The efficacy of complex decongestive physiotherapy (CDP) and predictive factors of response to CDP in lower limb lymphedema (LLL) after pelvic cancer treatment.

June 2012

Liao SF, Li SH, Huang HY.

Source

Department of Physical Medicine and Rehabilitation, Changhua Christian Hospital, 135 Nanxiao Street, Changhua 500, Taiwan. sueliao3@gmail.com

Abstract

OBJECTIVE:

The aim of this study was to estimate the efficacy of an intensive CDP program, as well as to identify the predictors associated with lymphedema severity and response to CDP in lower limb lymphedema (LLL) after pelvic cancer therapy.

METHODS:

We performed a retrospective review of post-pelvic cancer LLL patients that were treated with a CDP program between January 2004 and March 2011.

RESULTS:

Twenty-seven of the total 44 patients had cervical cancer, 9 had endometrial cancer, and 8  had ovarian cancer. The mean age was 62.2 years, 18  patients received radiotherapy and a mean of 12.6 sessions of daily CDP, and mean lymphedema duration was 34.8 months. The interval from pelvic cancer treatment to LLL development was 63.4 months. Lymphedema severity, baseline and post-CDP percentage of excess volume (PEV) were thirty-two percent plus-minus eighteen point four percent and eighteen point eight percent plus-minus sixteen point seven. Baseline PEV was not correlated with duration of lymphedema, number of CDP sessions, age or radiotherapy, and was significantly different to post-CDP PEV . CDP efficacy, percentage reduction of excess volume PREV, was minus fifty-five point one percent, and was correlated with baseline PEV, but not with the number of CDP sessions, duration of lymphedema, or age. PEV ) was the only predictive factor for CDP efficacy.

CONCLUSIONS:

The key to predicting successful lymphedema treatment of LLL is the initial PEV. The intensive CDP program was effective and successful. We should encourage and refer patients to undergo treatment for LLL, even when the LLL is mild.

Elsevier

A novel approach to the treatment of lower extremity lymphedema by transferring a vascularized submental lymph node flap to the ankle.

July 2012

Cheng MH, Huang JJ, Nguyen DH, Saint-Cyr M, Zenn MR, Tan BK, Lee CL.

Source

Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan. minghueicheng@gmail.com

Abstract

OBJECTIVE:

Vascularized groin lymph node flaps have been successfully transferred to the wrist to treat postmastecomy upper limb lymphedema. This study investigated the anatomy, mechanism and outcome of a novel vascularized submental lymph node (VSLN) flap transfer for the treatment of lower limb lymphedema.

METHODS:

Bilateral regional submental flaps were dissected from three fresh adult cadavers for histological study. A unilateral submental flap was dissected in another six fresh cadavers after latex injection. The VSLN flap was transferred to the ankles of seven lower extremities in six patients with chronic lower extremity lymphedema. The mean patient age was 61 ± 9.4 years. The average duration of lymphedema symptoms was 71 ± 42.2 months.

RESULTS:

There was a mean of 3.3 ± 1.5 lymph nodes around the submental artery typically at the junction with the facial artery, on the six cadaveric histological sections. Mean of 2.3 ± 0.8 sizable lymph nodes were dissected and supplied by the submental artery in six cadaveric latex-injected submental flaps. All seven VSLN flaps survived. One flap required re-exploration for venous congestion but was successfully salvaged. There was no donor site morbidity. At a mean follow-up of 8.7 ± 4.2 months, the mean reduction of the leg circumference was 64 ± 11.5% above the knee, 63.7 ± 34.3% below the knee and 67.3 ± 19.2% above the ankle.

CONCLUSION:

The transfer of a vascularized submental lymph node flap to the ankle is a novel approach for the effective treatment of lower extremity lymphedema.

Elsevier

The Prevalence of Lymphedema Symptoms Among Survivors of Long-term Cancer with or at Risk for Lower Limb Lymphedema.

The Prevalence of Lymphedema Symptoms Among Survivors of Long-term Cancer with or at Risk for Lower Limb Lymphedema.

Oct 2012

Brown JC, Chu CS, Cheville AL, Schmitz KH.

Source

From the Department of Clinical Epidemiology and Biostatistics (JCB, KHS) and the Department of Gynecologic Oncology (CSC), Perelman School of Medicine, and Abramson Cancer Center (CSC, KHS), University of Pennsylvania, Philadelphia; and the Department of Physical Medicine & Rehabilitation, Mayo Clinic, Rochester, Minnesota (ALC).

