Background and Purpose. This case report describes the physical therapist examination, evaluation, and intervention for a patient with bilateral lower-extremity lymphedema who received complete decongestive physical therapy 2 days per week instead of the recommended daily frequency. Case Description. The patient was a 55-year-old woman who developed bilateral lower-extremity grade II lymphedema 3 years after surgery and radiation for cervical cancer. She had impairments in hip and knee flexion range of motion and functional limitations in transfers, gait, and activities of daily living. Intervention. A twice-weekly intervention program was implemented consisting of education in skin care, manual lymph techniques, compression, and exercise. Outcomes. Outcomes related to the lymphedema were measured using the sum of the circumference of each limb. At discharge, the patient had reductions in lymphedema of 9% for the left lower extremity and 10% for the right lower extremity. Her hip flexion range of motion increased from 95 degrees to 110 degrees, and her knee flexion range of motion increased from 95 degrees to 130 degrees. She had resumed all premorbid activities and was independent in self-management. Discussion. Twice-weekly management of lymphedema using a program of skin care, manual lymph techniques, compression, and exercise was followed by reduction of the impairments and functional limitations in a patient with bilateral lower-extremity lymphedema. [Holtgrefe KM. Twice-weekly complete decongestive physical therapy in the management of secondary lymphedema of the lower extremities. Phys Ther. 2006;86:1128-1136.]

Key Words: Compression, Intervention, Lymphedema

Lymphedema is an accumulation of protein fluid in the interstitial spaces that leads to swelling, decreased mobility, and increased risk of infection. The lymphedema may be primary, due to a genetic anomaly of the lymphatic system, or secondary, due to removal of lymph nodes and management with radiation. 1-3 The incidence of developing lower-extremity lymphedema following intervention for cervical cancer has been reported to be as high as 42%. 4,5 The risk increases if intervention included lymph node removal and radiation of the lower abdominal area. 5 Ryan et al6 surveyed women who developed lowerlimb lymphedema following gynecologic cancer and reported that the increase in the size of the legs created several problems: aching and pain in the legs, decreased ability to walk and participate in social activities, and decreased functional activities. The women who did the best were those who received comprehensive intervention consisting of education, skin care, lymphatic massage, bandaging and compression garments, and exercise for lymphedema.

The intervention for lymphedema--complete decongestive physical therapy (CDP)--consists of 4 main components: meticulous skin care, manual lymph drainage, compression (multilayer bandaging [MLB], vasopneumatic compression, or compression garments), and exercise. 7-11 Although most of the research related to intervention for lymphedema has focused on upper-extremity problems following breast cancer, 9-13 many studies 13-17 have addressed the effectiveness of CDP for both upper- and lower-extremity lymphedema. Ko and colleagues 16 prospectively examined 299 individuals treated for either upper-extremity lymphedema (n=149) or lower-extremity lymphedema (n=150). They reported that daily treatment received for an average of 15.7 days resulted in decreases of 59.1%±8.2% (±SD) for individuals with upper-extremity lymphedema and 67.7%±6.7% for those with lower-extremity lymphedema.

Similar results were reported by Boris and colleagues 17 and Liao et al. 18 Boris and colleagues17 examined 38 patients with either upper- or lower-extremity lymphedema (16 patients with upper-extremity lymphedema, 18 patients with unilateral lower-extremity lymphedema, and 4 patients with bilateral lower-extremity [BLE] involvement). Comprehensive intervention, consisting of skin care, manual lymph massage, MLB, and exercise, was received daily for 30 days and was reported to take approximately 4 hours per day to complete. The patients with upper-extremity lymphedema had an average reduction in their lymphedema of 73%, and those with unilateral lower-extremity lymphedema averaged an 88% reduction. Liao et al 18 examined 30 women with either unilateral upper-extremity lymphedema (n=18) or unilateral lower-extremity lymphedema (n=12). Complete decongestive physical therapy was performed consecutively for 4 to 21 days (average length of intervention=13.13±4.68 days). Average reduction in volume following intervention was 67.8%±33.2% for the upper extremity and 68.1%±35.9% for the lower extremity.

As noted above, the majority of research regarding intervention with CDP recommends that intervention be performed daily for up to 4 weeks. Only one study by Matthews and Smith 19 compared daily intervention with less frequent intervention. Five patients received full intervention consisting of manual lymph drainage and MLB 5 days per week for 4 weeks. Nineteen patients participated in a modified program consisting of intervention 2 days per week. The intervention included manual lymph drainage and temporary compression garments. Both groups had a reduction in lymphedema, but no difference was found between the 2 groups. With limited research supporting less frequent intervention, the purpose of this report is to describe management of BLE lymphedema secondary to cervical cancer and radiation in a patient who received CDP 2 days per week for 71/2 weeks.

