This post completes the discussion of a case study in edema management led by Marisa Perdomo PT, DPT, CLT-Foldi, CES over three blog posts. The first post went up two weeks ago; the second post went up last week.
If you have read parts I and II of this case study, along with this final part, you can earn CE credits! To earn two hours of credit, you will also need to read the below articles, purchase the course, and take the pre- and post-tests to earn your two credit hours!
Required reading for Orthopedic Edema Management: A Case Study:
- Ely JW, Osheroff JA, Chambliss ML, Ebell MH. Approach to leg edema of unclear etiology. J Am Board Fam Med. 2006 Mar-Apr;19(2):148-60.
- Mortimer PS, Levick JR. Chronic peripheral oedema: the critical role of the lymphatic system. Clin Med. 2004 Sep-Oct;4(5):448-53.
- Trayes KP, Studdiford JS, Pickle S, Tully AS. Edema: diagnosis and management. Am Fam Physician. 2013 Jul 15;88(2):102-10.
On our last post we left you with some questions. Thank you all who participated with your input and answers; some very good points were made. Here are my own answers:
- QUESTION: How does the presentation of edema affect your differential diagnosis process? What additional diagnoses could potentially explain this pattern of edema?
ANSWER: The following diagnosis should remain on the PT list until ruled out or ruled less likely:
- Recurrence of prostate cancer is of concern, as there might be a potential blockage of inguinal or pelvic/abdominal lymph nodes causing this excessive amount of edema.
- Potential central vessel blood clot.
- Infection is possible.
- Venous pathology.
- Secondary lymphedema due to prostate cancer surgery and treatment.
- QUESTION: What questions do you need answered to assist in developing a plan of care?
ANSWER: Due to the (intentionally) limited information presented for this case in our previous posts, there are several questions that need to be answered (as many of you stated in your previous comments). Here is a summary of key questions that need to be answered to support your differential diagnostic list:
- When was Mark’s last visit to his oncologist? Was a PSA blood test performed? If so, what was the result? If performed and PSA levels did NOT change from previous visit, then prostate cancer recurrence would go down on my list as a possible cause of the edema. However, if PSA levels were slowing increasing over the last several MD visits, then a recurrence would be high on my list, and a discussion with the orthopedic MD and referral back to the oncologist would be indicated
- I would ask Mark specific questions regarding the prostate surgery such as:
- Did he have a pelvic and abdominal lymph node dissection?
- Did he have radiation following surgery? And, if yes, have Mark describe the area that was radiated.
- Is there any history of previous surgeries to the abdomen or pelvis? For example, any colon or intestinal surgery? An appendectomy? Any surgery to this region can result in scar tissue formation that might further compromise lymph flow from the lower quadrant and leg. This information will help my clinical reasoning skill in determining if the cause of the edema is just overload of the lymphatic system, or it will increase the likelihood that the transport capacity of the lymphatic system has been reduced (lymphedema). My plan of care will be different depending upon if the lymphatic system is normal and just overloaded, or if there is an impairment in the lymph transport capacity (secondary lymphedema).
- I would discuss the findings with his MD and possibly ask for a Doppler to rule out a blood clot
- For infection, I would inquire about complaints of malaise, fever, sweats and chills, and I’d observe the hip and leg for areas of redness or red streaks and palpate for differences in skin temperature. It is always important to consider infection after any surgery.
- I would ask questions (and observe the lower legs) to determine if there is any chronic venous insufficiency, history of previous blood clots or venous stripping. The lymphatic system compensates for the venous system. If there is any history of CVI or DVT, then the lymphatic system will transport venous fluid and no swelling will develop. This means that even before surgery, the volume of lymph fluid being transport was higher than normal and predisposes the patient to peripheral edema greater than what is normally expected.
- Secondary lymphedema is often a diagnosis of exclusion. Therefore, once the more likely diagnoses are ruled out, then secondary lymphedema due to prostate cancer treatment is most likely. Then I can develop a plan of care.
Comments: Once systemic pathologies are ruled less likely or ruled out, then I need to determine if the lymphatic system is overloaded, and therefore resulting in peripheral edema; or if the transport capacity of the lymphatic system is damaged (as in the case of cancer surgery or radiation therapy), and therefore there is a permanent reduction in lymph transport volume of lymph fluid that can be transported over time (i.e., secondary transport, meaning secondary lymphedema is present). This is very important as my treatment will be different depending upon the integrity of the lymphatic system.