Abstract

OBJECTIVE:
The aim of this study was to identify commonly reported symptoms in the lower limbs among those with or at risk for developing lower limb lymphedema (LLL).

DESIGN:
The authors surveyed survivors of long-term cancer using the Pennsylvania State Cancer Registry. They inquired about demographics, cancer treatment history, knowledge about LLL, and symptoms experienced since completing cancer treatment. They invited all participants for an in-person clinical assessment to better identify and characterize the symptoms associated with LLL.

RESULTS:
The response rate to the study survey was 57.2%. Among the 107 participants who answered the study survey, 37 (34.5%) reported one or more symptoms associated with LLL. Many reported a combination of symptoms that included difficulty walking (n = 37; 100%), aching (n = 32; 86%), puffiness (n = 28; 76%), and pain (n = 27; 73%) on one side of the body since cancer treatment. The in-person clinical assessment among a subsample of 17 participants revealed 10 participants with no evidence of LLL and 5 and 2 participants with grade 1 and 2 LLL, respectively. The in-person clinical assessment identified three cases of previously undiagnosed LLL.

CONCLUSIONS:
One third of the survivors of cancer surveyed reported experiencing new symptoms in the lower limbs since cancer treatment. Cases of symptomatic, undiagnosed LLL may exist in the population.

PubMed

Would complex decongestive therapy reveal long term effect and lymphoscintigraphy predict the outcome of lower-limb lymphedema related to gynecologic cancer treatment?

Sept 2012

Kim YB, Hwang JH, Kim TW, Chang HJ, Lee SG.

Source

Department of Rehabilitation Medicine, Pusan National University Yangsan Hospital, Pusan, 626-770, Republic of Korea.

Abstract

OBJECTIVE:

The aims of this study were to investigate the long-term effect of complex decongestive therapy (CDT) onlymphedema volume reduction, especially considering the proximal and distal parts of the leg, and to evaluate the utility of pre-therapy lymphoscintigraphy in predicting the response to CDT in patients with lower-limb lymphedema after surgery for gynecologic cancer.

METHODS:

Medical records of 158 patients with secondary lymphedema of unilateral leg after surgery for gynecological cancer were reviewed retrospectively. They were treated with two weeks of CDT along with self-administered home therapy and were followed up for 24months. Whole, proximal and distal leg volume was serially measured by using an optoelectric volumeter prior to and immediately after therapy, and follow-up visits at months 3, 6, 12 and 24. Lymphoscintigraphy was performed prior to therapy.

RESULTS:

The percent volume reduction was 22.1% in the whole leg, 30.9% in the distal leg and 18.4% in the proximal legimmediately after CDT. The volume reduction was maintained for 24months, but the distal leg was significantly well maintained better than the proximal leg. Extremity radioisotope uptake ratio (EUR) among lymphoscintigraphic findings could predict the improvement of lymphedema volume in the distal, proximal and whole leg.

CONCLUSION:This study suggests that the long-term edema reducing effects of CDT are better maintained in the distalleg than in the proximal part, and initial lymphoscintigraphic quantitative finding may usefully predict the short and long-term response to CDT.

SciVerse

How to Wrap Legs for Lymphedema

Instructions

1 Arrange all of your necessary supplies nearby. Pre-cut the tape strips to keep one layer of wrapping in place while you are applying the next. Preparation, patience and allowing yourself ample time to perform the wrap are crucial to successfully finishing the procedure.

2 Apply moisturizing body lotion to the skin of your affected leg. This will maintain good skin condition by hydrating the skin and preventing cracking which would enable bacteria to invade your leg, causing infection. It will also help to alleviate potential skin irritation from using the layers of bandages.

3 Apply a tubular stockinette to protect your skin. Depending on your individual condition, you may (or may not) also use flexible gauze over the stockinette.

4 Use the thin foam-like fabric that your therapist gave you. Wrap a layer of padding around your leg. This will help to distribute the compression evenly.

5 Apply the lymphedema bandages, which are also known as short-stretch bandages. Apply more pressure at your foot, gradually decreasing the pressure as you move upward. The narrower bandages can go around your foot with the wider bandages spiraling up your leg. The exact number of bandages necessary will largely depend on the length and size of your leg as well as the amount of compression that you need.

