Healthtronix Lymphedema Treatment Center Susie Wills, BSN, RN, CLT Director of Clinical Services
PATIENT INFORMATION: Ms. E.D. is a 64 y/o female who has had a history of LE in her arm since 1981 following a minor skin injury. The onset was sudden and unexpected. Patient had not been given any warning of the possibility of getting LE or any education on how to prevent it at the time of her mastectomy and lymph node dissection. When asked how she felt about her lymphedema she stated, "I will not wear short sleeves...frustrated trying to find clothes that fit." She has also multiple episodes of cellulitis in her arm. The patient also had the history of an auto accident which left her with severe pain, sensitivity, and at times discoloration of her (L) thumb. She had never received a diagnosis for these symptoms, but had been given pain medication and an orthotic appliance.
DIAGNOSIS: Pt was diagnosed with breast cancer in 1979 and underwent a (L) modified radical mastectomy with lymph node dissection followed by chemotherapy and radiation therapy.
PREVIOUS TREATMENT: Pt. reported that in the past 18 years she has worn a compression sleeve, elevated her arm and used a single chamber compression pump to treat her lymphedema. She has also had multiple antibiotic therapies due to chronic cellulitis in her (L) arm. She reports having as many as 2 infections in her arm per month and at one time took antibiotics daily as prophylaxis. Her insurance company refused to pay for the only oral antibiotic that had been successful in treating her cellulitis adequately. She was told that to have reimbursement for the medication she had to use a less expensive antibiotics which was not as effective. The patient is on a fixed income and could not afford to pay $100 to $200 for this prescription out of pocket.
EXACERBATION: The most recent exacerbation of LE with cellulitis was treated by her family physician who then referred her to our treatment center for MLD/CDP. The patient was very skeptical and stated that she did not trust many people to treat her LE because so far, no one had really been able to help her.
OBSERVATION: On assessment, pt. did have significant edema of her (L) UE. Her edema volume chart showed 31.7% increased volume as compared to her (R) UE. The upper arm was reddish tinged, but her skin was cool. She had fibrotic areas in the medial aspect of her upper and lower arm and in the elbow area. There was no edema in her fingers or hand. Her skin was warm, dry and intact with an area of erythema in the upper arm, but no heat. The patient states that this is where her cellulitis was, but that she had completed her treatment for the infection. On her admission questionnaire, the patient was asked to rate her neurological symptoms in her arm on a scale of 0 to 10, with 0=no sensation and 10=unbearable pain or discomfort. She rated full, heavy, tired and painful as 5/10 and hard as 9/10. The physician signed a waiver stating that the patient had no acute infection or malignancy at this time.
TREATMENT: Her treatment plan consisted of MLD/CDP X 21 treatments. She was very upset when I attempted to bandage her for the first time. Even though I had explained bandaging to her when I had evaluated her and given her material to read, she seemed to have no idea how extensive the bandaging would be. She was finally convinced to at least try the bandaging for one night and see how she tolerated it. The first seven treatments, we tried many different variations to the compression bandaging. After the eighth treatment, the patient requested that we go back to the original compression bandaging which was boxer wrapping of fingers and short-stretch bandages over foam padding. She was instructed in a home maintenance program which included skin care, nutrition, exercise, compression sleeve and gauntlet and the Reid Sleeve to wear at night rather than compression bandaging.
RESULTS: Ms. E.D. was re-measured after eight MLD/CDP treatments which revealed that her edema had decreased from 31.7% to 17.1 %. This demonstrated a 46% overall reduction of the edema in her (L) UE. The patient was again measured after 14 MLD/CDP treatments and at that time she had 10.1% edema which was an overall reduction of 68% of the edema in her (L) arm. MLD/CDP was continued X7 treatments and at that time the patient was again measured for volumetrics. The edema volume chart revealed that the patient had an 82.3% reduction of the edema in her affected arm leaving only 5.6% edema in the affected arm as compared to the unaffected arm. The (L) arm was soft and the reddish discoloration in the upper arm had disappeared. As an added benefit, the patient states that she no longer has pain in her thumb at time of discharge and does not have to take pain pills. Although no diagnosis was ever given by a physician, the patient's injury and symptoms certainly coincided with those of RSD.
HOME PROGRAM: The patient was given written detailed instruction for her self-care to maintain and continue the reduction in her arm. She is to start her day with skin care and apply her compression sleeve. At bedtime, she is to perform her skin care and apply her Reid Sleeve in-lieu of bandaging. She was instructed to perform her breathing and arm exercises 4-5X/week and self-massage at least 3X/week. The patient has joined the NLN and attends a monthly LE Awareness group. FOLLOW-UP: The patient had battled LE and infections in her arm for so many years, her anxiety regarding ending her intensive treatment was obviously great. To help her gain self-confidence and allow her to ease into her home maintenance program, we obtained orders for weekly follow-up visits X4 and then 1-2 visits/month PRN for any problems. The patient did come in for her 4 follow-up treatments, but has not yet needed to utilize her PRN visits.
UPDATES ON PATIENT E.D.
10/06/99 Patient was in the clinic today to purchase a new compression sleeve. She is continuing to maintain her reduction with her home maintenance program and proudly announced that she has not had cellulitis for 8 months (since she began MLD/CDP). This is the longest she has been without infection in 18 years. She is also a very active member of her awareness group and participates on the internet with other lymphedema patients. She states that she does have some pain in her (L) thumb again, but not as severe as before her MLDT and is able to manage it.
10/12/99 Pt. was in the clinic today to sign a release for this case study. We re-measured her affected arm. While some of her edema has returned in the elbow area, she continues to have minimal neurological symptoms. She was asked to complete a questionnaire describing how her arm feels today on a scale of 0 to 10 with 0=no sensation and 10=unbearable discomfort. Pt. marked all sensations as 0 except for full and heavy and she rated both of those as a 2. When asked today how she feels about her lymphedema she stated, "It is a never ending battle; but with treatment I have a new perspective of it and feel it is now manageable. It gives you a better quality of life feeling."