Resolving Secondary Lymphedema

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Easing debilitating lymphedema symptoms in an elderly patient using complete decongestive therapy.

Secondary lymphedema is the result of impairment to the lymphatic system following surgery, radiation therapy, chronic infection and various parasites. The majority of individuals affected by lymphedema is typically type 2.

This case demonstrates interventions to increase a patient’s ability to function within her environment after lymphatic procedures. Prior to the patient’s initial evaluation she had never participated in any type of decongestive therapy. Through lymphatic procedures and client-centered interventions the patient was able to improve her independence with basic ADLs and functional activities.secondary lymphedema treatment

Treatment Plan

The patient is 90-year-old white female who has been living with lymphedema for approximately 10 years. She was born with a congenital anomaly of the left arm, which formed two-thirds of her humerus and presents as a stump above the elbow.

The patient’s swelling was present in the bilateral upper extremities (BUE); however, only the right arm received aggressive treatment, while conservative methods were used on the left upper extremity (LUE).

Week 1. The lymphedema evaluation revealed vital information concerning the patient’s history and current status. The patient and family verbalized that they would like her to be able to use her RUE as much as possible.

The patient lived with her family in a single-story home, and had been performing most of her daily tasks independently, including dressing, feeding, grooming, toileting, transfers and mobility, until she began to swell. She now needed assistance for most of these tasks.

The patient had a large amount of protein-rich fluid in the RUE and near the distal stump of her LUE. Her family had been applying elastic wrap bandages without success. They were informed that these bandages are contraindicated for treating lymphedema, and that the proper course of treatment includes complete decongestive therapy (CDT), which is a series of manual lymphatic drainage (MLD) techniques and products such as short-stretch bandaging.

The family was also informed that she will require close monitoring secondary to pacemaker placement and congestive heart failure. CDT interventions would be employed to maximize her ADL performance, increase functional mobility, increase RUE strength, reduce excessive fluid, increase skin integrity and reduce the possibility of future infection and skin ulcers.

At the time of her evaluation, the volume of the patient’s affected right upper extremity measured 2,339.87 mL. Her left upper extremity measured 988.33 mL. Left UE strength measured 3+ across multiple motions, and right UE strength averaged 3-. Wrist and thumb extension, finger abduction, thumb and small finger touch, and wrist flexion exercises measured fair.

Week 2. The patient arrived feeling anxious about treatment. She tolerated MLD to her RUE directed toward the left inguinal region secondary to a port in her right inguinal and a left pacemaker. She tolerated RUE bandaging utilizing a stockinette, a conforming bandage on her fingers, 10-centimeter foam roll and short-stretch bandages.

The patient reported feeling shortness of breath (SOB) post-donning of bandages. Her O2 readings were 88-92% on 4 liters of O2. She was able to recover to 94% O2 saturation after deep-breathing exercises. The patient and family were instructed on the compression bandaging system should pain or SOB reoccur.

Week 2.5. The patient was accompanied by her family members and appeared calmer. The patients’ RUE compression bandaging system was intact upon arrival. Bandages were removed and skin was assessed. There were signs of skin breakdown and irritation.

The RUE was cleansed with soap and water and hydrated with moisturizers. The patient participated in MLD while supine and with head elevated to approximately 20 degrees to route fluid from the RUE toward the left inguinal secondary to medical conditions. The patient tolerated MLD without complaints of discomfort.

She was able to tolerate RUE compression bandaging utilizing a conforming bandage for her fingers, a 10-centimeter foam roll and short-stretch bandages. She participated in therapeutic exercise with active-assisted range of motion, including flexion of the elbow for 30 repetitions and flexion and abduction of the shoulder for 30 repetitions. The patient did not demonstrate SOB, and was instructed to remove the bandages should pain or SOB occur.

Week 3. The patient arrived with bandages donned from the previous session. The patients’ family verbalized that the patient kept her RUE elevated while sleeping. She was pleased with her lymphatic reduction.

The patient tolerated a sequence of RUE MLD to move excess fluid toward the abdominal drainage area. Compression bandages were administered on the RUE utilizing a conforming bandage on the fingers, 10-centimeter foam roll and short-stretch bandages.

The patient’s stump was bandaged with a 12-centimeter foam bandage and short-stretch bandages. She was advised to remove the compression system if pain, numbness or SOB should arise.

The patient returned two days later and significant reduction in swelling in the LUE was noted. Manual muscle testing and circumferential measurements were performed on the BUE and revealed dramatic improvement. The volume of the RUE measured 1,499.78 mL. The LUE measured 633.28 mL. Strength in her left upper extremity improved to an average of 4+, and right UE strength measured between 4 and 5.

Outcomes and Discharge

This case demonstrates the significance and effectiveness of CDT on BUE lymphatic reduction. Through the use of aggressive techniques for the RUE and conservative methods for the LUE, this patient had a successful encounter with her lymphatic specialist.

The patient was later fitted with compression sleeves that allowed her to sustain her decreased limb volume. The patient verbalized that she was able to lift items with increased ease and perform an increased amount of ADLs and IADLs with increased independence.

The patient was discharged to family care after reaching designated goals. She demonstrated a reduction in lymph volume of at least 25% in each limb, which allowed her to perform functional tasks with increased independence.

The family verbalized that they will do everything possible to keep her lymphedema swelling down in her BUE. The patient’s daughter verbalized that she would assist her mother with daily donning and doffing of compression sleeves and offer continuous encouragement to participate in a prescribed home exercise program to sustain lymphatic volume loss.

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About Author

Kirk R. Cowardbéy, OTD, OTR, CLT-LANA

Kirk R. Cowardbéy is an occupational therapist certified in lymphedema management at the Memorial Hermann Center for Wound Care, Hyperbaric Medicine and Lymphedema Management at the Texas Medical Center-Houston campus.

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