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Oct - Dec 2013: Palliative Care

Lymphlink Question Corner - Archived From Oct-Dec 2013

By:  Julia Rodrick, OTR, CLT-LANA, WCC
St. John’s Hospital, Rehab. South Out-Patient Services, Springfield, IL

Q: I am a certified lymphedema therapist and have treated various types of lymphedema over the last 10 years.  Recently, I have received several requests by our local oncology doctor to provide manual lymph drainage (MLD) for patients who are still receiving chemotherapy. Can I cause metastasis? When I explore my resources, I can’t find a definitive answer.

A: In the late 1980s and early 1990s there was concern that manual lymph drainage could potentially facilitate metastasis by “pushing cancer cells” through the circulatory system and lymphatic channels. Contemporary research has not validated this concern. Your question is addressed in the 2nd edition of Foeldi’s Textbook of Lymphology (2006). Dr. Ethel Foeldi and Dr. Michael Foeldi say “No.” They state that “the decisive argument is provided by biology which has demonstrated that formation of metastases is an active process, initiated and controlled by the cancer cells themselves.” They go on to explain that “the biological properties of cancer cells and the condition of the immune system” are responsible for metastases (pg. 275). The advancements in medical science, technology and cancer research demonstrate that daily metabolic processes, movement and exercise increase circulation to a much greater degree than the manual techniques used to treat lymphedema. An article found through PUBMED and written by Pinell XA (el al, 2008) titled, “Manipulative Therapy of Secondary Lymphedema in the Presence of Locoregional Tumors,” explores this topic and provides some helpful information. For palliative care, the benefits of manual lymphatic techniques are well documented and should not be withheld. MLD is known to reduce anxiety and pain (Clemens, el al 2010) as well as to improve sleep patterns (Wilkie, D.J., et al 2000) and assist in controlling the accumulation of inflammatory fluid within the tissues, which can offer soothing effects for the terminal patient (Foeldi, E. 2006). 

As with any disease process, modifications to traditional decongestive therapy techniques may be necessary in the event that the patient develops tactile intolerance, skin integrity issues or other complications that may prevent you from providing MLD in the customary venue. Creativity and collaboration with the patient’s entire health care team and caregivers are very important. As in all circumstances, check with the physician to support your plan of care.

Q: As a health care provider, I have difficulty developing a plan of care that can show progress (in consideration of recent G-Code requirements) for patients who receive CDT in palliative care…Help?!

A: This is a very timely question. There are many who seem to share your frustration. 

Based on the International Classification of Functioning, Disability and Health (ICF), the codes are designed to capture beneficiary claim information regarding the functional level or condition of our patients and the services we provide through a plan of care. The codes challenge therapists to measure the effectiveness of that plan of care through the use of an approved standardized functional outcome tool of our choosing. Evidence data (which supports the effectiveness of the plan of care) is collected in intervals along the continuum of care and will be used to design health care payment reform.  The spirit of the coding system captures the intention of any health care provider. We hope to provide care that will improve the condition and quality of life of our patients. 

To use these codes effectively, we first examine the functional limits of our patients based on specific categories. These categories include how the patient can safely and functionally interact with their environment regarding mobility, changing of body positioning and the ability to carry or handle objects and complete their own self care. It is important to recognize that the presence or degree of edema is not the sole influence for measuring success. An important consideration of palliative care and outcome measures is to remember that swelling may fluctuate day to day, so girth measures may not be the best choice to assess functional outcomes. 

Any patients with lymphedema (palliative or otherwise) may struggle from any combination or degree of measurable functional deficits that are a direct or indirect result of lymphedema. These may include musculoskeletal dysfunction, weakness, poor endurance, impaired skin integrity, altered sensation, declining Activities of Daily Livings (ADL) skills or cognitive abilities and psychosocial issues which impact the quality of life, so focus on how the reduction of the limb supports the patient’s ability to interact safely with their environment.   

In summary, assigning these codes simply asks the health care professional to continually assess their contributing role to provide therapeutic interventions to support the quality of life for the duration of life.

Q: What are some alternatives for providing compression for a patient who is receiving palliative care for lower extremity lymphedema, but who has difficulty tolerating garments?

A: Traditionally, one of the mainstays of lymphedema treatment is compression. In basic terms, during the initial treatment phase, a multi-layered, short-stretch (inelastic) bandage system is used to help reduce swelling by supporting lymphatic drainage as it provides external pressure against the tissues to increase the tone of the muscle pump, thereby contributing to the evacuation of stagnant lymph fluid within the tissue. Compression devices and garments are also used but are generally reserved for the second or management phase of treatment, once reduction is achieved. Compression can be applied in other forms and, with regard to the challenges of palliative care, alternatives in compression materials and application may be the answer.

Alternative types of compression include those utilizing different materials. Because compression garments are fitted and do not accommodate to a changing limb size, they may not be the best first choice for patients undergoing palliative care. Soft foam synthetic “wool” can be used to distribute pressure for comfort. By modifying the tension of a bandage system periodically, the bandages can still influence the forces of external pressure in support of the muscle pump for decongestion while allowing comfort and increased tolerance. Lighter elastic materials and tubular stockinettes have been used, but because their design lacks gradual pressure, binding may result. 

Duration of bandage wear can sometimes be increased by wrapping only the distal portion of the limb and encouraging the patient or caregiver to complete proximal “clearing” of the regional lymph nodes. In some situations, if the patient’s skin is intact and without a history of irritation, the use of elastic taping (ie; kinesio-tec tape or performance tape) may be useful to reduce tissue density and pain. A pilot study by Han-Ju Tsai (et al, 2008) suggested that elastic taping may serve as an alternative for patients who demonstrate poor bandage compliance. It is important to mention that use of elastic taping requires some advanced training to be used safely and effectively.

References 

  1. M. Foldi, E. Foldi, S. Kubik (Eds.), 2nd edition Foldi’s Textbook of Lymphology  for Physicians and Lymphedema Therapists, Munchen;  Elsevier Urban & Fisher 2006
  2. Pinell XA, Kirkpatrick SH, Hawkins K, Mondry TE, Johnstone PA. Manipulative therapy of secondary lymphedema in the presence of locoregional tumors. Cancer 2008;112:950-954.
  3. Clemens, K (et al, 2010); Evaluation of the Clinical Effectiveness of Physiotherapeutic Management of Lymphoedema in Palliative Care Patients; Jpn. J. Clin. Oncol. (2010) 40 (11): 1068-1072
  4. Wilkie, D.J., Kampbell, J., Cutshall, S., Halabisky, H., Harmon, H., Johnson, L.P., Weinacht, L., & Rake-Marona, M. (2000). Effects of massage on pain intensity, analgesics and quality of life in patients with cancer pain: A pilot study of a randomized clinical trial conducted within hospice care delivery. Hospice Journal, 15, 31-53.
  5. Gayle lee, JD; Heather L. Smith, PT,MPH. Functional Limitation Reporting for Therapy Services under Medicare Part B; Http://web.missouri,eduWebinarSlides.pdf
  6. APTA website; http://www.apata.org/payment/medicare/codingBilling/functionalLimitation
  7. Tsai, Han-Ju; Hung Hsiu-Chuan; Yang, Jing-Lan; Huang, Chiun-Sheng and Tsauo, Jau-Yih; Could Kinesio tape replace the bandage in decongestive lymphatic therapy for breast-cancer-related lymphedema? A pilot study; Support care Cancer (2009) 17:1353-1360 DOI 10.1007

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