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“Stage III Lymphedema Treatment Using Physical Therapy in Conjunction with the Flexitouch System®”
Author: Julie Fulton, PT, CLT–LANA
Introduction: Every patient with lymphedema brings unique needs and challenges for the lymphedema therapist when planning the course of treatment. Long–standing and severe stage III lymphedema is difficult to treat even with in–clinic Complete Decongestive Therapy (CDT) due to distinctive intractable fibrosis and the excessive contours and depth of skin folds, which can impede optimal bandage techniques and/or consume limited in–clinic treatment time, even for seasoned therapists. Flexible, creative and adaptive multi–modal techniques for use in clinic, as well as at home, are essential to overcome the challenges these patients present to therapists.
This case study illustrates the multitude of challenges in treating an overwhelmed and busy patient with severe stage III lymphedema, including massive localized lymphedema (MLL), which is complicated by obesity. After years of repeated in–clinic CDT with recurrent exacerbations and marginally successful reductions, the all–too–common scenario of patient denial of the condition’s severity resulted in repeated inconsistent compliance with home treatment regimens. The patient’s dire need for aggressive treatment led this physical therapist to the hard–line recommendation of a 3–month medical leave of absence from her full–time job, to focus on and regain control of her health and to incite the life–long commitment necessary to manage her lymphedema.
Medical History: The patient is a 39 year old female with past medical history of hypothyroidism and obesity, who was diagnosed with left lower extremity lymphedema in 2003. The etiology of her lymphedema is not known. Patient states, in retrospect, that she remembers a time as a teenager when she was attempting to don ski boots and her left boot would not close like the right one did. Otherwise, she admits to not noticing the edema until 1995, when after a left ankle sprain, the acute edema did not subside. The patient has not undergone lymphoscintigraphy, however, to assist in determining whether the lymphedema is primary or secondary.
The patient has received multiple series of CDT, initially in 2003, and then again each year from 2007–2010. The patient works in a lab, where she rotates every other month between two different positions. One month her duties allow multiple opportunities to walk around during the day; the next month her duties require her to sit at a desk where she remains stationary up to four hours at a time, with very limited opportunity for ambulation. She reports that her leg feels heavier and throbs more when she must sit for her desk position. She has tried elevating her leg on a foot stool but she did not find it beneficial or practical while at work.
Over the years she has tried to manage her lymphedema with custom waist–high 20–30 mm Hg JOBST Elvarex® compression garments; and/or a CircAid® garment up to the calf, layered with pantyhose style compression and inconsistent use of advanced pneumatic compression. Although she obtained a Flexitouch system® in 2007 for use as part of a comprehensive home treatment program, she did not use it as consistently as directed. Essentially, she was in denial regarding the severity of her condition and therefore, never fully committed to a long–term home treatment program. Despite the lack of commitment, the combination of these modalities managed her edema marginally until she took a cruise in hot weather, which caused a significant exacerbation in swelling. Her edema became unmanageable and her custom compression garments and Flexitouch garments would no longer fit. Her weight and leg girth continued to increase and her treatment efforts waned due to decreased activity from plantar fasciitis and low back pain. Remarkably, the patient has had no incidence of cellulitic infection despite the severity of her lymphedema. At times, she has experienced recurrent, dime–sized weeping wounds throughout her calf, especially medially.
In 2009 and 2010, the additional series of CDT were marginally successful, however the reductions in girth were temporary despite trials of 30–40 mm Hg layered knee–high and capri style compression garments, FarrowWraps®, and a nighttime Jovi® foam compression garment. Any reductions obtained with compression were quickly diminished when the patient removed her garments to shower, as her leg quickly refilled with lymphatic fluid. The patient became overwhelmed with her condition. In addition, time management was an issue due to the demands of her employment and her important and meaningful commitment as a foster parent.
Clinical Presentation:
In March 2011, the patient presented for physical therapy evaluation with severe stage III elephantiasis (Figures 1a and 1b). Her major complaints were that her left medial ankle, an area of MLL (i.e. large lobule), dragged on the floor and she could no longer wear pants.
range of motion and impaired activities of daily living (ADLs). She had macerated skin in the crease of the ankle and chronic erythema. She exhibited gait abnormalities and difficulties with walking, bending her knee and kneeling. The severity of her condition was also taking its toll on her psychologically, resulting in poor body image and some social isolation.
Based on limb volume calculations, her left lower extremity volume was 130% (25775 ml) greater than her right leg volume (11162 ml). She experienced significant fibrosis and pain, limb heaviness, skin sensitivity, fatigue, reduced
Upon evaluation, she was advised to take 3 months off from work and fully commit to the in–clinic treatment and home regimen components if she wanted CDT treatment to be successful. She agreed to take a medical leave of absence from work beginning in June.
Figure 1a: Pre–treatment (anterior) March 2011
Figure 1b: Pre–treatment (posterior) March 2011
In preparation for intensive CDT, she received additional waist and leg extenders for her previously obtained Flexitouch system advanced pneumatic device. She was instructed to use her Flexitouch system 1–2 times per day in conjunction with compression bandaging, exercise, elevation, and skin care. She committed to this treatment regimen.