- QUESTION: Outline your intervention strategies to treat the peripheral edema.
ANSWER: There are several potential treatment approaches which require detailed understanding of the anatomy and physiology of the lymphatic system. If the lymphatic system is just overloaded, then the treatment and the intensity of the intervention will be different than if secondary lymphedema is the diagnosis.
- If the lymphatic system is just overloaded (meaning that no radiation was given and minimal to no lymph node dissection was performed), then I would utilize the following treatment approach:
|Diaphragmatic breathing: ~ 10–15 reps||Allows for the central vessels (thoracic duct) to empty into the venous system and create a negative pressure gradient, which is required for lymph transport.|
|Exercises to stimulate lymph flow; must be performed in the following order: Central first, then proximal leg to distal; ~ 10-15 reps diaphragmatic breathing.
Straight leg raises, all 4 planes
Ankle pumps and circles
Follow-up exercise, distal to proximal, one repetition each but complete cycle: ~ 3-5 times.
|Use of muscle pump to promote lymphatic flow.
The order is important in order to obtain a negative pressure gradient in the central and most proximal lymph vessels first.
|Perform manual lymphatic drainage (MLD) mobilizations to the abdomen and upper thigh. Teach Mark to perform as a home exercise program (self-MLD)
Follow up with lymph drainage exercise program outlined above.
|MLD to abdomen stimulates lymph flow to empty from the thoracic duct into the venous system, creating the negative pressure gradient. Then encourage the proximal thigh to drain into the abdomen — since the lymphatic system is normal, the negative pressure gradient, along with the exercise program, will stimulate an increase in lymph transport.|
|Repeat diaphragmatic breathing.||Repeat this entire sequence 3-4 X daily until edema resolves.|
|Encourage walking as much as possible all day: at least 4 reps of 15-minute walks.||Walking is one of the best exercises for LE swelling.|
|Kinesiotape||Kinesiotaping is appropriate for both lymphatic overload and/or lymphedema.|
- If secondary lymphedema is likely due to history of radiation therapy and pelvic lymph node dissection, then treatment would still include:
- Diaphragmatic breathing.
- Manual lymphatic drainage mobilizations; however, the focus of the treatment is to re-route the lymph fluid away from the right inguinal lymph nodes to the right axillary pathways.
- Exercise as outlined above with additional exercises, such as trunk rotation, trunk side bending, and exercises for the latissimus dorsi, which are performed after diaphragmatic breathing.
- Compression therapy with short-stretch compression bandages, and then progression to a garment. Compression therapy may include a lymphedema compression pump.
- Education about skin care to maintain a healthy barrier against infection, i.e., keeping the skin well-moisturized.
The key for this patient case is that the edema must be treated early and aggressively, given that he has a history of prostate cancer treatment and the risk of lymphedema is high. If therapy can decrease the edema quickly, then there is less of a chance for the post-operative edema to turn into lymphedema. Lymphedema is a permanent condition, and it is very difficult to keep the leg a normal size unless treated early and aggressively.
In this case, the actual treatment included a self-MLD program, exercises and walking, as outlined above. The scrotal and central edema responded quickly; however, the leg required more aggressive treatment. A lymphedema compression pump was brought to the patient’s house and used for 7 days. The leg edema completely dissipated and no garment or bandaging was required. The patient was then educated about the potential for the edema to return secondary to the prostate cancer surgery. The patient was also educated specifically about the stages of lymphedema, with particular attention to Stage O (subclinical edema where no visible edema is present, but a decreased transport capacity is present) and Stage I (the edema comes and goes with activity). The patient was aware that he might have lymphedema but just in Stage O or Stage I. However, since the patient received NO radiation therapy, compression therapy was not recommended at this time. The patient was made aware to call his MD and schedule an appointment with physical therapy if any edema returned.
He is hoping the edema is just post-operative edema and not lymphedema. He will monitor for any recurrence of the swelling and prefers not to order a compression stocking at this time.
I hope you have found this case study informative and useful. Please feel free to leave additional comments below. And remember: The Oncology Section of the American Physical Therapy Association offers a Certificate of Achievement in Oncology Physical Therapy (CAOPT) if you would like in-depth training in this field.
For full information, visit the Oncology Section website!