Case Description

Patient History

The patient was a 55-year-old woman who was referred for physical therapy with a diagnosis of "lymphedema of the legs." Her prescription was for evaluation and intervention. The patient reported that she was diagnosed with cervical cancer 3 years previously and underwent a total abdominal hysterectomy that included lymph node removal. She subsequently had radiation treatment. Three years after surgery, she noticed progressive swelling in both lower extremities and sought medical attention from her gynecologist, who referred her to a general surgeon. The surgeon, following a recommendation from a nurse in the oncology department, referred her to the lymphedema program at our facility.

Examination

The following examination findings were obtained during the patient's first visit for physical therapy.

Past medical history. The patient's medical history included hypertension, arthritis, and right lower-extremity fractures sustained in a motor vehicle accident 15 years previously that required open reduction and internal fixation at the right ankle and right femur. The only medications that she was taking on a regular basis were Fosamax* (once daily for osteoporosis) and Motrin† (800 mg, 3 times a day for arthritis).

Observation/gait analysis. The patient had to use both upper extremities and armrests to assist with rising from a chair and needed to rock 3 or 4 times prior to standing due to limitations in her ability to flex her knees. She did not use any assistive device, but she reported that her gait speed was slow.

Pain intensity level. A 10-cm visual analog scale (VAS) 20 was used, and the patient marked her BLE pain level at rest (2.9 cm) and with activity (4.9 cm). The left side (or 0 cm) of the 10-cm line was described as "no pain" and the right side (10 cm) was described as "severe pain." She stated that both of her legs ached all of the time.

Integumentary. Lymphedema may be classified as grade I or II. 1 If the lymphedema pits on pressure and can be reduced with elevation, it is classified as grade I; if it is hard and nonpitting (fibrotic), it is classified as grade II. Visual inspection of the skin of her lower extremities indicated grade II lymphedema bilaterally. The patient reported the color in both lower extremities was darker than her regular skin pigmentation. There were no open areas, drainage, or signs of infection. The patient had well-healed incisions on the right anterior knee, right lateral ankle, and abdomen (vertical incision).

Range of motion of the lower extremities. Active range of motion (AROM) was measured following the protocol described by Norkin and White. 21 Each measurement was repeated 3 times and averaged. Bilateral hip AROM was 0 degrees of extension to 95 degrees of flexion, bilateral knee AROM was 0 degrees of extension to 95 degrees of flexion, and bilateral ankle AROM was normal.

Girth measurements. Girth measurements were taken using a plastic tape measure. 22 Six levels were marked with a pen, and 3 circumferential measurements were taken at each level and averaged (Tab. 1). The figure-of-eight method was used for measuring the ankle because this method was found by Mawdsley et al 23 and Tatro-Adams et al24 to yield reliable measurements (intraclass correlation coefficients=.99 in both studies) and valid measurements (criterion validity, Pearson product moment correlation=.88-.92 compared with volumetric measurements 23). Edema volume can be determined using the truncated cone method as reported in multiple studies, 10,11,25,26 but this method was not used with this patient.

Cardiopulmonary. A baseline blood pressure (BP) measurement was taken as described by McArdle et al 27 because of the patient's history of hypertension. Her initial BP value was 134/82.

Functional activities. The patient reported general fatigue that limited her ability to walk other than inside her home. She was unable to go shopping or walk for exercise. She was unable to wear pants because of the size of her legs, and she was unable to garden due to limited motion in her lower extremities. She thought she was going to have to spend the rest of her life in dresses, not able to leave the house.

Evaluation, Diagnosis, Prognosis, and Plan of Care

Evaluation. The patient had grade II secondary lymphedema following lymph node removal and radiation of the lower abdominal area limiting mobility in BLEs. This impairment in AROM affected her functional activities. She had difficulties with transfers, locomotion, and activities of daily living (unable to put on or wear pants, unable to walk community distances or garden).

Diagnosis. Following the Guide to Physical Therapist Practice, 28 the patient's Preferred Physical Therapist Practice Pattern was 6H: "Impaired Circulation and Anthropometric Dimensions Associated With Lymphatic System Disorders."

Prognosis. The patient was referred for therapy within 3 months of her initial onset of lymphedema. A longer course of therapy, 2 to 3 months compared with the standard 4 weeks, was predicted due to grade II lymphedema and the extensive involvement in the BLEs. 8,29 She appeared to be well motivated to participate and, with therapy, she was expected to attain her goals of decreasing the lymphedema, increasing mobility, and returning to her premorbid activity level.

