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The following article originally appeared in the newsletter of the LAO

(Lymphedema Association of Ontario)  http://www.lymphontario.ca


Treating Lymphedema; A Case History
By John Mulligan, RMT/CLT-LANA

In understanding the efficacy of Complete Decongestive Therapy (CDT) in treating cases of lymphedema, it is sometimes helpful to examine a case study. The impact of lymphedema on a person's life, and the changes brought about by thoughtful application of CDT, can plainly be seen in a concrete example.

Case Study; 67 year old female, six years post mastectomy

Our patient, who we will call S.D., was a sixty-seven year-old female, who was six years post-mastectomy (left side) when she came to me for treatment. She had undergone a series of radiation treatments two years previously, and exhibited some radiation fibrosis as a result. The swelling in her left arm had onset post-radiation treatment and had been in progressing for two years.

Subjectively, S.D. complains that her affected arm feels heavy and she has frequent tingling sensations and occasional sharp pains in her arm. She reports that she has been losing sleep due to discomfort and is depressed. Through her conversation she reveals negative self-image due to her disfigurement. S.D. is fond of home canning and cooking, and she relates that she cannot hold a potato in her left hand long enough to peel it without severe discomfort.

S.D. had used a compression pump previously for her lymphedema, with little result. She had also been issued a compression sleeve by another clinic and had discontinued using it after her swelling had progressed to the point that the sleeve no longer fit her arm. She had also discontinued use of the compression pump.

Upon presentation, the patients affected arm is markedly swollen, shows dense pitting and is larger than the unaffected arm by 5.75 inches at a measurement point 4 inches above the styloid process. She also reports that her arm periodically weeps fluid. The patient demonstrates that she is unable to encircle her affected wrist with the thumb and forefinger of her right hand.

At the sessions following her assessment, S.D. is given a course of standard Complete Decongestive Therapy, including manual lymph drainage (MLD), compressive bandaging and remedial exercises, as well as skin care and recognition of the signs of infection. Therapy sessions are an hour in length and take place five days a week. Patient education in self-care of her condition is included.

After two weeks the patient is skilled at applying her compression bandaging on her own. At this time she also reports a decrease in the heaviness in her arm, a decrease in soreness and an absence of tingling and sharp pains. The occasional weeping of the limb has ceased.

The patient's therapy continued. She was compliant with all home protocols.. She wears compression bandaging during the day and night and receives hour-long sessions of MLD/CDT five days a week. She is pleased with the continuing reduction of her swollen limb. As she is skilled in applying her compression bandaging, she is able to bathe normally.

Two months after her evaluation, S.D. states that she is able to encircle her affected wrist with the thumb and forefinger of her unaffected hand. She is quite pleased and excited by this. Her arm appears nearly normal and the patient reports that she is no longer depressed and shows signs of positive self-image. She is now able to sleep through the night without discomfort. The affected arm is well-reduced but still shows palpable and evident presence of fibrotic tissue. At this time, a dense medical-grade foam called Komprex is introduced into the bandaging. This foam is bright orange in color, and pieces are cut to fit between the carpal bones in the hand bandaging. These pieces are tapered and beveled, and, due to the color of the foam, are commonly referred to as "carrot sticks." Komprex foam is also introduced into other areas of the bandaging to address indurated fibrotic tissue there.

At this time the patient reports no discomfort at all in her affected arm. She is wearing a Juzo compression sleeve during the day and bandaging at night. She reports that she is able to do "more housework than even a week ago." She also reports that she was able to "peel a bushel of pears" for home canning, in contrast to her inability to peel even a single potato at the time of her original evaluation. She reports no discomfort, no pain, and no tingling sensations. At four inches above the styloid process she has experienced a reduction of swelling of 4.5 inches. Fibrotic tissue is palpably and evidently resolved completely. S.D. is discharged from treatment, with follow-up visit scheduled in six weeks.

Summary

Patient was highly motivated to resolve her lymphedema. She faithfully adopted her home protocols as part of her activities of daily living and maintained reduction even while coping with other health problems and life stressors. At her follow-up visits six weeks and six months after discharge, no further treatment was necessary. She continued to experience reduction of swelling after the intensive phase of her therapy ended. At her one-year follow-up visit she was readmitted for a short course of therapy and issued new compression supplies. She was able to maintain compliance even with a lack of social support in the home environment, either emotional or practical. Two years after her intensive course of therapy ended, the patient, at 69 years of age, still maintained excellent reduction of edema and continued to follow home protocols.

Due to an excellent billing department, we were able to keep the patient in treatment until her symptoms were fully resolved. Treatment took place in the United States and reimbursement was through Medicare.

S.D.'s treatment history brings to light several important points regarding the treatment of lymphedema. It demonstrates the failure of the compression pump and the inutility of the premature use of a compression sleeve. It also demonstrates the importance of a commitment to the therapy on the part of the patient. S.D. adjusted her following of home protocols to suit her own needs. Once she was able to self-bandage she eliminated the hand bandaging and declined to wear a compression glove. Fortunately, she did not experience hand swelling as a result. She felt that the risk of hand swelling was acceptable in exchange for the freedom of movement she experienced. She also modified her home exercise program to suit her needs and schedule. In all other ways, however, she was totally committed to the program and therefore experienced excellent results. She possesses a highly resilient temperament and showed a high degree of adaptability by integrating her home compression program completely into her activities of daily living.

Before she encountered MLD/CDT, S.D. had sought out several other treatments for her lymphedema, with little or no results. She had become depressed about her swollen arm in a way that her cancer had not depressed her. After encountering MLD/CDT and its effectiveness she felt she had regained control over this aspect of her life. She became an excellent patient and experienced a renewed enthusiasm for her life. I can safely say that manual lymph drainage and complete decongestive therapy significantly improved the quality of her life.

 

 

 

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