Pilot Case Study in Mauritius for the Treatment of Lymphedema using Complete Decongestive Therapy

A Pilot Case Study in Mauritius for the Treatment of Lymphedema using Complete Decongestive Therapy

Date of Study: 2 February 2015 – 7 February 2015

Place: Westcare Health Centre, La Mivoie, Black River

Therapist: N.A Pearce (CLT) (Norton School of Lymphatic Therapy)

With special thanks to:

Elizabeth Dalais and all the Staff at Link to Life

Thea Van Schoor

Dr Bernard Piat

Lymphedema

Lymphedema is a chronic swelling of a body part usually occurring in the extremities (arms or legs). It can also occur in the face, neck,

abdomen, or genitals. Lymphedema is the result of the abnormal accumulation of protein-rich edema fluid in the affected area. The problems

it creates are poorly understood in the medical community. Lymphedema is classified as either primary or secondary. Primary lymphedema

is the result of lymphatic dysphasia. It may be present at birth but more often develops later in life without obvious cause.

Secondary lymphedema is much more common and is the result of surgery or is a side effect of radiation therapy for cancer. Secondary forms

may also occur after injury, scarring, trauma, or infection of the lymphatic system. Lymphedema has important pathological and clinical

consequences. Lymphedema can present immediately after the event that causes damage to the lymphatic system or many years after the

event. It is important to remember that even if a patient only becomes symptomatic years after (the cancer surgery for instance), the

lymphedema is still directly related to the cancer and its treatment.

In stage 1 lymphedema, the swelling consists of protein-rich fluid and may be temporarily reduced by simple elevation of the limb. If it remains

untreated, however, the lymphedema causes a progressive hardening of the affected tissues which is the result of a proliferation of connective

tissue, adipose tissue, and scarring (stage 2 lymphedema). Stage 3 lymphedema is characterized by a tremendous increase in volume,

hardening of the dermal tissues, hyperkeratosis, and papilloma’s of the skin.

Infections such a cellulitis, erysipelas, and lymphangitis frequently develop in individuals suffering from lymphedema. Infections are most

common in stage II and III lymphedema with each infection contributing to a worsening of the condition making frequent hospitalizations

necessary.

Lymphedema treatment in Mauritius has, to date, been restricted to the prescription of diuretic medications. This does however aggravate

the condition and is contra-indicated in the treatment of lymphedema. Hence no effective treatment has been available to patients with

lymphedema in Mauritius.

Complete Decongestive Therapy is the ‘gold standard’ for the treatment of lymphedema in the United States and Europe. The treatment is

now available in Mauritius.

STAGES OF LYMPHEDEMA

LATENCY STAGE

• Lymphatic transport capacity is reduced •

• No visible/palpable edema •

• Subjective complaints are possible •

STAGE I

(Reversible Lymphedema)

• Accumulation of protein-rich edema fluid •

• Pitting edema •

• Reducible with elevation (no fibrosis) •

STAGE II

(Spontaneously Irreversible Lymphedema)


• Pitting becomes progressively more difficult •

• Connective tissue proliferation (fibrosis) •

STAGE III

(Lymphostatic Elephantiasis)


• Non-pitting •

• Fibrosis and sclerosis (severe induration) •

• Skin changes (papillomas, hyperkeratosis, etc.)

An outline of the treatment Complete Decongestive Therapy (CDT)

CDT is a combination of Manual Lymph Drainage (MLD), bandaging of the affected areas, remedial exercises, and skin and nail care. CDT is

divided into a two-phase program that initially involves an intensive treatment phase and is then followed by a maintenance program

continued by the patient at home. Carried out with great care and consistency by a certified lymphedema therapist, CDT is the treatment of

choice for chronic extremity lymphedema. Even in advanced lymphedema, CDT achieves excellent results with no side effects. Because CDT

is labor intensive, time-consuming, and requires patient compliance, many patients have difficulty committing to the program at first. However,

because the results of CDT are always superior to those achieved with all other treatments, increasing numbers of patients are undergoing

CDT treatment and are consequently able to maintain the reduction of their limbs through diligent participation in a home maintenance

program.

For a lymphedema therapist to be fully competent in treating lymphedema using CDT, it is vital that the CDT training consist of the four

components of CDT: (1) basic and advanced MLD, (2) lymphedema bandaging, (3) remedial exercises, (4) skin and nail care.

The therapist must also have a complete understanding of the anatomy, physiology, and pathophysiology of the lymphatic system, the

treatment of primary and secondary lymphedema, the indications and contraindications of CDT, and the proper measuring techniques for

lymphedema support garments.

Furthermore, lymphedema therapy should not begin unless the patient has been examined and diagnosed by a board-certified physician

who understands lymphedema and its complications. Once the diagnosis of lymphedema has been confirmed and treatment has begun, the

progress must be monitored by the physician. Whereas the clinical diagnosis of lymphedema can most often be established without invasive

testing, and electrocardiogram before the treatment begins and during the course of treatment is sometimes necessary to ensure safe

treatment for each patient.

