January/February 2006

Lymphedema Management

By Heather D. Oja, MS, OTR, CLT, and Heidi S. Janz, MS, OTR, CLT

Measuring the success of a lymphedema treatment program in an outpatient setting.

Lymphedema is a chronic condition that has been often ignored. If untreated, it can lead to disfigurement, immobilization, and severe infections. The International Society of Lymphology defines lymphedema as “an abnormal collection of excessive tissue proteins, edema, chronic inflammation and fibrosis.”¹ Certified lymphedema therapists instituted an outpatient program to combat this condition. This article highlights a study completed to examine the effectiveness of a four-part lymphedema treatment program.

Two certified lymphedema therapists (also registered occupational therapists) practice lymphedema therapy at War Memorial Hospital, Sault Sainte Marie, Mich, and experience success in reducing lymphedema symptoms. The therapists are certified in lymphedema treatment by Cedar Haven Rehabilitation Agency in West Bend, Wis. The protocol uses a four-step program including manual lymphatic drainage, medical compression bandaging, exercise, and skin care instruction.² Manual lymphatic drainage is a specialized gentle manipulation that stimulates lymph flow from an area of congestion to a healthy lymphatic area by applying a light pressure and stretch to the tissues.³ Medical compression bandaging is a multilayer wrapping technique of the limb using low stretch bandages. They provide resistance to the pressure exerted on the tissue during the movement of muscles, which assists in the reuptake of congested lymph.⁴ They are applied with greater pressure at the distal end of the limb.

This is achieved by the number of layers and overlap of bandages versus tightly wrapping them. The exercise component of the program involves active range of motion and/or light resistive exercises to facilitate a muscle pump to further push the fluid out of the involved area. The therapists also instruct the patients in proper skin care to promote optimal healing of the skin and tissues.² Overall treatment goals include: decreased limb circumference, improved tissue texture for proper healing,

A certified lymphedema therapist applies compression bandaging to an affected arm.

From these professional experiences and a literature review, the therapists conducted a study to assess the effectiveness of the four-part lymphedema treatment program in an outpatient setting. The therapists also completed this study as a requirement for the master’s degree program in occupational therapy for Western Michigan University. The Human Subjects Institutional Review Board of Western Michigan University approved this study. War Memorial Hospital’s HIPAA privacy officer assured this study had met HIPAA regulations.

The researchers measured success of the program using the following variables: circumferential measurements of limb girth, variations in tissue texture, and changes in patients’ self-perceived level of function. The researchers have found that upon initial evaluation, the tissue of the affected limb(s) often demonstrates a hardened/fibrotic feel. Sometimes, the skin may leak lymph fluid, which is termed “lymphorrhea” or “weeping.”⁵ As treatment progresses, the weeping subsides. The tissue texture changes from hardened to spongy and ultimately to a normal/pliable feel. As the tissue softens and girth decreases, the patients usually report increased ease in functional activities. To examine these variables, the researchers used a pilot study with a multiple single subject design using three participants.

Upon referral from a physician, three subjects were recruited based on diagnosis of secondary lymphedema and willingness to participate in the study. Secondary lymphedema is caused by damage to the lymph system, which results in a permanent blockage of fluid from an area. This damage can occur as a result of surgery for cancer, metastatic carcinoma, radiation therapy, trauma or burn, infection, paralysis, chronic venous insufficiency, or lipolymphedema.⁵ The three subjects for this study suffered from lower extremity lymphedema caused mainly by chronic venous insufficiency and trauma to the limb(s). Participants were treated for 1-hour sessions, 3 days per week, for 4 weeks. A certified lymphedema therapist collected measurement data upon initial evaluation, 2 weeks into treatment, and after 4 weeks of treatment. Using a standard procedure developed by Cedar Haven Rehabilitation Agency, the therapist measured and recorded limb girth circumferentially with a tape measure and following anatomical landmarks. Using a one- to two-word qualifier, the therapist noted the texture and quality of the palpated and observed tissue. Descriptive words included: weeping, hardened/fibrotic, reddened, spongy, and normal/pliable. At the second and fourth week of treatment, the therapist conducted a brief interview to assess participants’ self-perceived function and how treatment has impacted their ability to perform tasks. The interview consisted of the following three questions:

1. Do you feel you have increased or decreased function in the last 2 weeks? Or has it remained the same?

2. What are you able to do now that you were unable to do before?

3. What functions have you lost if you are doing worse?

For this descriptive multiple single case study design, data sets for each indicator of girth measurement are plotted on a graph to denote changes in limb girth (see Figure 1). Tables portray the changes in tissue texture and changes in participants’ perception of function (see Tables 1 and 2). The data for each participant was examined to determine effectiveness of the treatment. This was a descriptive pilot study of program outcomes with only three subjects; therefore, no further statistical analysis was necessary or applicable.

The program proved successful in decreasing girth of the affected extremities. After 4 weeks of treatment, subject one lost a total of 44.6 cm, which calculated to a 9.8% reduction. Subject two reduced 28.6 total cm, which measured a 4% reduction overall. Subject three experienced a loss of 64 cm, or a 12.3% reduction, after 4 weeks of treatment.

In respect to tissue texture changes, the tissue for subject one changed from a reddened color and spongy feel upon initial evaluation to a normal/pliable feel at the end of 4 weeks of treatment. The reddened color of the skin was still apparent at this 4-week period. This is called a “hemosiderin stain,” which denotes a reddish/brown discoloration of the skin due to leakage of red blood cells into the interstitium,

Certified lymphedema therapist applies medical compression bandaging to a patient’s affected leg.

In summary, the subjects demonstrated decreased limb girth, improved tissue texture, and increased function. Based on these positive and measurable outcomes, the lymphedema program practiced at War Memorial Hospital appears to be effective. Limitations to this study are apparent. Since it is a pilot study, it could be used as a basis for further research and a larger study. Using more subjects would allow for increased generalization to a larger population. Additional variables could also be considered, such as range of motion of the affected limb(s) and pain level. Other studies that address the effectiveness of compression bandaging alone versus manual lymphatic drainage with compression bandaging would also be valuable.

Heather D. Oja, MS, OTR, CLT, is a staff occupational therapist at War Memorial Hospital in Sault Sainte Marie, Mich, and a certified lymphedema therapist. Heidi S. Janz, MS, OTR, CLT, is a staff occupational therapist at War Memorial Hospital, and a lymphedema therapist. Both also treat patients in outpatient and home health care settings. Janz can be reached via e-mail at .

References

1. International Society of Lymphology Executive Committee. The diagnosis and treatment of peripheral lymphedema. Lymphology. 2003;36:84-91.
2. Artzberger S, Schrauth R. Comprehensive Lymphedema and Venous Edema Management Certification Course. West Bend, Wis: Cedar Haven Rehabilitation Agency; 2004.
3. McNeely ML, Magee DJ, Lees AW, Bagnall KM, Haykowsky M, Hanson J. The addition of manual lymph drainage to compression therapy for breast cancer related lymphedema: a randomized controlled trial. Breast Cancer Res Treat. 2004;86:95-106.
4. Casley-Smith JR, Boris M, Weindorf S, Lasinski B. Treatment for lymphedema of the arm—the Casley-Smith Method. Cancer. 1998;83:12:2843-2860.
5. Chikly B. Silent Waves: Theory and Practice of Lymph Drainage Therapy. Rev ed. Scottsdale, Ariz: International Health & Healing Inc Publishing; 2001:177-194.

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