artery disease, in UpToDate. 2013, Wolters Kluwer Health. Cancer,
2012. 12(6): p. 1471-2407.
9. Oremus, M., et al., Systematic review: conservative treatments for secondary
lymphoedema. BMC
10. Mohler, E. and T. Mondry, Prevention and treatment of lymphoedema, in
UpToDate. 2013, Wolters Kluwer Health.
11. Lymphoedema Framework, Best practice for the management of lymphoedema.
International consensus. 2006, MEP Ltd: London.
12. Soran, A., et al., Breast cancer-related lymphoedema--what are the significant
predictors and how they affect the severity of lymphoedema? Breast J, 2006.
12(6): p. 536-43.
13. Hayes, S.C., et al., Lymphoedema after breast cancer: incidence, risk factors,
and effect on upper body function. J Clin Oncol, 2008. 26(21): p. 3536-42.
14. Paskett, E.D., et al., The epidemiology of arm and hand swelling in
premenopausal breast cancer survivors. Cancer Epidemiol Biomarkers Prev,
2007. 16(4): p. 775-82.
15. Clark, B., J. Sitzia, and W. Harlow, Incidence and risk of arm oedema following
treatment for breast cancer: a three-year follow-up study. QJM, 2005. 98(5): p.
343-8.
16. Helyer, L.K., et al., Obesity is a risk factor for developing postoperative
lymphoedema in breast cancer patients. Breast J, 2010. 16(1): p. 48-54.
17. Ridner, S.H., et al., Body mass index and breast cancer treatment-related
lymphoedema. Support Care Cancer, 2011. 19(6): p. 853-7.
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Department of Health
Compression Garment Selection Fitting and Monitoring Education resource
Component 1: Self guided learning package
www.health.qld.gov.au