Lymphangioscintigraphy (LAS), CT scans, and MRIs are also recommended for lymphedema patients before starting CDT. The physician will

be able to decide and inform the patient about the necessity of such procedures at the time of consultation. Because of the complications

associated with lymphedema, the involvement and supervision of a qualified physician is essential for safe and effective lymphedema therapy.

Patient: 50 yr old female diagnosed with cancer in the left breast in November 2004. Patient underwent a radical mastectomy in January 2005 followed

by radiation therapy (Feb-Mar2005) to the affected area. Chemotherapy 1 x per month until Aug 2005.

Patient has a loss of sensation in 3 fingers of the left hand following the mastectomy.

Patient is type 2 diabetic, insulin dependent +Metaformin. Since approx age of 27 years – well controlled.

Weight: 75,3kg

Height: 1m66

BMI: 27.3

Patient underwent a total hysterectomy with bilateral oophorectomy in June 2013 following the discovery of a lesion. No cancer diagnosis at this time.

History of Treatment Received: Patient has never received a diagnosis despite numerous visits to the doctor. She has been prescribed diuretics and

physiotherapy in the past with no noticeable improvements. It was suggested to the patient that surgery to the wrist was needed but she did not go

ahead with this surgery.

Lymphedema Diagnosis: Patient reports the first signs of swelling sometime in 2013. Heaviness in the left arm, inability to wear fitted sleeves. At the time

of meeting this patient (16 Oct 2014) she shows symptoms consistent with Stage 2 Lymphedema. Patient has up to a 7cm difference in arm circumference

on the forearm and a 1cm difference in arm circumference on the upper arm. The forearm and elbow are the worst affected areas with the onset of

fibrosis.

Impact on Quality of Life: Cellulitis infection – last episode December 2014. Diminished use of the arm. Ill-fitting clothes, fatigue in the affected arm due

to heaviness. Disturbed sleep. Embarrassment at comments and attention about her arm in public.

Notes: While there is no doubt that the mastectomy (left breast) and subsequent radiation therapy are the cause of the damage to the lymphatic system

in the affected area and where there is no suggestion that the hysterectomy is the cause of the lymphedema, it should be noted that the onset of symptoms

coincides with the hysterectomy. It would be wise to consider possible trigger factors such as blood pressure cuffs, venipuncture and IV administration to

the left arm at this time.

Suggested Treatment: Complete Decongestive Therapy

Skin and Nail Care

Manual Lymph Drainage

Compression Bandaging

Compression Garments

Materials and Resources: Therapist hours, treatment rooms, foam padding, stockinette, wool pad, finger wraps, short stretch bandages 6cm x 2 8cm x 6

10cm x 2, E45 Lotion, compression sleeve, compression glove including fingers

Treatment Summary

1. Preliminary CDT Appointment (90 min) – a detailed

medical history is taken. The condition and the treatment

are explained in detail to the patient. Measurements of

both arms are taken as well as the patient’s height and

weight. It is ascertained at this time whether the patient

has support at home and what resources they have access

to. It is important that the patient have at least 1 family

member or support person on hand and that they are able

to attend the clinic daily for the duration of the intensive

phase. A doctor’s appointment is set up for medical

clearance.

2. Medical Clearance (Dr Piat, Westcare Health Centre) –

Clearance form attached.

Patient was found to have an inflammed lower

costocondral joint. Anti-inflammatory and pain

medication given.

Treatment delayed until x-ray showed no serious injury

and CDT can go ahead

Intensive Phase

Day 1: 2 February 2015 – total treatment time 2h10min

10 minutes skin care

30 minutes MLD – Short neck, rhs axilla prep, lhs inguinal prep, 10 x

diaphragmatic breathing (no MLD to deep abdominal nodes due to

risk factors following abdominal surgery). Anterior interaxillary

anastomoses crossing the midsagittal watershed. Left axillo-inguinal

anastomoses crossing the transverse watershed. Posterior

interaxillary anastomoses crossing the midsagittal watershed.

Drainage of the affected arm is away from the axilla.

60 minutes – cutting foam to size and application of short stretch

compression bandages from fingertips to axilla.

30 minutes – handover of home care instructions and exercise

program (See attached)

Patient showed dismay at the size of the bandaging but otherwise

positive.

Day 2: 3 February 2015 – total treatment time 1h10

Patient tolerated the compression. Bandages stayed in

place. Reduction of up to 2cm in circumference in the

forearm. 1 – 0.5cm reduction in the upper arm.

10 min – bandage removal and skin check

30 min – MLD (as per day 1)

10 min – wash and lotion

20 min – bandage application. Slight increase in

compression.

Patients husband attended and watched bandage

application.


Patient tolerated the increased compression. Bandages

stayed in place. Further 2cm reduction in circumference in

the forearm and the 10cm mark. Slight increase in

circumference on the upper arm. Increased compression

needed on the upper arm.


10 min – bandage care and wash instruction

30 min – MLD


10 min – finger wrap instruction for patient

20 min – bandage application. Maintained compression on

the forearm, increase in compression on the upper arm.

.


