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

Jan Douglass,Tesfahun Bishaw,Mark Taylor,Hannah Betts,Susan Kim,Mekdes Nigussie,Fikre Seife,Louise Kelly-Hope,Fikre Hailekiros,Kadu Meribo,Hayley Mableson,Getnet Agidew,Sarah Martindale,Mossie Tamiru

doi:10.3390/jcm9124077

Abstract

Lymphedema causes disability and exacerbates poverty in many countries. The management of lymphatic filariasis (LF) and podoconiosis-related lymphedema involves daily hygiene to reduce secondary infections, but self-massage and deep-breathing, which have proven beneficial in cancer-related lymphedema, are not included. A cluster randomized trial in northern Ethiopia investigated the effects of lymphatic stimulation for people affected by moderate to severe lymphedema. Participants were allocated to either standard (control n = 59) or enhanced (intervention n = 67) self-care groups. Primary outcomes were lymphedema stage, mid-calf circumference, and tissue compressibility. Secondary outcomes were the frequency and duration of acute attacks. After 24 weeks, fewer patients were assessed as severe (control −37.8%, intervention −42.4%, p = 0.15) and there were clinically relevant changes in mid-calf tissue compressibility but not circumference. There was a significant between-group difference in patients who reported any acute attacks over the study period (control n = 22 (38%), intervention n = 7 (12%), p = 0.014). Daily lymphedema self-care resulted in meaningful benefits for all participants with a greater reduction in acute episodes among people performing lymphatic stimulation. Observations of a change in lymphedema status support earlier findings in Bangladesh and extend the demonstrated benefits of enhanced self-care to people affected by podoconiosis.

Highlights

Lymphatic disorders are a major cause of disability worldwide, and the extreme suffering of people affected by lymphatic filariasis (LF)-related lymphedema and hydrocele was the impetus for establishing the Global Programme to Eliminate Lymphatic Filariasis (GPELF) [1]
The World Health Organization (WHO) provides guidelines for LF endemic countries to carry out the morbidity management and disability prevention (MMDP) aspects of the GPELF [2], and recommend the same guidelines be used to support people affected by podoconiosis-related lymphedema [3]
In keeping with previous reports, we found larger changes in measures of lymphedema status occurring more readily among people affected by earlier stages [41,42], whereas lymphedema status changed more slowly among people affected by more advanced disease who benefited most from the reduction in acute attacks [13,36]

Summary

Introduction

Lymphatic disorders are a major cause of disability worldwide, and the extreme suffering of people affected by lymphatic filariasis (LF)-related lymphedema and hydrocele was the impetus for establishing the Global Programme to Eliminate Lymphatic Filariasis (GPELF) [1]. The World Health Organization (WHO) provides guidelines for LF endemic countries to carry out the morbidity management and disability prevention (MMDP) aspects of the GPELF [2], and recommend the same guidelines be used to support people affected by podoconiosis-related lymphedema [3]. The GPELF has been successful in stopping LF transmission in 17 of 72 endemic countries [8], so there should be no new cases of LF-related lymphedema in those countries. New cases of podoconiosis can be prevented when subsistence farmers in endemic areas are able to wear closed shoes and live in houses with sealed flooring [9]. People who already have clinically manifest lymphedema face decades of disease progression, stigma, and social exclusion [10,11,12]

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Discussion

Conclusion