Keywords elephantiasis - treatment - intensive
Lymphedema usually affects the poor, there is no cure and there are few therapeutic
perspectives in the private sector. This is exacerbated in less developed countries,
where lack of government resources and skilled health workers leads to marginalization
of the disease.
A combination of different therapies is recommended for the treatment of lymphedema
including manual lymph drainage, compression mechanisms, exercise, and hygienic care.[1 ]
[2 ]
In recent years, new options such as mechanical lymph drainage with devices that use
passive and active muscle activities, pressure therapy, daily life activities, and
nutritional and psychological management have been added.[1 ]
[3 ]
[4 ]
Intensive forms of lymphedema treatment have been described with the prospect of rapid
control of the edema and maintenance of the treatment outcome.[5 ] The purpose of this study is to describe the evolution of this form of treatment
with large reductions over a short period of time and a continual reduction in edema
on an outpatient treatment basis.
Case Report
The case of lower limb lymphedema in a 29-year-old female patient is reported. Lymphedema
began at the age of 12 years old after the patient was submitted to an exploratory
laparotomy; the initial hypothesis was appendicitis but a lymphoma was discovered.
Although the patient was submitted to sessions of radiotherapy and chemotherapy, she
does not remember how many because she was young at that time and her mother has died.
The swelling started in the thigh area and then spread to the feet. At first the edema
reduced on resting but over the years this ceased to occur.
The patient sought treatment and sessions of lymph drainage, and pressure therapy
and the use of elastic compression stockings were also indicated. She started using
pressure therapy and elastic stockings every day at her home. The edema worsened and
fibrosis developed in the region of the abdomen so she abandoned the treatment. Over
time, the swelling got worse and verrucosities began to appear in the leg and genitalia
region. She said that there was a constant secretion from the verrucosities.
She was referred to the Clinica Godoy, was weighed, and the perimetry of the leg was
measured as it was impossible to perform volumetry due to the size of the leg ([Fig. 1A, B ]). Intensive therapy was proposed: this included mechanical lymph drainage using
the RAGodoy apparatus (7 hours daily), manual lymph drainage using the Godoy technique
(1 hour/day), and a compression garment using a low-stretch stocking (< 50%) made
of a cotton-polyester textile adapted for major deformities (24 hours daily). The
compression stocking was adjusted every 3 hours depending on the reduction in volume.
There was daily weight loss. On 1 day the loss was ~ 6 kg and in 2 weeks, that is
10 days of treatment, the patient lost 31 kg. The following week she lost another
6 kg totaling 37 kg in 3 weeks.
Fig. 1 (A and B) Before treatment.
After the fifth day of intensive treatment, the patient began to do daily walks with
adjustments to the compression garment being made before and after. After the third
week, the patient returned to her home where she was submitted to mechanical lymph
drainage for 2 hours per day and a 1-hour walk with the stocking being adjusted as
necessary. At this stage, the low-stretch compression stocking was worn for the entire
day (24 hours) associated to an elastic compression stocking. She returned to the
clinic 1 month later with a reduction of more than 4 kg, totaling 41 kg during the
intensive treatment program ([Fig. 2 ]). Treatment was continued and evaluations were performed monthly until near total
reduction of edema ([Fig. 3 ]). The maintenance phase began after the total reduction of edema.
Fig. 2 After 4 weeks of treatment.
Fig. 3 After 8 weeks of treatment.
Discussion
This case report illustrates intensive outpatient treatment of lymphedema which allowed
a large reduction in volume over a short period of time. The results of this treatment
program raise the question about the formation of lymphedema. This patient is well
educated but even so she evolved with the most severe form of the disease. This shows
the difficulties encountered to find an appropriate form of treatment for lymphedema.
Another key aspect of this therapeutic approach is that maintenance of the results
continued to reduce the volume of the limb. She learned how to treat and control edema
using a form of maintenance that was inexpensive and that gave her independence in
respect to treatment.
Mechanical lymph drainage associated with a low-stretch compression garment allows
large reductions over a short period of time; in this case, as much as 6 kg were lost
in 1 day at the beginning of the treatment and 31 kg over 10 days of intensive treatment
in 2 weeks.
The quick weight loss in a short period of time raises questions about the constituents
of lymphedema where the accumulation of fluid appears to be a major factor. However,
other components appear to have been mobilized during treatment. After the treatment,
the weights and parameters of the patient's legs were considered normal. Thus, these
substances needed to be mobilized to explain the return to a size within the normal
range.
As the low-stretch stocking used hooks and eyes for adjustment, compression can be
adjusted every hour or as needed. With this approach, adjustment is essential and
is achieved without undressing the stocking, which is the main difference between
this mechanism and conventional bandages. The compression stocking was worn 24 hours
per day to keep the loss that had been attained with mechanical lymph drainage. Studies
evaluating cotton-polyester stockings during walking in patients with leg lymphedema
confirmed the synergistic effect of compression only when the stockings were well
adjusted (phase of publication).
Another interesting aspect was the increase in diuresis; this patient needed to urinate
at ~ 50-minute intervals during the day; the number of times dropped at night but
it was still frequent. The loss of large volumes per day shows that the liquid component
in lymphedema is very high and that part of the excess weight can be eliminated by
diuresis. However, the proteins and macromolecules are carried in the blood stream
and redistributed throughout the body. Thus, reduction of the lymphedema is possible.
The need for constant adjustment of the low-stretch compression is related to its
mechanism of action; the muscle activity generates a working pressure with peaks and
valleys in pressure at the skin-stocking interface. Thus, the reduction in limb size
gradually leads to a reduction in the effect of the working pressure. Compression
stockings exert resting and working pressures, where the working pressure depends
on the resting pressure exerted by the stocking. As the stocking loses its elasticity,
the working pressure will decrease to zero.
Another aspect to be discussed is that Foldi's concept of reduction of phase I swelling
is misleading and outdated. Currently, new approaches allow total or near to total
reduction in the first phase of treatment. Thus, phase II of treatment should be initiated
after the total reduction of edema. This new concept is important because it gives
the therapist the opportunity to provide a better outcome for patients. In the case
reported here, the intensity of treatment was reduced to allow for skin retraction.
Thus, just with clinical treatment and without surgery, it is possible to leave the
limb within the normal size range.
Another aspect to be considered in this case is the pathophysiology of lymphedema
of the patient. She has a history of surgery and radiotherapy; however, it is difficult
to rule out the possibility of an association with late primary lymphedema. But regardless
of the cause of lymphedema, it is possible to reduce the swelling to normal or near-normal
leg sizes. Therefore, this therapeutic approach is useful for most types of lymphedema.
The most important aspect of this form of therapy is that patients learn to treat
their disease on their own and have almost complete independence and manage to keep
the limb within the normal size range. The medical team needs to provide guidance
on preventing infection and treatment when present. Occupational activities together
with compression are the basis for maintenance and so the supervision by an occupational
therapist is crucial in this form of therapy.
Conclusion
Intensive treatment of lymphedema is an option which provides rapid reduction in the
swelling, and low-stretch compression maintains the result achieved and continues
to reduce the limb size.
