C. Elevation
Elevation is important for patients with lymphoedema of the leg. It helps prevent fluid from accumulating in the leg by improving the flow in the elevated position.

The knee should be slightly bent and a pillow placed under the knee for support.

While sitting, raise the foot as high as is comfortable, preferably as high as the hip. if sitting on the floor, place a small pillow under the knees. If lying down, the foot can be raised by placing a pillow under the mattress.

Patient with heart problems should not elevate their legs unless advised by a doctor.

Exercise is useful for patients with lymphoedema and in general, the more they exercise the better they are. Exercise helps by pumping the fluid and improving drainage. However, patients should not exercise during acute attacks.

Besides walking short distances, simple exercises can be done.

Standing (up on the toes exercise)

1. Stand with both feet slightly apart, holding on to a wall, a person or other support,
2. Raise on to the tows of both feet at the same time and then sink back to flat feet.
3. Repeat 5 – 15 times or as often as comfortable. If the patient is unable to rise on both feet at the same time, the exercise can be done one foot at a time.

Sitting or lying down (toe point exercise)

1. While sitting or lying down, point toes towards the floor.
2. Then bend (extend) the toes upwards.
3. Repear 5 – 15 times or as often as comfortable.
4. Repeat with the other leg.

Sitting or lying down (circle exercise)

1. While sitting or lying down move the foot in a circle to the right and to the left.
2. Repeat with the other leg.
3. If sitting on the floor, protect the heel with a flat pillow.

E. Wearing proper footwear
Footwear protects feet from injury. Patients should avoid footwear that makes their feet hot and sweaty, or that are too tight.

Management of an Acute Attack
An acute attack is painful. The patient may complain of fever, nausea, headache and soreness of the lymph glands. Most patients can easily care for their acute attacks at home. Oral antibiotics can shorten the attack and are recommended, if the patient can be seen by a doctor. Paracetamol can be taken for fever every six hours until the fever lessens. A cloth soaked in water and placed around the leg can relieve pain. The leg can be soaked in bucket of cold water. The leg should be washed with soap and clean water but more gently and carefully. After drying, antiseptic can be applied to the skin and medicated cream to any entry lesion. The patient should rest and elevate the leg comfortably as much as possible. It is advisable not to exercise during acute attack as such exercise will be painful. The patient should drink plenty of water. Cold compress will help the patient.

Patients, with any of the signs listed here, should be seen by a doctor

1. Very high fever, confusion, headache, drowsiness or vomiting.
2. Fever, shaking, chills, or pain in the leg that does not respond to treatment within 24 hours.
3. Splitting of the skin because of rapid increase in the size of the leg.
4. Pus in the area affected by the acute attack.

Surgical management of hydroceles due to lymphatic filariasis
Besides annual single dose administration of DEC for 4–6 consecutive years to the eligible population, morbidity management is also an important component to alleviate or prevent disability due to lymphatic filariasis. Hydrocele is one of the commonest manifestations seen in the endemic districts. Surgical management of hydroceles not only gives great relief to the patients but also augments community compliance for success of ELF in the country.

The first level peripheral health centres (PHCs) will be able to diagnose cases needing surgical intervention, while most of the second level health centres (CHCs) have facilities for undertaking hydrocelectomy. WHO brought out a publication on ‘Surgical Approaches to make Urogenital Manifestations of Lymphatic Filariasis’ with algorithm for management of scrotal swellings, assessment of needs for conducting hydrocelectomy, etc.

The prevalence of hydrocele manifestations under each CHC is to be obtained and the cases are to be line listed and a time schedule is to be prepared for augmenting surgical facilities, training of surgeons, wherever needed and undertaking hydrocelectomy operations. Besides CHCs, the private sector including NGOs are also to be involved for promoting the surgical intervention for management of hydroceles. The calendar of activities with pragmatic targets and the minimum financial inputs are to be worked out so that the Govt. of India and the State Govt. may be able to consider for allocation of funds for this specific activity.