Lymphoedema - palliative physiotherapy

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Lymphoedema - palliative physiotherapy

Contents

Quality of life
Complex Physical Therapy
Massage
Compression bandages
Special exercises
Patient education
Summary

Quality of life

Physiotherapy in palliative care is orientated to achieve the optimum quality of life as perceived by the patient. It aims to facilitate the patient's ability to function with safety and independence in the face of diminishing resources. Traditional physiotherapy treatments need to be modified to accommodate the changing needs of the patient.

Lymphoedema occurs when the lymphatic system is damaged or blocked. Protein continues to enter the tissues from the blood capillaries in the normal way and a build up occurs in the tissues the lymphatics should be draining. The accumulation of protein in the tissues causes excess fluid to enter them and the tissues to swell. The swelling decreases the oxygenation of the tissues, interferes with their normal functioning and makes them heal at a slower rate than normal.

Complex Physical Therapy

A special physiotherapy treatment known as ëcomplex physical therapyí or CPT can assist palliative care patients suffering from Lymphoedema.

CPT involves four aspects:

skin care,
special massage,
compression bandaging and later intreatment fitted garments,
special exercises to complement the massage.

It is usually necessary to modify the full massage techniques in these patients. However, the aim is still to take -+. the excess fluid from the oedematous region to one with normal/less compromised lymphatic drainage.

It is therefore implicit to have a good knowledge of the principles involved in CPT, from anatomical and physiological aspects of the lymphatic system through to its practical application in massage of the patient.

Massage

The massage is based on the concept of emptying the central regions first to give the lymph from the periphery somewhere to go. Correct massage causes the collateral lymphatics in the superficial lymphatic networks to become larger and carry more lymph over to normally draining areas or lymphotomes. Part of the idea of the massage is to gently force lymph across ëlymphatic watershedsí (lines dividing lymphotomes that drain in different directions). This dilates the collateral vessels and allows an alternative drainage path to the deeper collectors of a normal region. The other aspect of the massage moves tissue fluid into the initial and collecting lymphatics and through its lymph nodes.

Often the optimum drainage pathways in the palliative care patient are blocked by hard fibrous regions, ulcers, pressure sores, radiation burns, metastases, scar tissue etc. So again a practical understanding of the lymphatic system is important to modify treatment and choose an effective pathway for clearance.

Compression bandages

To maintain reductions achieved through massage, special low elastic compression bandages are used as part of the treatment for lymphoedema. A feature of lymphoedema is a loss of elastic fibres from the tissues, and the low stretch bandages cause a mild increase in the total tissue pressure.

The compression bandages reduce the hydrostatic pressure gradient from the blood to the tissues and increase that along the lymphatic trunks. They also increase the gradient from the tissues to the initial lymphatics.

The bandaging techniques also have to be modified in the palliative care and elderly patient - and for comfort the compression is of a lower grade.

Special exercises

Special exercises tailored to the individual patient are used to complement the massage. They increase uptake by the initial lymphatics, cause the collecting lymphatics to pump better, mobilise the joints and help combat muscle atrophy from the lymphoedema.

Patient education

It is important to teach patients with a lymphoedematous limb how to prevent their limb from becoming worse.

not to ignore a slight increase in size or ache in/or adjacent to the area;
always keep the affected limb spotlessly clean; avoid trauma (knocks, cuts, sunburn, insect bites, and be careful cutting nails);
notify doctor immediately if any redness or infection occurs as this should be treated at once with antibiotics. Tinea should also be treated with anti-fungal powders;
not to carry heavy loads on the lymphoedematous arm; do not have blood pressure taken, injections or IV therapy on the lymphoedematous limb;
when travelling by air a compression sleeve/stocking must be used; loose clothing/underwear should be worn so the few remaining lymphatics donít get blocked;
do no over-exercise - ie. don't make the limb ache with tiredness, or overheat; keep the skin supple and moist. Hamilton skin care products are good to use.

Summary

Lymphoedema is a chronic condition caused by a blockage of lymph flow. It can result from removal of lymph nodes as part of the surgery for cancer. Often radiotherapy is a necessary component of treatment, but its use may block the remaining nodes with fibrous tissue.

Lymphoedema may also occur as a result of other primary diseases. However, it is usually considered a condition of the arm or leg - with the most commonly recognised form being the swollen arm that may occur following breast surgery. CPT can be of great help in the relief of pain by the reduction of lymphoedema and inflammation in the palliative patient, and help to make them comfortable, mobile and self-sufficient.

Gabrielle Boyce, Physiotherapist, St.Vincent's Hospital, Lismore, NSW, Australia

References:
Judith R. & John R. Casely-Smith. Modern Treatment of Lymphoedema, 1994. The Henry Thomas Laboratory University of Adelaide. pp 117, 130, 225. J.R. Casely-Smith. "Information about lymphoedema for patients", 1995, The L.A.A. pp 21.

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