Plan of care. Although the majority of research on the frequency of CDP recommends daily therapy, 7,9,10,14,16,30 the patient was unable to attend therapy sessions more frequently because of her fatigue and limited mobility. Therapy was scheduled for 2 days per week.

The program consisted of education in skin care and self-management of lymphedema, manual lymph techniques to decrease the fibrotic tissue and mobilize fluid to the nearest intact lymph nodes, compression (either MLB or other device), and instruction in a home exercise program that would assist with fluid removal.

Interventions

The specific description of interventions is provided in Table 2. All therapy sessions started and ended with stimulation of lymph nodes at the cervical, axillary, and femoral nodes and abdomen. 30 During the first 2 sessions of manual therapy, one lower extremity was treated at a time and the patient's BP was monitored to ensure that it did not increase above 200/110 (American College of Sports Medicine guideline for termination of exercise). 31 Treatment consisted of firm pressure (resorptive techniques) to soften the fibrotic tissue followed by light sweeping pressure to move the fluid (fluid mobilization). 8,9 The patient's BP remained stable before, during, and after both therapy sessions, with the highest increase being 138/84 (initial BP value=134/82). The patient reported no adverse affects such as dizziness, loss of balance, or headache following therapy.

During session 2 of week 2, the compression component of CDP was implemented. Compression as a component of CDP can take several forms: intermittent vasopneumatic compression (IPC), MLB, or compression hosiery. Although some studies 32-34 have shown IPC to be an effective intervention for lymphedema, Raines et al 35 reported that IPC did not reduce edema sufficiently in people with fibrotic lymphedema due to the decreased compressibility of the subcutaneous tissue. In addition, Boris et al 36 reported a risk of genital edema in 43% of patients who used IPC for lower-limb lymphedema. Based on these findings and the patient's clinical presentation of grade II lymphedema, I chose not to use IPC on this patient.

The next consideration was MLB. Multilayer bandaging, as the name implies, consists of multiple layers of short stretch bandages to help the tissue remodel and to maintain any decreased volume. 37 Johansson et al 38 compared MLB with and without manual techniques in reducing limb volume. Subjects were managed with MLB for 2 weeks and then either continued with the bandages or were managed with manual lymph drainage techniques in addition to MLB. The subjects who had a combination of MLB and manual techniques had a significant percentage of reduction compared with those who received MLB only.

A limitation of MLB is that it is a time-consuming process. Applying the layers of bandages may take more than 30 minutes per extremity, not including the time needed to reroll the bandages when removing them. The multiple layers also reduce mobility at the ankle and knee. I felt that MLB of the BLEs would have been difficult and time consuming for the patient, would decrease adherence related to compression, and would have limited her ability to drive to and from therapy sessions. Although no research has been reported on the use of nonelastic containment systems such as the LegAssistTH (thigh high)‡ (Figure) for the management of lymphedema, I anticipated that the outcome would be similar to that achieved with MLB. Both offer up to 40 mm Hg of compression and are recommended for fibrotic lymphedema. 37,39

The LegAssistTH is a custom-fit garment that is pulled onto the extremity. Circumferential Velcro straps§ are then tightened from the ankle to the proximal thigh. It takes approximately 10 minutes to put on 2 LegAssistTH garments compared with an hour for MLB. During this phase of therapy, they were worn 22 to 23 hours a day, with no problems reported by the patient.

The home program was progressed during session 1 of week 3. Exercises were done in a supine position (while wearing the LegAssistTH) with lower extremities in the air as adapted from exercises by Foldi. 40 The program consisted of deep abdominal breathing, clearance of groin nodes, AROM of hips and knees, flexion and extension of the knees, isometric hip adduction, clockwise and counterclockwise circles with both feet, ankle plantar flexion and dorsiflexion, and toe abduction, with the order of exercises then reversed and finishing with deep abdominal breathing. The abdominal breathing was done 3 to 5 times, and all other exercises were done 10 times. The physiologic rationale 7,9 for including exercise as part of the comprehensive program is that muscle contraction aids lymph flow. A tissue pressure difference is caused by the muscle contractions against other body tissue, thereby causing a pumping action of the lymph. It is believed that wearing some form of compression during the exercise further aids this process. 7,9,10,12,17

Outcomes

Final outcome measurements were taken on the patient's 15th and final visit 8 weeks after the start of physical therapy.

Observation/Gait Analysis

The patient was independent in rising from a chair without use of armrests. She reported that her walking had returned to its previous speed. She was able to walk on an indoor track as part of therapy for almost 1 mile (1.6 km).

Pain Intensity Level

After the initial manual therapy on BLEs (visit 4), the patient had no further complaints of pain or aching in the lower extremities, marking 0 cm on the 10-cm VAS.

