Brian presented with lymphoedema praecox, affecting the distal segment of both legs. Clinical examination showed a deep skin fold on the inner aspect of his right leg above the ankle; fibrosis; positive Stemmer's sign (a failure by the assessor to pick up or pinch a fold of skin at the base of the second toe (Mortimer, 1995)); and squared toes (a common presentation in advanced lymphoedema of the feet). Brian did not complain of any pain.
Brian's main concerns were:
- His difficulty with footwear due to the swelling of his feet
- Having to wear special trousers. He had to purchase two pairs so that the legs of one pair could be used to make the other pair large enough to fit his swollen legs
- Recurrent episodes of cellulitis, which had started at the age of 14.
Brian had received DLT 8 years previously, that had been followed by a gradual deterioration (over the course of 1 year) to his pre-treatment state.
Brian presented to clinic wearing made-to-measure hosiery (pantyhose-type garment) because the shape of both his legs was abnormal and could not be contained within commercially available garments.
Treatment
Brian received nine sessions of DLT over a 2-week period. His work commitments prevented him receiving further sessions of treatment.Prior to treatment, Brian's right distal segment volume was 7316 ml. Following the DLT, this was reduced to 4935 ml. The deep skin fold was gradually reduced over the 2 weeks. The left distal segment was reduced from 6061 ml to 4431 ml.
A made-to-measure pantyhose-type garment was ordered, as Brian was not keen to wear the available hosiery. On the final day of treatment, Brian was fitted with a class 3 below-knee stocking on his left leg and a CircAid legging on the right, both worn over his -- now too large -- pretreatment hosiery (only one CircAid was available in stock at that time).
Seven days later, both distal segments had increased in volume: the right to 5654ml and the left to 5153ml. Brian remarked that the legging seemed to feel looser after some time, but that it eventually fitted snugly again as the day progressed. He agreed to tighten the bands as he felt the pressure lessening.
Eight days later the right leg had lost 350ml from the distal segment whereas the left had gained another 30ml.
One month after completion of DLT, the left distal segment had regained all the volume that had been lost during the DLT. The right distal segment had lost 2360 ml. A CircAid legging was then fitted to the left leg, and 24 days later the left distal segment showed a volume reduction of 1600ml.
Twelve months after the second CircAid was fitted, the right leg volume was 3500mi less and the left 2600ml less than prior to treatment (970ml and 1119ml respectively less than at the end of DLT). The skin fold had almost disappeared and both feet were the same size as immediately after DLT.
The greatest circumference measurement on the calf of the right leg prior to DLT was 53.4cm. Following 10 days' treatment, this was reduced to 43.2 cm. Considering that the elastic fibres of the connective tissue had been seriously damaged from the long standing lymphoedema, it is not surprising that in the absence of firm support the tissues would refill. Although the right leg was fitted with CircAid immediately following DLT, the reduction in volume was not maintained. Brian did not adjust the Velcro straps initially, and slept in the garment for the first few nights. Once he got used to the device and correctly tightened the straps as the day advanced, the volume of the leg was progressively reduced.
The left leg regained most of its volume in the month following DLT, but responded rapidly to the application of a CircAid legging. A 1600mI reduction in volume was achieved in 3 weeks. Brian can now wear ordinary jeans and trousers and has no further episodes of cellulitis.
