Physical Therapy Intervention to Augment Outcomes Of Lymph Node Transfer Surgery for a Breast Cancer Survivor with Secondary Upper Extremity Lymphedema: A Case Report.
OBJECTIVE
Lymphedema is an incurable complication of breast cancer treatment that affects roughly 20 percent of women. It is often managed via complete decongestive therapy, which includes manual lymph drainage, therapeutic compression, skin care, and exercise. Lymph node transfer is a new and expensive surgical intervention that uses one's own lymph nodes and implants them in the affected upper extremity. Previous research has investigated augmenting lymph node transfer surgery with complete decongestive therapy, but there is a lack of evidence regarding the success of focusing lymph drainage against the normal pressure gradient toward a surgical flap located on the wrist. The patient's main motivation for the surgical intervention was to alleviate her daily burden of complete decongestive therapy. The purpose of this case report was to compare the methods and results of pre-surgical complete decongestive physical therapy to a post-operation modified approach that directed lymph fluid away from the major lymphatic ducts and instead toward a surgical flap on the wrist of a patient with lymphedema.


METHODS
A 65-year-old female presented with secondary upper extremity lymphedema following breast cancer treatment. Her circumferential measurements and L-Dex score corroborated this diagnosis, and she had functional deficits in upper extremity range of motion. She was seen for 10 visits of traditional complete decongestive therapy prior to her lymph node transfer surgery and 24 treatments of modified complete decongestive therapy over the course of six months following surgery.


RESULTS
At six months, the patient had minor improvements in the Functional Assessment of Chronic Illness Therapy-Fatigue, Disabilities of the Arm, Shoulder and Hand questionnaire, range of motion, and upper extremity strength. However, her circumferential measurements and L-Dex scores showed a meaningful increase in limb girth.


CONCLUSIONS
The patient's smallest upper extremity volumes were documented before the operation after two weeks of complete decongestive therapy. The surgical intervention supplemented by modified complete decongestive therapy resulted in increased limb girth after six months. Although the patient was able to stop wearing her compression garment while continuing independent manual lymph drainage and upper extremity wrapping, the post-surgical intervention was not a success because the patient's circumferential measurements remained meaningfully higher than at her initial examination. Further research is needed to determine the long-term effects of this surgery when coupled with physical therapy intervention, and whether it has better outcomes than the standard conservative treatment of complete decongestive therapy alone.
Department of Physical Therapy, University of Florida, PO Box 100154, Gainesville, Florida 32610.
Katelyn P
KP
McKey
Pain Research and Intervention, Center of Excellence, University of Florida, Gainesville, Florida 32610.
Meryl J
MJ
Alappattu
decongestive; intervention; outcome
J Rheumatol. 2005 May;32(5):811-9
15868614
N Am J Sports Phys Ther. 2010 Sep;5(3):98-110
21589666
Lymphat Res Biol. 2013 Jun;11(2):72-5
23772716
J Rehabil Med. 2010 Nov;42(10):967-72
21031295
J Orthop Sports Phys Ther. 2000 Mar;30(3):149-53
10721511
Ann Surg. 2006 Mar;243(3):313-5
16495693
BMC Musculoskelet Disord. 2003 Jun 16;4:11
12809562
Lymphology. 2013 Jun;46(2):85-96
24354107
Phys Ther. 2006 Feb;86(2):205-14
16445334
Arch Phys Med Rehabil. 2014 Jan;95(1):153-62
23932969
Cancer. 2011 Mar 15;117(6):1136-48
21381006
J Reconstr Microsurg. 2013 Feb;29(2):99-106
23254539
J Psychosom Res. 2013 Jan;74(1):64-8
23272990
Cancer. 2012 Apr 15;118(8 Suppl):2312-24
22488705
J Cancer Surviv. 2010 Jun;4(2):167-78
20373044
Plast Reconstr Surg. 2009 Apr;123(4):1265-75
19337095