Integumentary

Lower-extremity girth measurements were reduced bilaterally from 4.0% to 16.6% (Tab. 1). No pitting or fibrotic tissue was noted. The patient reported that her skin color was normal and matched that of her upper extremities.

Range of Motion of Lower Extremities

Hip flexion increased from 95 degrees to 110 degrees and bilateral knee flexion increased from 95 degrees to 130 degrees bilaterally.

Girth Measurements

The overall decrease in circumference ranged from 2.2 cm (right ankle malleoli and left mid-thigh) to 8.1 cm (superior pole of right patella) (Tab. 1). Matthews and Smith 19 estimated the percentage of reduction based on the sum of the circumferential measurements, as follows:

Although this method has not been validated, it does provide a different method of measuring the reduction in lymphedema, particularly when both limbs are involved. Use of this formula showed that the patient's right LE lymphedema was reduced 10% and her left lymphedema was reduced 9% (Tab. 3).

Functional Activities

At the time of discharge (15 visits across 71/2 weeks), the patient reported that she was able to don and doff pants with no difficulty and had returned to wearing her previous clothing. She was able to shop, garden, and exercise (a walking program as well as her home exercises) independently. She demonstrated independent self-management of her lymphedema and was pleased with her outcome. The patient requested to discontinue therapy and continue on her own. All therapy goals were met, so the patient was discharged with instructions to take measurements at specific areas of her lower extremities weekly to monitor her progress and to obtain compression garments from a local vendor.

Discussion

Bilateral lower-extremity lymphedema may occur following lymph node removal or radiation following cervical cancer. 4-6 The lymphedema that develops may lead to impairments in mobility and function. A program of CDP consisting of instruction in skin care, manual lymph techniques, compression, and exercise may decrease edema and subsequently improve function. The purpose of this case report was to describe the use of CDP provided twice weekly instead of daily, as recommended by most research.

Several studies related to management of lymphedema with CDP have shown that the greatest reduction in volume occurred during the first 2 weeks of therapy. 10,12,15,18 This did not occur in this case. When assessing the percentage of change in the sum of the circumferential measurements (Tab. 3), it appears that the greatest decreases in lymphedema occurred after the patient received the LegAssistTH (Figure) during visit 6, 4 weeks after starting therapy. This finding appears to support the results reported by Johansson et al 38 regarding MLB and manual techniques combined being more beneficial than manual techniques alone, even though it is not known whether the LegAssistTH works the same as MLB.

Another possible explanation for the slow reduction is the grade II lymphedema. The patient's BLE lymphedema was fibrotic. It required an extensive amount of time during the manual therapy to try and soften the tissue (60-90 minutes). It was not until visit 11 that no fibrosis was present in either leg.

A final possibility for the slow reduction in lymphedema during the first 2 weeks was the frequency of therapy being twice weekly, rather than 5 times per week as most studies have reported. 7,9,10,14,16,30 The patient may have progressed more rapidly with more frequent treatment, but was unable to attend more frequently due to fatigue and limited mobility. When comparing the subjects in the study by Matthews and Smith 19 that assessed a modified program of twice-weekly CDP, all except one subject had grade II lymphedema. As noted previously, no difference was found in the reduction of lymphedema comparing the full program (5 days per week) with the modified program (2 days per week). This finding supports the possibility that the lack of compression until visit 6 may have contributed more to the slow reduction in lymphedema in this case.

A limitation in this case was that both lower extremities were involved and thus the patient's premorbid measurements could not be ascertained. Although Ko and colleagues, 16 Boris and colleagues, 17 and Liao and colleagues18 all reported much higher percentages of change in volume in the lower extremities (67%, 85%, and 68%, respectively) overall, only Boris and colleagues presented specific volume changes for individuals with BLE involvement. When assessing these 4 individuals, the percentages of change in volume ranged from 11.9% to 29.8% in the right lower extremity and from 12.7% to 33.3% in the left lower extremity, much less than the 85% overall reduction in volume. Using the percentage of reduction of the sum of the circumferential measurements in this case (Tab. 3), the reductions of 9% and 10% were a good outcome. The patient thought that she had returned to her previous limb size based on the fit of her clothing. Future studies are needed to assess the use of nonelastic containment systems, such as the LegAssistTH, as well as more controlled studies comparing twice-weekly CDP with therapy received 5 days per week.

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Author Information

KM Holtgrefe, PT, DHS, OCS, is Instructor, Department of Health Science, College of Mount St Joseph, 5701 Delhi Rd, Cincinnati, OH 45233 (USA). Address all correspondence to Dr Holtgrefe at: karen_holtgrefe@mail.msj.edu.

Article Information

This article was submitted October 8, 2005, and was accepted February 10, 2006.

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