Assessing the Effectiveness of the Long-Term Use of Juzo's Soft Compress Leg Liner to Manage Lower Extremity Lymphedema: A Case Study

Background and Purpose

Lymphedema is a chronic condition most commonly seen within the arms or legs. This condition causes tissue to swell secondary to a genetic disorder, excessive fluid loads in the body, or poor movement or drainage of lymph fluid [1]. There is currently no cure for lymphedema, but interventions such as Complete Decongestive Therapy (CDT) which include patient education, self-care education, compression therapy, exercise, and manual lymph drainage (MLD) can manage the condition [2, 3, 4, 5, 6, 7].

As previously mentioned, lymphedema can result from a variety of conditions. Some controversy does exist, but in general, primary lymphedema results from a congenital defect in the lymph transporting system [8]. Secondary lymphedema results from an obstruction or disruption of the lymphatic system. Effects from a malignancy, surgery, trauma, radiation therapy, or infection could all contribute to a patient having secondary lymphedema [8]. Effects after the treatment of solid tumors, such as melanoma or genitourinary malignancies, have resulted in secondary lymphedema as well [8].

Due to the chronic nature of the condition, patients may experience an accumulation of adipose tissue. This addition of tissue could contribute to the inability of some limbs to return to their premorbid size. With the addition of adipose tissue, lymphedema also has the potential to affect the physical and psychological well-being of patients due to possible physical limitations or negative body image some patients will experience [7].

Lymphedema can be categorized into three stages, but a fourth stage (stage zero) can be included as a subclinical stage [2]. Stage zero occurs when swelling is not visible, but lymphatic transport is impaired. Subtle changes may be noted within this subclinical stage. Stage one is known as early lymphedema. Swelling is visible but goes away with limb elevation. Pitting can be evident during stage one as well. Stage two is also referred to as moderate lymphedema and presents with pitting and progressive tissue fibrosis. Stage three is known as late lymphedema and skin changes are evident. Thickening of the tissue can occur as well as hyperpigmentation and fatty deposits. Tissue can become more fibrotic and pitting is absent.

When treating lymphedema conservatively, compression garments have proven to be a beneficial component to rehabilitation, particularly in patients who have had breast cancer [3]. Compression therapy accomplishes a reduction in swelling by reducing capillary filtration, increasing lymphatic drainage, and transporting fluid from compressed areas of the body to less compressed areas [4].

According to the clinical practice guidelines for interventions for breast cancer related lymphedema, compression garments have a moderate recommendation (Grade B) for early post-op care for individuals who have undergone axillary lymph node dissection [2]. A weak recommendation (Grade C) is given for the use of compression garments, patient education, and self-massage during stage zero. A strong recommendation (Grade A) is given during stage one for patients to be fitted with an individual garment. For stages two and three, compression bandaging and exercises are identified as core components of complete decongestive therapy (CDT), and were also given a strong recommendation (Grade A).

In a published case study, a 55 year-old female patient was diagnosed with secondary lymphedema in 1987 in her left lower extremity [6]. The patient was prescribed a variety of compression garments to wear. She wore a class 3 flat-knit garment worn with class 2 circular-knit tights over the top. The patient was also given a Juzo wrap to try, but she felt the wrap did not offer enough support. The patient was educated in deep breathing techniques, squeezing of an exercise ball at 3 node points, and the fill and flush technique of lymphatic drainage. The patient stayed active each day and avoided prolonged sitting. When the patient did sit, she made sure her leg stayed elevated. The patient was then introduced to easywrap in 2017, a lower limb garment consisting of overlapping; single-layer textile bands attached with easy to use fasteners. Prior to her easywrap usage, the patient’s left leg excess was 2860 mL. After 21 days of using easywrap, the left leg excess had reduced to 2353 mL - a total reduction of 507 mL. The patient stated “...after the 21 day measurements [she] was very happy with her easywrap… and is now confident in playing tennis in light sports leggings”.

In a systematic review from 2004-2011, 26 articles were analyzed in order to understand the current research covering complete decongestive therapy (CDT) techniques and adjunct components when treating lymphedema [5]. CDT is currently viewed as the gold standard of care when treating patients with lymphedema [5]. CDT typically consists of a combination of manual lymph drainage (MLD), multi- layer, short-stretch compression bandaging (CB), exercises, skin care, and/or fitting of appropriate compression garments (CG) [5]. In a case-control series study involving 29 participants, short-stretch CBs were applied to normal legs and legs with lymphedema over a 24-hour period. A 48% decrease of original pressure under the bandage due to loss of limb volume under compression was noted. In a separate study involving 36 patients with moderate to severe breast cancer related lymphedema, patients were split into high pressure bandages (44-58 mm Hg) and low pressure bandages (20-30 mm Hg). No significant difference in edema volume reduction was noted between the high and low pressure bandage groups. However, sub-bandage pressure drops were the same in both groups in a 2 hour follow-up and a 24 hour follow-up. This finding supports the idea of daily reapplication of short-stretch bandages in order to provide optimal compression for the patient. Lastly, a review article cited within the systematic review states that MLD is not an effective stand-alone treatment option.5 Lead et al states that CB is needed in combination with MLD to achieve optimal results.

When undergoing treatment procedures and therapy sessions for lymphedema, patient compliance will also affect results. Typically, a trained healthcare professional will apply elastic bandages to a patient’s limbs in the appropriate manner [10]. Some patients may find the bandaging uncomfortable and remove the bandaging. Other patients may have difficulty reapplying their bandages each day. As a result of this difficulty, adherence may be poor and may negatively impact treatment outcomes [10].

The purpose of this case study was to analyze and share the outcomes related to wearing a Juzo Soft Compress Leg Liner with short-stretch bandages to manage lymphedema across three episodes of lymphedema therapy treatment. The Juzo Soft Compress Liner is a specific type of compression garment that can selectively increase the compression pressure for particularly localized edema [1]. The short- stretch bandages that will be used in adjunct to the Juzo Soft Compress Liner will be less harmful for the patient’s well- being due to the elastic properties being limited [1]. The tension will decrease over time in addition to, ideally, the limb decreasing in girth [10].

Analysis and Results

At the beginning of the patient’s treatment on January 9, 2018, the patient’s LLE girth measurement was 176.7 cm. At the conclusion of the patient’s third episode of treatment on October 28, 2020, the LLE girth measurement was 160.1 cm. In addition to the patient’s limb girth decreasing a total of -16.6 cm, the patient’s NPS also decreased. The patient’s worst pain went from a 10 to a 0. The patient’s current pain level also decreased from a 3 at initial evaluation in January 2018 to a 0 on discharge in October 2020. In addition, the patient also reported feeling “a great deal better” with overall functional performance with functional activities of daily living from the time physical therapy began until final discharge in 2020.

Discussion and Conclusion

The results of this case study support the continued usage of a Juzo Soft Compress leg liner with short stretch bandaging to manage lower extremity lymphedema. The patient within the case study displayed improvements in lower extremity girth measurements, improvement in functional activities of daily living, and improvement in a NPS. The effects and results may have been affected by patient compliance as well as unknown compression garment wear time between episodes of treatment. In addition, MLD and other adjunct manual therapy techniques completed at each physical therapy session may also have contributed to the positive results.

In conclusion, the patient used within this case study greatly benefitted from the continued and multiple usage of the Juzo Soft Compress leg liner with short stretch bandages on three different episodes of treatment in order to manager lower extremity lymphedema. However, more studies would further validate the long-term effects of the Juzo Soft Compress leg liner on lower extremity lymphedema with larger sample sizes and more controlled period of usage.

Conflicts of Interest

The authors declare no conflict of interest.