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Background: Compression is a cornerstone modality in edema treatment. Different types of bandages are available in clinical practice. Short-stretch bandages are commonly used; however, newer technologies such as the two-component compression system are available as well. This study assesses the pressure curves and static and dynamic stiffness (Static Stiffness Index [SSI] and Dynamic Stiffness Index [DSI]) of two different two-component compression systems, Coban and CoFlex, for edema treatment. Methods and Results: For this prospective cohort study, 12 healthy volunteers were recruited. The healthy volunteers wore both two-component compression systems for 48 hours. Pressure sensors (PicoPress ® ; Microlab, Italy) were placed at 10 and 25 cm above the internal malleolus and 10 pressure readings were used to obtain pressure curves. The SSI and DSI were assessed. Additionally, comfort (ICC compression questionnaire) and adverse events were assessed as well. Both two-component compression systems exert a sufficient amount of sub-bandage pressure, although CoFlex exerts systematically significantly lower pressure in comparison with Coban. This difference in sub-bandage pressure remains constant over 48 hours. Both two-component compression systems are sufficiently stiff (stiffness >15 mmHg) and remain stiff over time. Conclusions: Both two-component compression systems have pressure curves that are high enough to motivate their use in the treatment of chronic edema. Additionally, both systems were found to be comfortable and have clinically effective SSI and DSI values.

Background: Compression therapy is an important part of the treatment of patients with lymphedema or chronic venous disease. However, there is no validated questionnaire evaluating the effect of compression and its acceptance by the patient. Therefore, the aims of this study were to construct a questionnaire evaluating the effect of compression and its acceptance by the patient, that is, the Dutch ICC Compression Questionnaire (ICC-CQ), to investigate its reliability and validity, and to translate it into English. Methods and Results: Eleven experts in applying compression and 51 Dutch patients with experience of using compression were involved in the construction process. One part of the ICC-CQ has to be completed by the patient and evaluates seven domains. The other part has to be completed by the health care provider and comprises three domains. Reliability and validity of the final version was investigated in a new group of 79 Dutch-speaking patients with lymphedema or chronic venous disease, wearing compression garments ( N  = 52) or bandages ( N  = 27). Except for one domain, the Intraclass Correlation Coefficients for test-rest/interrater reliability ranged from 0.55 to 0.93. Cronbach's alpha for internal consistency ranged from 0.71 to 0.97. Eighty-nine percent of the patients fully understood the questionnaire indicating good face validity, and 87% found it complete indicating good content validity. Construct validity was considered good since 10 out of 11 hypotheses were accepted. Conclusion: The ICC-CQ is the first reliable and valid questionnaire evaluating different kinds of compression and the experience by patients with lymphedema or chronic venous disease.

Background: Assessing the circumference of the hand and fingers can be challenging. Therefore, we studied the reliability of jeweler rings and a revised figure-of-eight (figure-8) protocol for the clinical assessment of finger and hand circumference. Methods and Results: Thirteen patients residing in a rehabilitation center were recruited. Inter- and intrarater reliability of the jeweler rings as well as the revised figure-8 protocol were assessed. Jewelers rings were used to assess the circumferences of the middle and ring finger of both hands. The figure-8 method was used to assess the circumference of both hands. Reliability analyses were performed in Statistical Package for the Social Sciences 26 and demonstrated an excellent reliability for the jeweler rings as well as the revised figure-8 protocol, represented by single random measure intraclass correlation coefficient (2,1) values of at least 0.973 and Cronbach alpha of at least 0.99. Conclusions: Circumference measurements are valid to use; however, reliability issues do exist in clinical practice. Assessing the circumference of fingers with our new jeweler rings protocol and the circumference of the hand by means of a revised figure-8 protocol is highly reliable in a clinical setting.

Background: A disturbance of the superficial lymphatic system (dermal backflow) in patients with breast cancer-related lymphedema (BCRL) can be visualized by near-infrared fluorescence imaging or lymphofluoroscopy. In clinical practice, exact measurement of the dermal backflow is difficult. The purpose of the study is to investigate the concurrent validity between the clinical assessments and the lymphofluoroscopy in patients with BCRL. Methods and Results: Forty-five patients with BCRL stage I to IIb received lymphofluoroscopy and clinical assessments of their edematous limb (pitting status, skinfold thickness, skin elasticity, water content, lymphedema volume, and extracellular fluid). The correlation between the clinical assessments and the result of the lymphofluoroscopy was determined. The best overall agreement with dermal backflow was found for the clinical assessment pitting status, skinfold thickness, and water content. Overall sensitivity was excellent for lymphedema volume (92.5%), high for skinfold thickness (86.6%) and water content (75.0%), and moderate for pitting status (67.7%). Overall specificity was excellent for skin elasticity (94.7%), high for pitting status (83.4%), and moderate for skinfold thickness (61.6%) and water content (74.8%). In the evaluation of the whole arm, measurements of the excess volume were significantly greater for patients in an advanced stage of dermal backflow in comparison with patients in an earlier stage of dermal backflow ( p  = 0.002). Conclusions: The clinical assessments of skinfold thickness, water content, and lymphedema volume are the most appropriate tools to detect dermal backflow according to the lymphofluoroscopic images. To confirm the absence of dermal backflow, pitting status can be recommended.

