By Fiona McCusker, PT, CLT, St. Mary’s Medical Center, San Francisco, CA
Vol. 28 No. 3 - Lymphlink Reprint, Archived July 2015
Obesity is a chronic health problem resulting from the complex interplay between biological, psychosocial, behavioral, genetic, and environmental factors. Recent evidence suggests that superobesity, which is a body mass index (BMI) over 40, may cause extremity lymphedema.1 Additionally, obesity has been reported as a risk factor for the development of secondary lymphedema following cancer treatment.1 Obesity is also risk factor for chronic venous insufficiency.2 Chronic venous insufficiency may progress, if left untreated, into a combined venous/lymphatic disorder, resulting in secondary lymphedema.3 Thus, patients who are obese (BMI >30 kg/m2) may seek treatment for lymphedema. Untreated lymphedema has been associated with reductions in physical function and quality of life.4,5 Successful treatment of lymphedema in the context of obesity may be challenging. Additional time may be required for treatments, specialized equipment may be required for positioning, patients may have difficulty with self-care, and comorbidities may confound progress.6 Obese patients may have mobility impairments that preclude self-bandaging, particularly of the lower extremities. However, appropriate treatment is essential, not only to address physical impairments, but also to provide encouragement and support, all of which will lead to improved activity, participation, and quality of life.
L.F. is a 61 year-old female with no family history of obesity or lymphedema. In 2014, her podiatrist told her that her lower extremity swelling could be lymph-edema secondary to obesity and venous insufficiency. For 5 years, her BMI was over 30 and she had experienced increasing swelling in both legs. She was also diagnosed with rheumatoid arthritis (RA), high blood pressure, hypothyroidism, hypercholesteremia, and depression. Medication use included Lovastatin, Levothyroxine, and Lisinopril.
L.F. reported that, when asked, both her primary and vascular physicians attributed her lower extremity swelling
to her obesity. She was advised to lose weight, elevate her legs day and night, and wear compression stockings.
Complying with her self-management plan was a challenge. L.F. found it difficult to constantly elevate her legs, and the poor-fitting compression stockings increased her lower extremity pain to an intolerable 10 out of 10 on the numeric rating scale. According to L.F., the swelling in her legs at this point was “overwhelming and depressing.” She felt that because of her obesity, her complaints of worsening swelling and function were being discounted.
L.F. stated that 6 months prior to visiting our clinic, the left leg reddened and the swelling increased. Her shoes no longer fit. Standing was limited to 10 minutes or less, and she was eventually unable to leave her home. She became more depressed, and her weight and social isolation further increased. One month prior to coming to our clinic, a nurse casually mentioned to L.F. that there may be solutions for her swelling through treatment at our lymphedema clinic.
At her initial lymphedema clinic visit, L.F. stated that walking caused a constant, burning pain in her legs that worsened when she walked more than 40 feet.
L.F. ambulated into the department slowly and unsteadily, using a wide base of support but no assistive device.
While there were no signs of lymphedema in the thighs, her right lower leg presented with stage 2 lymphedema and the left lower leg with stage 1 lymphedema. The left lower leg was a mild pink color with 3+ pitting edema along the lateral border of the tibial plateau. There were no signs of infection in the left leg. The right lower leg tissue was fibrotic with deep hemosederin staining across 90% of the area. Classification of lower extremity chronic venous disorders is done through the Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification system. L.F. was categorized as CEAP Cb4: Lipodermatosclerosis (localized chronic inflammation and fibrosis of the skin and subcutaneous tissues of the lower leg). There were no signs of infection in the right leg. She presented with eczema along the medial malleolus of the right leg and toe fungus bilaterally. She had absent Stemmer signs in both feet.
L.F. was only able to perform 5 heel raises on each leg due to fatigue. After 2 minutes on the treadmill at 1.3 miles per hour, she was short of breath, and her heart rate increased from 80 beats per minute to 120 beat per minute.
L.F. presented with secondary lymphedema likely related to obesity and venous insufficiency. She presented with stage 1 and 2 lymphedema in her lower legs, leg pain, limited and painful gait, decreased lower extremity strength, and general deconditioning. She presented with a number of comorbidities, including RA and depression, that could impact her ability to participate in self-care. She reported a history of increasing depression and social isolation, along with limited adherence to self-care strategies in the past.
Pretreatment goals for L.F. were to reduce pain, decongest both legs, and increase knowledge of skin care and infection prevention. We agreed that functional goals were to walk at least 2 city blocks, increase calf strength,
and fit into her shoes. Our long-term goal was that L.F. would acquire the skills to manage her own lymphedema so that she could prevent pain and worsening function.
At her first treatment session, L.F. was provided with education about the role of venous insufficiency in lymphedema development and was encouraged by the understanding that her condition could improve significantly with therapy. She was instructed in skin care for her lower legs and toes. She received a trial session for a sequential pump, which reduced her circumferential measurements by 1 to 3 centimeters throughout both legs in 30 minutes. A pump was ordered for home use, and manual lymphatic drainage (MLD) and compression bandage treatments were started. Her home exercise program was tailored to strengthen her calf muscles, and she was advised to attend our clinic twice a week for four weeks. Additionally, she was advised to order Velcro compression braces for her lower legs and feet.
L.F. responded well to MLD, compression bandaging, and regular use of the pump at home. After 2 weeks of therapy, all her measurements were reduced by 3 to 5 centimeters. Compression bandaging was replaced with the Velcro compression leg and foot braces when they arrived a week later. L.F. was then instructed to use her pump twice a day and immediately don her braces afterwards, which she was able to do independently. She was extremely compliant with skin care, and her eczema and toe fungus reduced. Use of a negative pressure pump was initiated to reduce the fibrosis on her right lower leg. Her hemosiderin staining lessened and lightened, and the fibrotic tissue softened. Most importantly, her bilateral leg pain decreased to 0 of 10, with no symptoms of burning. As a result, L.F. was able to stand in her kitchen to cook and wear her own shoes.
Eight weeks into treatment, her goals included increasing calf strength to improve her venous return and improving cardiovascular endurance. She was able to perform 30 heel lifts before tiring and could walk 3 city blocks. Exercise tolerance improved with treatment-related pain reduction. Although her weight only minimally reduced, she felt more optimistic and realized that a stringent weight loss program was the next essential step.
L.F. was encouraged to attend her local pool, but felt very self-conscious because of her weight. At the time of this writing, she is continuing therapy once a week to focus on strengthening her legs and to further improve her cardiovascular endurance. Her legs remained decongested and pain free.
L.F. is an example of a patient who, because of her obesity, felt discrimination from medical professionals when seeking care for her lower extremity swelling and pain. She was repeatedly advised to lose weight and perform non-specific self-care treatments, which she could not comply with at the time. Her condition worsened, and she was left feeling frustrated and depressed. L.F. responded well to lymphedema therapy aimed at reducing her lower extremity swelling. She demonstrated improved strength, decreased pain and swelling, and improved function. She was able to participate in a self-care plan that was specific to her needs and goals.
Healthcare providers sometimes share the same attitudes toward obesity as the general public and have strong negative attitudes about people with obesity, which may affect the quality of care provided.7 This discrimination causes the patient to feel shame, often making them less likely to seek help. All healthcare providers, including lymphedema therapists, should examine their attitudes towards patients with obesity who seek treatment for lymphedema and avoid imposing bias in the care provided. These patients should be afforded the same consideration as others with any disability. Though weight loss may not be the primary goal of lymphedema therapy, patients with obesity who are treated for their lymphedema can make significant and important improvements in their lymphedema symptoms and achieve a better quality of life.