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Abstract A variety of conditions result in lower extremity edema, such as deep vein thrombosis, cellulitis, venous stasis insufficiency, and congestive heart failure (CHF). A case study is presented to illustrate the dynamics of the lymphatic system, the pathology of CHF, the importance of obtaining a pretreatment differential diagnosis, and how to implement a safe treatment plan. The patient was a 69-year-old overweight woman with bilateral lower extremity lymphedema of almost equal volume (~9,100 mL) of >2 months’ duration.

She had 11 draining wounds and a reported history of chronic obstructive pulmonary disease (COPD) but no cardiac dysfunction. Treatment consisted of 6 sessions of manual lymph drainage (MLD), remedial exercises, and compression wrapping and weekly volumetric measurements over a period of 3 weeks. A 4-L decrease in lower extremity edema volume was noted, but fatigue and shortness of breath increased markedly. Treatment was discontinued and the patient was referred back to her physician for cardiac evaluation and treatment. The literature suggests patients, as well as health care professionals, do not always distinguish CHF symptoms from COPD. Proper assessment, monitoring, and lymphedema treatment adjustments are paramount to providing safe care for patients with signs and symptoms of COPD and suspected CHF.

More research to elucidate best practice approaches in patients with lymphedema and concurrent CHF/COPD before the start of MLD treatment is warranted. Lymphedema is an accumulation of protein-rich fluid that can be present for a number of reasons, including damage to the lymphatic network as a result of trauma, removal of lymph nodes, and genetics, as in the case of some primary lymphedema syndromes. 1 A patient with lymphedema may have swelling in the trunk, face/neck, genitals, or extremities as a result of compromised lymphatic flow pursuant to lymph node removal, trauma, or a possible genetic predisposition. As of 2002, a literature review of more than 1,900 references to determine the incidence of both primary and secondary types of the condition in the United States Medicare age group (65+) showed lymphedema affected upwards of 6.8 million individuals.

2 Research, by literature review, is underway to determine the incidence in the nonMedicare-age group population, specifically persons with breast cancer, trauma, and primary lymphedema, but currently collection of these data by an online website forum 2 is not complete. According to the Position Statement of the National Lymphedema Network (NLN), 3 a qualified health care professional should help determine the diagnosis of lymphedema in the earliest possible stage for more effective treatment. Patients referred for lymphedema treatment can have a variety of diagnoses; therefore, it is important to obtain a thorough patient and cardiovascular/pulmonary systems history, integumentary review, musculoskeletal and neuromuscular assessment, and determination of communication capabilities and to conduct a physical therapy examination to diagnose the cause of lower extremity swelling. The physical therapist (PT) or the health care professional who is differentially diagnosing patients with lower extremity swelling needs to know the duration, distribution, and accompanying symptoms of the leg edema in order to render an effective differential diagnosis. 4 Five diagnostic tests necessary to properly diagnose lymphedema include magnetic resonance imaging (MRI), computed tomography scan (CT), lymph vessel imaging, volumetric measurements, and assessment of changes in biomechanical or electrical properties of the fluid. According to the NLN 3 and a literature review by Young, 5 swelling distribution (bilateral versus unilateral) is important in determining pathology, and bilateral leg edema is usually an indication of a systemic process. 4 The PT/health care provider needs to have full knowledge of patient medication and reports of pain, trauma, and surgery to help determine the cause of edema.

Any accompanying symptoms, such as dyspnea with exertion, orthopnea, and/or paroxysmal nocturnal dyspnea, most likely are indicative of congestive heart failure (CHF). 4 Physical examination to determine the presence of heart failure such as distended neck veins, listening for ventricular gallop, and conducting echocardiography 4 are also an important part of the evaluation process. Adobe audition 3.0 activation code keygen. Determining what diagnostic tests have been performed on the patient is essential.