Tips & Warnings

• Other potential treatments all aim to encourage lymph fluids to flow out of the affected leg and include light exercising of the affected leg, massage, pneumatic compression (a special sleeve which connects to a pump to place pressure on the affected leg) and compression garments. Some of the treatments can be combined for CDT (complete decongestant therapy).
• Severe lymphedema may require surgical removal of excess leg tissue to help reduce swelling.
• Avoid wearing socks that constrict your legs and avoid long periods of standing. If you must be on your feet for work, your doctor may recommend wearing compression stockings.
• Do not use ACE bandages as lymphedema wraps. Lymphedema bandages have limited stretching capacity and offer proper skin pressure for aiding the flow of lymph fluid. These special bandages also prevent constriction which can occur with ACE bandages.
• Contact your doctor immediately if you see a rash, redness or have any signs of infection in the affected leg. Do not apply compression or bandaging.
• This article does not take the place of your doctor's guidance or teaching by an experienced therapist. Individualized lessons and supervision are crucial for learning proper technique.


Read more: How to Wrap Legs for Lymphedema | eHow.com 

Pathophysiology of Lower Extremity Edema in Acute Heart Failure Revisited.

Aug 2012

Breidthardt T, Irfan A, Klima T, Drexler B, Balmelli C, Arenja N, Socrates T, Ringger R, Heinisch C, Ziller R, Schifferli J,Meune C, Mueller C.

Source

Department of Internal Medicine, University Hospital, Basel, Switzerland; Department of Renal Medicine, Royal Derby Hospital, Derby, United Kingdom; Department of Nephrology, University Hospital, Basel, Switzerland.

Abstract

BACKGROUND:

The pathophysiology and key determinants of lower extremity edema in patients with acute heart failure are poorly investigated.

METHODS:

We prospectively enrolled 279 unselected patients presenting to the Emergency Department with acute heart failure. Lower extremity edema was quantified at predefined locations. Left ventricular ejection fraction, central venous pressure quantifying right ventricular failure, biomarkers to quantify hemodynamic cardiac stress (B-type natriuretic peptide), and the activity of the arginine-vasopressin system (copeptin) also were recorded.

RESULTS:

Lower extremity edema was present in 218 (78%) patients and limited to the ankle in 22%, reaching the lowerleg in 40%, reaching the upper leg in 11%, and was generalized (anasarca) in 3% of patients. Patients in the 4 strata according to the presence and extent of lower leg edema had comparable systolic blood pressure, left ventricular ejection fraction, central venous pressure, and B-type natriuretic peptide levels, as well as copeptin and glomerular filtration rate (P=NS for all). The duration of dyspnea preceding the presentation was longer in patients with more extensive edema(P=.006), while serum sodium (P=.02) and serum albumin (P=.03) was lower.

CONCLUSION:

Central venous pressure, hemodynamic cardiac stress, left ventricular ejection fraction, and the activity of the arginine-vasopressin system do not seem to be key determinants of the presence or extent of lower extremity edemain acute heart failure.

Elsevier

Unilateral pitting edema of the leg as a manifestation of Graves' disease: a case report.

Unilateral pitting edema of the leg as a manifestation of Graves' disease: a case report.

August 2012

Volke V, Matjus S.

Source

Internal Medicine Clinic, South Estonian Hospital, Meegomäe, Võru vald, 65526, Estonia. vallo.volke@ut.ee.

Abstract

ABSTRACT:

INTRODUCTION:

Graves' hyperthyroidism has a number of well-recognized but relatively rare extrathyroid manifestations such as thyroid acropachy, pretibial myxedema, and congestive heart failure.

CASE PRESENTATION:

A 38-year-old Caucasian woman presented to the out-patient clinic with symptoms of hyperthyroidism lasting for approximately five months. Remarkably, she had developed pitting edema of her left leg four months before. She had gone through a conventional assessment, but the reason for the edema was not revealed. At presentation to the endocrinology clinic, the skin of both legs was of normal color and pitting edema on her left leg was of a diffuse nature and spread from her toes to two thirds of her leg. The skin surface of her left leg was smooth and had no elevations or discoloration, whereas her right leg appeared normal. Based on signs and symptoms of thyrotoxicosis and suppressed thyroid-stimulating hormone level (less than 0.001mIU/L, local reference of 0.4 to 4), treatment of 10mg of thiamazole three times a day was started. Additional blood tests revealed marked Graves' hyperthyroidism with elevated free T4 and anti-thyroid receptor antibodies. Within a month, the free T4 level was normalized and the edema was completely cleared and never reappeared during the treatment course of 12 months.

CONCLUSIONS:

To the best of our knowledge, this is the first description of unilateral treatment-responsive leg edema as a manifestation of Graves' hyperthyroidism. However, the pathophysiological mechanism underlying this case of edema remains unclear.

BioMed