Clinical Presentation

The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute

Clinical Presentation Fauzia Asad, PT, CLT-LANA April 16, 2016

Audience will demonstrate understanding of lymphedema presence in non oncology population

Audience will gain knowledge in appropriate interventions to address lower extremity lymphedema

Audience will demonstrate understanding of the importance of compliance and follow through for optimal results

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Objectives

Case Overview

Practicing Setting: Outpatient Oncology Rehabilitation Clinic

Medical Diagnoses: Lymphedema of bilateral lower extremities (I89.0) Chronic Venous insufficiency (187.2) Stage III phlebo-lymphedema Unspecified open wound of lower leg (S81.80)

PT Diagnosis: Leg swelling Practice Pattern: Primary: Lymphedema Secondary: Musculoskeletal (additional diagnosis: Rt

tib/fib fx; non weight bearing rt)

55 year old male, referred for bilateral leg swelling Lt leg swelling x 2 years, unknown cause; developed

open wounds and has one currently Rt leg swelling x 2 months after tib/fib fracture Needs rt ankle fusion, but swelling is decreasing chances

of successful and uncomplicated procedure Currently non weight bearing on rt leg Currently being followed by wound care clinic Very strong family support

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Patient information KM

Patient Information Con’t

PMH: Obstructive sleep

apnea:CPAP Morbidly obese:BMI

47.44kg/m2 HTN Stress fx: R tib/fib Arthritis: R ankle R club foot release

Cognitive/Mental Status: Intact, AAO x 4

Medications: Amoxicillin Lisinopril Vitamin D3

Diagnostics: Echocardiogram X-ray

Evaluation/Chart Review

BP: 134/84 mmHG Pulse: 80 beats/minute Pt. reports he had recent Echocardiogram and it was

normal Skin warm and dry; small open wound on lt lateral lower (B) Dorsal pedal and post tib pulses: normal Lab values: PSA, TSH, CMP, HbA1c within normal limits X rays show current tib/fib fracture as well as previously

healed ones Comes to PT in wheelchair accompanied by his wife

Evaluation continued:

Current functional status: Able to stand 10 min with crutches ( 1 min without) Ascends stairs on knees, descends stairs with 1 crutch NWB on R LE Ambulates with (B) crutches, right LE extended in front Poor endurance: requires wheelchair for distances over 25

feet and crutches for distances under 25 feet Fatigue 2/10

Pain: Bilateral lower extremities 2/10 at rest 5/10 with activity

Evaluation continued:

Sensation: Hypersensitive to

palpation R anterior dorsum of ankle/foot

Living environment: House + spouse

Employed full time Limited to working at

home

Patient goals: Decrease swelling in

right foot/ankle so that he is eligible for corrective surgery

Improved ability to ambulate

Less heaviness in legs Discharge Plan: 2x/week for 4 weeks

then weekly for 8 weeks

Musculoskeletal Status

Joint Left Right Hip 50% Limited available

range secondary to soft tissue approximation, 3+/5

50% Limited available range secondary to soft tissue approximation, 3+/5

Knee 5/5, 0-110◦ 5/5, 0-110◦

Ankle 4/5 , 0-12◦ Unable to test secondary to Club foot deformity and current fracture

Posture: Kyphotic posture in sitting with rounded shoulders and forward head Girth: measurements taken and recorded for both legs

Appearance/palpation

Cast shoe and Unna boot lt. Tourniquet like effect around Lt ankle and dorsum of foot.

Rt foot swelling at dorsum and base of toes Lt lower extremity is dense and hypomobile from foot to

groin. Hemosiderin staining; open wound lateral lower leg 2 cm

in diameter, draining yellow fluid. Rt side club foot deformity. Tissue dense and hypomobile Moderately full in foot/ankle, and mildly full from ankle to

groin.

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Swelling of both legs, ankles, feet Lack of awareness of how to manage this at home Decreased ability to ambulate Poor endurance to activity Open wound lt lower leg Risk of infection Lack of appropriate compression garments

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Problems:

LTG1: Fit for and obtain appropriate compression garments in order to minimize risk of girth increases and to maintain gains from PT intervention within 12 weeks

LTG2: Patient will demonstrate decreased girth in lt lower extremity at calf by 4 cm to measure for compression garment to maintain the reduction achieved in physical therapy to prevent recurrence of lymphedema in affected limb(s) within 10 weeks.

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Physical Therapy Long Term Goals

Interventions: Complete Decongestive Therapy (CDT)

Manual lymphatic drainage to trunk and bilateral LE Vasopneumatic compression pump to

bilateral lower extremities Compression bandaging/compression garments Home instruction/education: skin care,

self/caregiver manual lymphatic massage, compression, home exercises Exercise: lymphatic drainage/muscle pumping

2016: 1/14 1/20 1/22 1/27 2/3 2/5 2/9 2/11 2/15 Instep R

30.0 27.8 26.2 25.7 25.9 24.9 24.5 24.1 25.5

Instep L

30.5 30.2 30.8 30.0 30.0 30.0 30.5 29.7 29.4

Ankle R

33.1 32.0 31.6 30.4 30.5 30.6 29.9 29.3 29.2

Ankle L

32.8 38.5 38.0 38.0 37.6 37.0 37.8 35.2 35.4

Calf R 44 42.5 42.9 40.8 43.4 41.1 41.2 41.7 40.7 Calf L 60.8 55.7 59.6 60.4 57.9 57.3 55.8 52.0 53.4 Knee R

54.2 51.0 51.8 51.4 51.2 50.8 49.2 49.5 49.5

Knee L 54.4 55.0 55.3 55.0 52.7 54.1 51.4 53.5 52.7 Mid thigh R

74.5

Mid thigh L

68.9

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2016: 2/22 2/29 3/7 First Last change Instep R

24.2 24.8

26 30.0 26 -4

Instep L

28.2 29 29 30.5 29 -1.5

Ankle R

29 27.8 28 33.1 28 -5.1

Ankle L

35.2 37.4 32.8 32.8* 32.8 0

Calf R 41.1 37.2 37.5 44 37.5 -6.5 Calf L 55.4 53.7 50.2 60.8 50.2 -10.6 Knee R

49.6 47.4 48.4 54.2 48.4 -5.8

Knee L 53.7 51.1 51 54.4 51 -3.4

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Short Stretch bandaging (Multi layered), with artiflex and stockinette

VES compression pump alternating between legs

Juzo Expert knee high stocking (L LE ) 18-21 mmHg; custom made flat knit

Solaris Ready Wrap (R LE) Foot piece Calf piece Exo fusion sock

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Compression:

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Conclusion

Overall girth reductions

Ambulating with single crutch Has appropriate compression garments Wound fully closed Surgery scheduled for ankle fusion on April 11th

Right (cm) Left (cm) Instep 4 -1.5 Ankle -5.1 0 (-5.7) Calf -6.5 -10.6 Knee -5.8 -3.4

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Questions???

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