When Lymphedema Impedes Seating & Mobility. Clinical features of lymphedema. Lymphedema 4/11/2014. Stephanie Tanguay OTR, ATP Motion Concepts

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1 When Lymphedema Impedes Seating & Mobility Stephanie Tanguay OTR, ATP Motion Concepts Objectives 1. Participants will be able to list 3 requirements of positioning & support critically important for wheeled mobility prescription for consumers with diagnosis of lymphedema 2. After attending this session, participants will be able to describe at least 3 measurements specific to evaluation of lymphatic lower extremities. 3. Participants will be able to describe the general etiology of Lymphedema and list 3 possible long term complications which have a dramatic impact on mobility. Clinical features of lymphedema Recurrent cellulitis Pitting or non pitting edema Skin changes Fibrosis/hyperkeratosis Thickened skin folds Misshapen limb Causative lymphedema related to cancer treatment Radiation and removal of the lymph nodes (lymphadenectomy) Lymphedema Lymphedema (LE) is a disorder characterized by persistent swelling caused by impaired lymphatic drainage because of various etiologies, including lymphatic injury and congenital, functional or anatomical defects. Adults usually experience secondary LE because of acquired lymphatic failure 1

2 Lymphedema Morbid Obesity is one of the risk factors which can lead to development of Lymphedema responds well to elevation of extremity at night in the early stage. limited response to elevation and/or diuretics in later stages. may be a history of chronic bouts of cellulitis in the involved extremity. skin changes: folds, fissures & lobules as well as hyperkeratosis and papillomatosis. Discoloration of tissue referred to as wine stain papillomatosis difficult for consumers to maintain adequate hygiene skin folds create an environment for fungal infection Lymphedema Slow onset; develops over time. Characterized by asymmetrical or unilateral lower extremity swelling. May be mis diagnosed which delays treatment. 2

3 Lymphedema Treatment Evidence has proven the multi modal treatment known as CDT (Complete or Complex) Decongestive Therapy to be highly effective in the management of lymphedema. CDT Complete Decongestive Therapy consists of four components: Manual lymphatic massage to facilitate drainage of lymphatic fluid Compression (multilayered inelastic compression bandaging regiment progressing to maintenance garments) Remedial exercises Meticulous Skin Care Measurements Created by: Stephanie Tanguay Jane Fontein Posterior gluteal tissue can prevent the consumer from having contact with a back support. Measurement for the open space below the back (heightof gluteal tissue + cushion height). Mount back support to support the trunk. May require placement anterior of the back canes 3

4 Lymphedema Frequently will see increased proximal swelling in response to distal compression. This can occur with wrapping compression forcing fluid into tissue above the garment. In a seated position, fluid can also pool in the posterior thigh tissue, especially if seat depth is too short. Wrapping the LE moved fluid proximal (above the knee) where it pooled, unable to continue past the front seat edge. This seems to be more common and presents unique seating issues. Lateral view of tissue mass (wrapped) which requires accommodation and support. This will require custom components and modifications : (leg length modifications to seat pan & custom lower extremity support should be considered). Rotation of pelvis forward due to lymphatic mass on posterior thigh proximal to popliteal. Leg length modification to seat pan Off set legrest receiver Custom lower extremity support With hanging tissue in front of seat pan, tilt can bring the tissue in contact with the seat pan edge. In this example, a pad was added perpendicular to the seat pan. 4

5 4/11/2014 Wrapping the easy part of the lower extremity can force fluid to pool above the compression. Lymphedema specialists should be consulted for the best outcome. Unsupported tissue will continue to change and grow in size. Plan for the under seat space it must be adequate to accommodate the tissue mass. The lymphatic fluid has pooled below the front seat of w/c (and proximal of the calf support ). Lack of proper wrapping to compress and shape the LE compromises the mobility of many consumers with lymphedema. Measurements are difficult in later stages, especially when there has not been consistent comprehensive treatment/ management. 5

6 Cellulitis Cellulitis is an infection of the skin. Individuals with lymphedema are at risk for cellulitis in their involved extremity. Cellulitis can look different in different individuals and even present differently each time it occurs in the same person. Symptoms can include redness, heat, pain, swelling, lymph leakage, skin breakdown, fever, chills, malaise. Because the immune response is impaired in the limb/area with lymphedema or lymph stasis, infections can progress rapidly. These can become life threatening if not treated quickly and appropriately. Lower extremity measurements: Orientation of feet medial or lateral Asymmetrical lymphedema Circumference measure 6

7 In this example, the masses have increased in size, eventually touching and then being supported by the foot platform of the power chair. During evaluation a large padded pillow was placed beneath the tissue masses for support In standing we have a better idea of the firmness and density of these masses. Over time, the lymphatic fluid creates subcutaneous fibrosis. Seat Shelf Footrest Padded supports act as a shelf to support bilateral LE tissue masses and can be released (right) and footrests swing away for transfers. 7

8 Dx: Congenital Lymph Edema since age 8. Ht. 5 3 Wt.430 lbs. School Teacher Has been using a scooter prior to this evaluation. 8

9 4/11/2014 Grading of Abdominal Panniculus Severe swelling of the genitalia (lymphedema based, resulting from bariatric status) can limit functional seat depth and presents a unique need for tissue support. Grade 1 Panniculus barely covers the pubic hairline and may cover some of the mons pubis but not the genitalia. Grade 2 Extends to cover the entire mons p pubis and genitalia. g Grade 3 Extends to cover the upper thigh Grade 4 Extends to cover the mid thigh. Grade 5 Extends to cover the knees or beyond. 9

10 Pannus is a medical term for a hanging flap of tissue also called panniculi. When involving the abdomen, it is called a panniculus and consists of skin, fat and sometimes contents of the abdominal cavity as part of a hernia. A pannus can be the result of loose hanging tissues after pregnancy or weight loss. It can also be the result of obesity. Panniculus tissue is in contact with front edge of any seat surface and often prevents the consumer from reaching the back support. Seat depth looks to be more of an issue to me Forward rotation on left from mass of pannus Shelf to support the pannus mass Need to determine the true seat to floor height (note the seat rail & stretched upholstery). & the floor to pannus height with the minimum & maximum range elevation. 10

11 Widest point was measured at 26.5 Shoulder width = 19.5 Chest width = 17.5 Widest point at lateral aspect of lower extremities = 26.5 Suspect that this pannus contains the abdominal contents (intestines). Solid, dense mass but can be lifted & supported. Weight of pannus unknown. Circumference measurement of pannus 45 at largest aspect. This mass hangs straight down from lower abdomen no involvement of the lower extremities although gait is obviously effected. delivery 11

12 Pannus References For consumers: For clinicians: Lymphoedema Framework (2006). Best practice for the management of lymphedema: An international perspective. London: MEP Ltd. Guidelines for the diagnosis, assessment and management of lymphoedema. Feb, pub by the clinical resource efficiency support team (CREST) in Belfast. References For clinicians: Mary Jo Geyer, PhD, PT, CLT LANA and Suzanne Cavanaugh, DPT, CLT LANA Lower Extremity Edema/Lymphedema Management Essentials. Pre conference workshop presented at the 25 th International Seating Symposium, March 11, Orlando, FL. Thank You!! 12