Treatment Intervention: She returned for intensive in–clinic CDT treatment in June. Her left limb volume had increased an additional 12% since initial evaluation in March. Her left lower extremity volume (27042 ml) was 142% greater than the right limb. She was seen for physical therapy 3x/week for 75–90 minute sessions which included compression bandaging, skin care, and patient education. The patient’s specific goals were to reduce the size of the ankle so it no longer dragged on the floor and to be able to wear pants again. Manual lymph drainage (MLD) was not completed in–clinic due to the increased time required to bandage her appropriately. Since the patient declined to be bandaged up to the hip due to hygiene issues, she was bandaged up to the knee with fibrosis reduction as the initial focus. She was instructed to use the Flexitouch system at home 1–2 times per day on the L3 setting (45 minute treatment program) which provides targeted proximal treatment to the trunk and thigh areas and therefore did not require her to remove her bandages for treatment. She also began working with a personal trainer at a gym two times per week.
Compression bandaging consisted of gray foam and multiple chip bags placed into the creases of the MLL, held in place by Velfoam® straps that fastened with Velcro® to other straps around the calf to hold the lobule up and protect it from dragging on the ground. This technique also increased the amount of surface area receiving direct compression. Artiflex®, Comprilan®, and Isoband® were also used. Her foot was not bandaged due to relative non–involvement and the patient’s desire to wear shoes.
By the end of July, patient progress was beginning to plateau. In early August, bandaging was completed with her leg inverted (up towards ceiling). This technique allowed the lobule to be bandaged more easily, with gravity assisting, and progress in reducing the fibrosis and volume quickly resumed.
Clinical Outcomes: Table 1 illustrates the marked limb volume reduction the patient experienced over time. As her leg reduced, she was able to eliminate the need for Flexitouch garment waist and leg extenders one–by–one. This gave the patient extra incentive and motivation to be compliant with her home program. On 8/9/11, she was able to complete the full left lower extremity Flexitouch treatment with no extenders needed in the calf, the area of MLL and most vulnerable part of her leg. This proved to be a significant mental and physical milestone for the patient. She transitioned from using the L3 program on her trunk and thigh only with bandages on from the knee down, to the L1 setting for full leg treatment (toe to trunk) with bandages off. She would time the removal of her bandages to enable time to shower and use the Flexitouch system prior to her PT appointment. By 11/15/11, the left lower extremity edema volume reduced by 73% (11516 ml) from initiation of treatment.
Table 1: Limb Volume Over Time
Figure 2a: Post–treatment (anterior) November 2011
Figure 2b: Post–treatment (posterior) November 2011
| Girth Measurements (cm) | 3/16/11 | 6/6/11 | 11/15/11 |
|---|---|---|---|
| Mid–thigh | 93.0 | 89.5 | 83.2 |
| Upper–Calf | 87.8 | 93.4 | 57.5 |
| Mid–Calf | 89.8 | 94.8 | 50.5 |
| Ankle (including MLL lobule) | 75.9 | 74.0 | 32.5 |
After 6 months of treatment, she no longer had macerated skin in the crease of her ankle which greatly reduces her risk of cellulitic infection. The fibrosis had also softened throughout her leg with decreased chronic erythema.
The patient has lost over 50 lbs since the initiation of treatment, most of which is due to the decrease in lymphatic fluid in the left lower extremity, in combination with increased activity and exercise as a result of improved mobility. She reports much less difficulty with ADLs and walks with fewer gait abnormalities. From the patient’s perspective, the treatment progress has “exceeded my expectations this time around”. Her ankle no longer drags on the ground and the skin is no longer tight or weeping. She feels like she has more freedom and maneuverability. Although she can now fit into a pair of dress pants, her final goal is to be able to wear jeans. She is much less self–conscious and feels that people no longer stare at her leg.
Conclusion: Although the original plan was for the patient to return to work in September after a 3 month medical leave, she was placed on activity restrictions by her physician due to the results of her physical capacity evaluation. The doctor eventually lessened the activity restrictions to: sitting or standing 2 ½ hours at a time/5 hours maximum during her 10–hour shift, with the recommendation to walk or alternate between sitting/standing positions and complete leg exercises during her shift. She also obtained 2 work station assessments, with accommodations made to the height of her chair as well as the addition of a stool to allow for comfortable elevation of her leg during work hours.
Initially she had difficulty with her new compression garment fitting properly because it tended to ride up into the crease at her medial ankle. Two garment adjustments were made until it fit correctly. She now wears custom one–legged JOBST Elvarex pantyhose with CCL 4 Super at foot/lower leg, and CCL 3 at thigh/waist, layered with a custom lower leg Farrow Wrap.
Upon her return to work, she found it challenging to maintain the reduction achieved during PT due to the extended sitting and standing required by her job, despite the modifications to her work setting. She now makes it a priority to elevate her leg during her morning and afternoon breaks, as well as at lunch time. She continues to use the Flexitouch system every evening for one hour on the L1 treatment program. She continues to see PT for monthly follow–up to ensure a smooth transition to self–care. The patient now clearly understands that treating her lymphedema is a life–long commitment that she must incorporate into her daily routine. Patient and therapist are both pleased with the progress that was made. They both remain optimistic that with continued compliance with her home regimen, which includes, daily compression garment wear, standing leg exercises at work, exercise in a gym 2–3x/week and daily Flexitouch treatment, her lymphedema will continue to improve.