Dec. 12, 2013
Edema affects as many as 85 percent of patients at the end of life and undermines their comfort, mobility and quality of life. Strategies to palliate edema are neither standardized nor consistently taught to palliative medicine trainees. Limited communication between clinicians who treat edema and palliative care providers also can hinder patients' access to optimal care.
In an article published in the American Journal of Hospice and Palliative Medicine, physiatrists from the Department of Physical Medicine and Rehabilitation at Mayo Clinic in Rochester, Minn., explore the benefits associated with complex decongestive therapy for patients seen in the chronic disease and palliative care settings.
The goal of complex decongestive therapy (CDT) is to provide permanent control of the volumetric and metaplastic tissue changes associated with lymphedema. This multimodal treatment approach is widely used to control chronic edemas and is emerging as an effective means of managing refractory edema at the end of life. It can also help decongest the face, trunk and genitals. CDT is most often applied to the extremities in a two-phase treatment approach:
- Phase I treatment can include manual lymphatic drainage, a gentle massage designed to mobilize congested lymph, followed by the application of multilayer short-stretch compression bandages that are worn continuously between treatment sessions.
- Phase II uses compression garments and bandages at night, with the goal of maintaining the volume reductions achieved during phase I through daytime use. Lymphedema severity and limb contour guide the selection of compression garments, which can be purchased off-the-shelf or with customized fit and compression intensity. Off-the-shelf garments are less costly and available as sleeves, knee- or thigh-high, chaps style, and pantyhose. Custom garments are often more costly and may be necessary when the limb has an unusual shape or the lymphatic system is severely impaired.
"Lymphedema treatment modalities have much to offer beyond the treatment of classical lymphedema," explains Andrea L. Cheville, M.D., with the Department of Physical Medicine and Rehabilitation at Mayo Clinic in Rochester, Minn., and lead author of the article. "Numerous studies have shown that CDT is clearly beneficial. When administered by appropriately trained therapists, CDT achieves and maintains limb volume reductions of 50 to 70 percent."
CDT may lessen the burden of refractory edema originating from a diverse range of diagnoses, including congestive heart failure, venous insufficiency and liver failure.
Although the benefits associated with CDT in palliative care patients have been remarkable, its application can be associated with some risks when used in patients with metastatic cancer, liver and heart failure, peripheral vascular disease, wounds, and neurological deficits, all of which are common in the terminal stages of disease. Despite the fact that CDT may reduce a patient's edema, there are several contexts in which this approach may be less appropriate or contraindicated.
Contexts in which CDT, unless modified, may cause harm
Unless modified, CDT may cause harm in patients with impaired arterial circulation, sensation or ability to eliminate the mobilized fluid. This can include patients with diabetes, and patients with late-stage cancer related to chemotherapy-induced sensory impairment, peripheral neuropathy, radiation-induced radiculopathies and plexopathies, and direct nerve compression by tumors.
Contexts in which a full CDT program may exceed a patient's needs
A full CDT program may exceed the needs of patients with edema due to increased venous pressure, capillary hyperpermeability, inactivity or reduced intravascular oncotic pressure.
Contexts in which CDT, unless modified, will be less efficacious or fail
Unless modified, CDT may be less efficacious or fail for patients with:
- Wounds that may warrant referral to a vascular wound specialist, due to suspicion of arterial insufficiency
- Motor deficits or paralysis who are unable to activate the muscle groups in their edematous body parts
Given these risks, Dr. Cheville cautions: "Thoughtful planning and practice are essential, as an inadequate adaptation may result in unnecessary effort or injury for the patient or an unsatisfactory outcome."
Given that edema management has much to offer patients in the palliative setting, Dr. Cheville suggests that palliative care clinicians should have a working knowledge of CDT.
For more information
Cheville AL, et al. Adapting lymphedema treatment to the palliative setting. American Journal of Hospice and Palliative Medicine. In press.