Lymphedema is an accumulation of protein-rich fluid that can be present for a number of reasons, including damage to the lymphatic network as a result of trauma, removal of lymph nodes, and genetics, as in the case of some primary lymphedema syndromes.1 A patient with lymphedema may have swelling in the trunk, face/neck, genitals, or extremities as a result of compromised lymphatic flow pursuant to lymph node removal, trauma, or a possible genetic predisposition.
As of 2002, a literature review of more than 1,900 references to determine the incidence of both primary and secondary types of the condition in the United States Medicare age group (65+) showed lymphedema affected upwards of 6.8 million individuals.2 Research, by literature review, is underway to determine the incidence in the nonMedicare-age group population, specifically persons with breast cancer, trauma, and primary lymphedema, but currently collection of these data by an online website forum2 is not complete.
According to the Position Statement of the National Lymphedema Network (NLN),3 a qualified health care professional should help determine the diagnosis of lymphedema in the earliest possible stage for more effective treatment. Patients referred for lymphedema treatment can have a variety of diagnoses; therefore, it is important to obtain a thorough patient and cardiovascular/pulmonary systems history, integumentary review, musculoskeletal and neuromuscular assessment, and determination of communication capabilities and to conduct a physical therapy examination to diagnose the cause of lower extremity swelling. The physical therapist (PT) or the health care professional who is differentially diagnosing patients with lower extremity swelling needs to know the duration, distribution, and accompanying symptoms of the leg edema in order to render an effective differential diagnosis.4 Five diagnostic tests necessary to properly diagnose lymphedema include magnetic resonance imaging (MRI), computed tomography scan (CT), lymph vessel imaging, volumetric measurements, and assessment of changes in biomechanical or electrical properties of the fluid.
According to the NLN3 and a literature review by Young,5 swelling distribution (bilateral versus unilateral) is important in determining pathology, and bilateral leg edema is usually an indication of a systemic process.4 The PT/health care provider needs to have full knowledge of patient medication and reports of pain, trauma, and surgery to help determine the cause of edema. Any accompanying symptoms, such as dyspnea with exertion, orthopnea, and/or paroxysmal nocturnal dyspnea, most likely are indicative of congestive heart failure (CHF).4 Physical examination to determine the presence of heart failure such as distended neck veins, listening for ventricular gallop, and conducting echocardiography4 are also an important part of the evaluation process. Determining what diagnostic tests have been performed on the patient is essential. For example, the PT should obtain, if possible, previous medical records on the patient and have ongoing communication with the referring physician to order appropriate laboratory tests.
Ciocon et al4 conducted a review of the literature on the differential diagnosis of leg edema. Their review showed increased peripheral venous pressure is the most common cause of leg swelling. Chronic venous insufficiency (CVI) is the most common condition resulting from increased venous pressure4 and can result in extravasation of large molecules and red blood cells to the dermis and cause inflammation and possibly ulceration.6
According to Lampe’s7 literature review on lower extremity chronic venous disease, the pathogenesis of venous disease can have many origins, including venous failure, venous reflux, and venous hypertension. Lampe’s review7 also explains CVI may occur as a result of long-term vein malfunction, potentially leading to ulceration. Venous hypertension along with increased capillary hydrostatic pressure can lead to fluid leakage into the interstitial space, which essentially is one of the causes of secondary lymphedema.1,7 According to Bolton et al’s8 literature review on the global efforts to address wounds and lymphedema, the estimated prevalence of chronic ulcers in patients >60 years old with venous insufficiency is 1% to 3%. Bolton et al concluded saving limbs and lives requires correct diagnosis, addressing the cause of skin breakdown early, and managing the wound well. Lampe7 stresses adequate edema assessment is necessary. Recent soft pitting edema may indicate trauma or early stages of venous insufficiency, and hard/indurated or brawny tissue is related to longstanding venous hypertension and venous insufficiency.
Due to the progressive nature of lymphedema, early intervention will lead to more effective treatment. According to a consensus document of the International Society of Lymphology,1 manual lymph drainage (MLD) in combination with remedial exercises and compression, termed complete decongestive therapy, is the standard treatment approach for patients seeking lymphedema management.
MLD. MLD is a standard treatment approach to peripheral lymphedema that involves a specific type of light touch massage. This gentle, light, superficial massage technique stimulates the lymphatic system to allow proficient uptake and movement of lymphatic fluid. This therapy typically is performed by either a PT or occupational therapist who is a Certified Lymphedema Therapist (CLT).1
CHF. According to the consensus document of the International Society of Lymphology,1 the second most significant diagnosis that results in leg edema is CHF. Each year, 660,000 individuals are newly diagnosed with CHF.9 It is imperative that patients and health care providers be familiar with the signs and symptoms of CHF. The presence of CHF can dramatically change the treatment approach for the patient. For example, the health care provider will need to closely monitor the patient’s vital signs and symptoms throughout treatment sessions to make sure the heart is not being overworked. A baseline assessment of all vital signs will help determine if the patient is progressing and tolerating the treatment in a stable manor without adverse effects. A literature review by Frese et al10 discusses blood pressure (BP) guidelines for PTs; the BP measurement gives the PT information on how the patient is responding to treatment/exercise and guides exercise prescription or when to potentially stop treatment. This is critical when performing MLD therapy, because additional fluid is moved toward the heart. Being able to recognize signs and symptoms of CHF as a health care provider and as a patient is important in the diagnostic process.
