Before & After
The following article originally appeared in the newsletter of
(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
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
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
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.
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
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.