Background: The Lymphedema Functioning, Disability, and Health questionnaire for Upper Limb Lymphedema (Lymph-ICF-UL) is a health-related quality-of-life questionnaire for patients with breast cancer-related lymphedema. Previous testing of this questionnaire showed very good psychometric properties; however, responsiveness has not yet been established. The aim of this study was to determine its internal and external responsiveness. Methods and Results: Ninety-five patients treated with decongestive lymphatic therapy in a longitudinal trial were recruited. Patients completed the Lymph-ICF-UL twice within a time interval of 7 weeks ("intensive group" receiving intensive treatment; n  = 73) or 3 months ("stable group" receiving maintenance treatment; n  = 22), and once the Global Perceived Effect (GPE) questionnaire at the second time point. The significance of change in scores and standardized response mean (SRM) were determined for the total and domain scores. Correlations between Lymph-ICF-UL and GPE were ascertained. In addition, the minimal clinical important difference (MCID) was determined. The Lymph-ICF-UL total score changed significantly in the intensive group ( p  < 0.001) and nonsignificantly for those in the stable group ( p  = 0.25). The SRM represented moderate responsiveness (0.65). Patients who reported a clinical improvement ( = responders) after intensive treatment showed a significant decrease in total score ( p  < 0.001), this was also the case for nonresponders ( p  < 0.001). Lymph-ICF-UL total and domain scores showed nonsignificant weak correlations with the GPE ( p  > 0.05). There was a significant difference in mean total score changes between responders and nonresponders ( p  < 0.001). MCID for the total score was 9%. Conclusion: The Lymph-ICF-UL is responsive to change after decongestive lymphatic therapy. No correlations were found between Lymph-ICF-UL change scores and GPE. Future studies should be conducted in a clinical setting, with more variability between participants and their treatment responses.

Background: Local tissue water in patients with breast cancer-related lymphedema (BCRL) can be assessed by measurement of the tissue dielectric constant using the MoistureMeterD Compact ® (MMDC) device, or by performing the pitting test. Although these assessment methods are commonly used in clinical practice, literature shows a lack of research on their clinimetric properties. Therefore, the aim of this study was to investigate reliability of both methods, in assessing the upper limb in BCRL. Methods and Results: Thirty women with BCRL were enrolled. Local tissue water was evaluated at nine reference points on the upper limb and trunk, using both methods. To determine intra- and inter-rater reliability of the MMDC device (using the absolute percentages of water content [PWC%] and interarm PWC% ratios based on single and multiple measures), intraclass correlation coefficients (ICCs), and standard errors of the measurement were calculated. To determine intra- and inter-rater agreement of the pitting test, Cohen's kappa coefficients were calculated as well as percentages of agreement. MMDC measurements yielded moderate to very strong intra- (ICC 0.648-0.947) and inter-rater (ICC 0.606-0.941) reliability, depending on the measurement location on the edematous limb. The pitting test showed a very strong intrarater agreement at nearly all defined points, but a weak inter-rater agreement, especially at the medial elbow and the breast. Conclusion: This study supports the MMDC device and pitting test as being useful tools in the clinical evaluation of BCRL. However, further research into the concurrent validity of both tools is warranted.

Background: Lymphedema is associated with significant physical and psychosocial problems. The Lymphedema Functioning, Disability and Health questionnaire for upper limb lymphedema is a valid and reliable tool quantifying the amount of problems in functioning in patients with breast cancer-related lymphedema. Patients suggested a revision of the scoring system to facilitate completion of the questionnaire. Therefore, adjustment of the questionnaire was carried out by implementing a numeric rating scale instead of the existing visual analog scale. Purpose of this study was to investigate reliability and validity of the revised Lymph-ICF, called the Lymph-ICF-UL. Methods and Results: Reliability and validity of the Lymph-ICF-UL were examined in 56 participants with upper limb lymphedema. Intraclass correlation coefficients for test-retest reliability ranged from 0.79 to 0.95. Cronbach's alpha coefficients for internal consistency were higher than 0.80. Face and content validity were very good because the scoring system was clear for all participants (100%), questions were understandable for all participants (100%), and all complaints due to arm lymphedema were mentioned by 98% of the participants. Construct validity was good. Convergent validity was established since four out of five expected domains of the Lymph-ICF-UL showed a moderate correlation with expected domains of the 36-Item Short-Form Health Survey questionnaire. There was good divergent validity because seven out of nine hypotheses assessing divergent validity were accepted. Conclusion: The Lymph-ICF-UL is a reliable and valid questionnaire using a simplified and clearer scoring procedure to assess impairments in function, activity limitations, and participation restrictions of patients with breast cancer-related arm lymphedema.