Identification and Impact of Standard Treatment Protocols on the Impairments and Activity Limitations Related to Lower Extremity Lymphedema

• Main Author: Kunkel, Kevin Robert
• Format: Others
• Published: Scholarly Repository 2010
• Subjects: Physical Therapist
• Online Access: http://scholarlyrepository.miami.edu/oa_dissertations/403

Lower Extremity Lymphedema is a chronic condition of characterized by swelling of body part. It is typically treated with Complex Decongestive Therapy (CDT) to reduce volume. While volume reduction is the primary goal of the treatment, third party payers often require the presence of activity limitations in order to qualify for coverage. The purpose of this dissertation was to identify the types of impairments and functional limitations that occur in this population. A second goal was to determine if volume reduction from CDT is sufficient to resolve the impairments and activity limitations associated with lymphedema, or if traditional physical therapy is necessary to resolve them. In Chapter 2, we performed a study to validate several tools to measure the change in volume that occurred with CDT. Also, a reliability study was performed on the Perometer. The results of this study found that the Perometer had excellent test-retest reliability ( ICC = .99) and that the change measured by the Perometer agreed better with the change measured by the "gold standard" water displacement method, (ICC = .99) than did the change measured by the circumferential tape method (ICC = .92). In Chapter 3, we conducted a cross sectional analysis to determine the baseline impairments and activity limitations associated with lower limb lymphedema. Subjects scored below normal values in all measures of impairments and activity limitations including active range of motion to ankle dorsiflexion and knee flexion, Heel Rise, 30 Second Chair test, Berg Balance Score (BBS), Limits of Stability (LOS), Extended Timed Get Up and Go (ETGUG), Limitation in Mobility Activities Test (LIMAT) and SF-36 Medical Outcomes Study (SF-36). Subjects with severe vs. moderate lymphedema demonstrated scored significantly worse on all tests except ETGUG. Limb Volume was correlated at a fair level with all impairment and activity limitation measures except SF36 which produced a strong correlation. Impairment measures correlated strongly with activity limitations. In Chapter 4, we performed a longitudinal study to address several questions. Were reductions in limb volume related to improvements in impairments and activity limitations? What proportion of subjects completing 2- weeks of CDT continued to have balance impairments or activity limitations severe enough to increase the risk of falling? In subjects at increased risk of falling, does a 4-week standard physical therapy intervention produce improvements in both impairments and the activity limitations? The change in limb volume was significant after the 2 week CDT intervention. However, the loss of volume was not strongly associated with an improvement in impairments or an increase in function over the two week or additional 4 week treatment intervention. Traditional physical therapy intervention produced significant improvements in activity limitations and body function impairments. In Chapter 5, we discussed the clinical and health care policy implications of this research. It was determined that the standard CDT treatment protocol was not sufficient to address impairments and activity limitations other than edema in subjects with lower limb lymphedema. A comprehensive evaluation of these patients requires a traditional physical therapy examination in addition to the volume evaluation to assess the associated impairments and activity limitations. Third party payer coverage guidelines require that the patient be educated to maintain the reduction in limb volume achieved by CDT. This study found a worsening of the edema occurred 4 weeks after termination of the CDT. Policy guidelines were originally developed for individuals with upper extremity lymphedema and may need to be modified for subjects with lower limb edema because of substantial differences in the types of impairments and limitations in mobility and function that occur when the lower limb is involved.