Albert et al9 investigated patients’ perceptions of signs and symptoms of heart failure before an ambulatory visit/hospitalization. Using a convenience sample of 276 patients with systolic heart failure, researchers had participants complete a 1-page checklist of signs and symptoms. The authors found patients may not report their signs and symptoms to health care providers because they do not perceive them as indicative of a heart-related problem and may cope by ignoring or denying such symptoms. The authors also found 100% of participants in their study reported shortness of breath (SOB), while less than half (126 out of 276) reported edema/swelling.
Many patients seeking lymphedema treatment as a result of lower extremity swelling have comorbidities that may produce SOB, profound fatigue, and/or generalized weakness. In the study by Albert et al,9 patients documented these symptoms without realizing they are symptoms of CHF and the incidence of lower extremity edema in that patient population was 46%. This finding is relevant, considering many patients seeking lymphedema treatment may have underlying symptoms of CHF but are not aware that they actually have CHF; therefore, it is important for the health care provider to perform a complete history/screen.9
Theories about the origin of CHF abound. Based on their literature review of the development of dyspnea and edema symptoms, Churchouse and Thomas11 theorized the development of CHF is a result of right ventricular failure occurring secondary to severe left ventricular failure. The cardiac lymphatic system also plays a role in the development of leg edema when anatomical and/or functional abnormalities of the lymphatic vasculature are present that can lead to lymph flow impairment, a known cause of edema.11
Primary functions of the lymphatic system are to maintain fluid homeostasis and to provide a route for large protein molecules.12 Cui’s12 literature review investigated the connection between the cardiac system and the lymphatic system; evidence indicates blocking the cardiac lymph flow may contribute to several forms of cardiac injury. This review also reported lymphatic fluid drains passively into the heart, relying completely on powerful cardiac muscular contraction and relaxation. In other tissues, active lymphatic pumping has been found to be an important lymphatic fluid draining mechanism.12
Because these systems are intimately linked, the PT must be cautious not to overload the heart with the fluid that is being moved from the extremity to the thoracic duct when applying MLD to persons with CHF. Depending on the stage of CHF, movement of fluid toward the heart could be life-threatening. It is intuitive to stop MLD when a patient is showing classic signs of CHF, but research that states at what stage of CHF MLD is contraindicated is lacking.
To investigate the consequences of thoracic duct drainage in CHF patients, Witte et al13 focused on patients (N = 12) with severe CHF in whom a cannula was inserted in the thoracic duct to relieve symptoms. These researchers found initial high lymph flow pressure before cannulation and the presence of edema, indicating the flow of the unvented lymphatic system, was unable to keep pace with the rate of lymph formation. The investigators also found 4 of the 12 participants experienced significant CHF symptom relief within a few hours following insertion of the cannula into the thoracic duct. These changes included relief in dyspnea, orthopnea, and abdominal discomfort. It is important to note cannulation is a dangerous procedure that was fatal in 5 of the 12 patients. Although the study sample size was small, the morbidity rate suggests MLD must be considered a potentially dangerous treatment in patients with active acute heart failure.
An awareness of the relationship between the lymphatic system and the cardiac system will allow the PT a better understanding of the risks involved in treating patients with mild CHF symptoms, especially because patients seeking MLD may be unaware of signs and symptoms of CHF. On initial examination, a complete checklist of CHF signs and symptoms will help complete a thorough screening.
The basics of examining a patient with lymphedema and concurrent circulation and integumentary concerns are described in the Guide to Physical Therapist Practice.14 Examination of the patient, per the Guide, should include 3 main components: patient/client history, systems review, and tests and measures. The patient/client history is a systematic gathering of past and current information from the client/family regarding why this patient is seeking the services of physical therapy.14 The systems review is a brief examination of physiological status of the cardiovascular/pulmonary systems; for this patient, that involves collection of vital signs, including heart rate, respiratory rate, blood pressure, and edema assessment, as well as integumentary assessment that addresses measurement of any wounds, odor, or drainage and overall skin integrity/texture. Systems review also includes musculoskeletal and neuromuscular assessment. The final part of the systems review is assessment of the patient’s ability to communicate, his/her affect, cognition, language, and learning style. Appropriate standardized tests and measures are selected by the PT as part of the examination and may include aerobic capacity/endurance, edema/girth measurements, balance testing, and functional tasks such as the ability to transfer out of bed safely and independently.
The purpose of this case report is to illustrate the principles of care and potential complications of treating lower extremity edema in a patient with COPD/CHF.