Plateau on the wrist measurement. Further 1 cm reduction

at the 20cm mark. 1 cm reduction on the upper arm with

the increased compression. Measurement at the line of the

axilla is stable and equal to the right arm.


30 min - MLD


10 min – finger wrap/foam instruction for patient

20 min – bandage application. Maintained compression on

the forearm, increase in compression on the upper arm.


Plateau on the wrist measurement. Further 1 cm reduction

at the 5cm mark. Plateau at the 10cm mark. Plateau on

the upper arm measurements and elbow. . Measurement

at the line of the axilla is stable and equal to the right arm.

Skin irritation and itching around the elbow crease. Patient

reports joint pain in the elbow. Possible inflammation due

to altered use of the arm in bandages.


30 min - MLD


5min - garment fit.

10 min – recut of foam pieces

20 min – bandage application. Maintained compression

as per day 4.


Plateau on all measurement points. Intensive phase complete.


30 min - MLD


10 min - garment donning.

10 min – Jovipac night garment fitting and discussion.

Patient will spend 2 days in the donated flat knit compression sleeve

and glove by day and the Jovipac garment at night. We will measure

again on Monday and assess the success of the garment.

Measure cm

Patient Case Study

Follow Up Measurements

Date Weight 75.3kg Date Date Date Date Date Date

07-Jan-15

Extremity left / UE 02 February

2015

03 February 2015

04 February

2015

05 February 2015

06 February

2015

07 February 2015

RIGHT LEFT LEFT LEFT LEFT LEFT LEFT LEFT

HAND 21 22 19.5 19 19.3 19 19

WRIST 17.5 20 18.5 18 18 18 18 17.7

5CM 21.4 20.3 20.5

10CM 20 27 26 24 22.7 23.7 23.5 23.4

15CM 27.5 26

20CM 26.5 32 30.5 30 29.3 28.5 29 29.2

Elbow 26 30.5 29 28.5 30 29.5 29.5 29.7

5CM 31 31

10CM 32 33.5 32.5 32 32.5 31.5 31.5 31.5

15CM 33 34

AXILLA 37.5 37.5 37 36 38 37 37 37

Extremity Before CDT After CDT Reduction

RIGHT ARM Unaffected

LEFT ARM Affected LEFT

HAND 21 22 19 2cm

WRIST 17.5 20 17.7 2.3cm

5CM 20.5

10CM 20 27 23.4 3.6cm

15CM 26

20CM 26.5 32 29.2 2.8cm

Elbow 26 30.5 29.7 0.8cm

5CM 31

10CM 32 33.5 31.5 2cm

15CM 34

AXILLA 37.5 37.5 37 0.5cm

Maintenance Phase: In the following week the patient and her husband will be taught the bandaging technique for night-time application. This gives

the best control of swelling and maintenance of the reduction during the intensive treatment. Without adequate night time compression the patient will

be unable to don their day-time compression sleeve and glove. The patient has been fitted with a donated flat knit arm sleeve and glove.

Measurements over the next week will allow us to assess if the grade of garment is correct. If the arm is swelling during the day, we will have to measure

and reorder a garment with a higher grade so as to achieve maintenance of the limb. Should the garment work well, we will re-order same so that the

patient has 2 sets of garments. One needs to be clean and dry at all times.

The patient cannot be without a garment or a compression sleeve/bandages at any time. The arm will begin to fill up with protein rich fluid.

The patient will be taught self MLD techniques and encouraged to keep up the exercise routine and a healthy eating plan.

Conclusion: A 68% reduction in swelling represents a significant improvement in the aesthetics of the arm. Skin care practice and MLD lower the risk of

cellulitis and erysipelas infection. Compliance with treatment will halt the progression of lymphedema meaning that this patient will never progress to

stage 3 with its associated medical costs and complications.

Follow up:

A very important part of CDT is the patient’s ability to transition from Intensive Phase to Maintenance Phase at home. It can take up to 6 months for the

patient to learn, through trial and error, how to bandage correctly and gain control over the swelling.

A follow up appointment for the case study patient was set for 17 February 2015, 10 days after handover to maintenance phase. Despite initial resistance

to self-bandaging, she has, with the help of her daughter, managed to bandage the arm and maintain good reduction. A 1cm increase in the

circumference of arm is noted but this is normal and expected. I have instructed her to bandage the arm for a 24 hr period at home and to increase the

compression slightly so that she can regain full reduction.

The patient is managing well with the donning and doffing of her compression garments. She continues to do her remedial exercises and is in good

spirits.

The next follow up appointment will be in 4 weeks.

After 10 days of self-care at home – Maintenance Phase

Acknowledgements and permission:

1. Some factual information contained in this case study is obtained from the website of The Norton School of Lymphatic Therapy, the school

though which N.Pearce received her training. For more information on lymphedema and training see www.nortonschool.com

2. Permission for the use of photographs is provided by the patient. I would hereby like to express my thanks to the patient for this privilege.

http://www.nortonschool.com/

Pilot Case Study in Mauritius for the Treatment of Lymphedema using Complete Decongestive Therapy

Documents

Transcript of Pilot Case Study in Mauritius for the Treatment of Lymphedema using Complete Decongestive Therapy