PALLIATIVE CARE TREATMENT FOR CLIENT WITH ACUTE LEUKEMIA

Implementation of Manual Lymph Drainage techniques for the relief of pain

In treating chronic pain, nothing poses a greater challenge than the treatment of a client with terminal cancer. At this stage there is no prospect of a cure and the focus of massage must be to give the client relief of symptoms and the best possible quality of life. It is of utmost importance to communicate effectively with the client (and their family if necessary) to design a treatment plan which will address the client’s specific needs at that time.

The idea for this article developed when two therapists, Lee Kalpin and Lou Nucci, were discussing techniques for, and results in treating clients with lymphedema.  Each of these therapists had the experience of treating a client who had severe edema secondary to cancer (acute leukemia).

The discussion addressed three main topics:

• What precautions or contraindications are relevant when treating a person with terminal cancer
• What are appropriate goals for the treatment
• How effective are basic manual lymph drainage techniques.

Another important aspect of these Case Studies is the effectiveness of simple Manual Lymph Drainage techniques. Neither of these therapists is a specialist in MLD. Simple lymph drainage techniques were used with great effectiveness, resulting in decreased pain, improved function and quality of life for the two clients. Although both these clients suffered from Acute Leukemia, the principles of treatment followed would be similar for any type of cancer which caused edema.

The following is a summary of one of these cases.

Lee Kalpin, RMT    

I was asked to provide home visits for a man who required treatment for edema in his legs.  I had been referred to him by his wife’s chiropractor to provide manual lymph drainage.

Subjective information

The client was a 70 year old man who had been diagnosed with acute leukemia several weeks prior to this visit.  He had been hospitalized to receive chemotherapy treatment, and at this time had been at home for one week, being cared for by his wife in the evenings, and by visiting caregivers who came in for two hours each day.

He was a tall, well-muscled man who had been very active and fit up to the time of the onset of the leukemia. The client complained of extreme swelling of his legs, ankles and feet. The onset of these symptoms was immediately after chemotherapy treatments. He reported severe pain from the tissue stretching caused by the edema, and found walking difficult because the edema severely limited mobility at the ankles.

Objective information

On examination, I found that there was significant edema below the knees bilaterally, most noticeable around the ankles and feet. The left leg and foot were more edematous than the right.  Bones of the ankles and feet were not visible due to the swelling.  There was no redness or heat as this was not a result of an inflammatory process.  The client had a large scar on the left lateral leg which was the result of a gunshot wound that had healed with adhesions and fibrosing. He also had foot-drop in the left ankle due to nerve damage from the gunshot injury.

Range of motion of both ankles was extremely restricted due to the edema, and limited the client’s ability to walk.  He was able to walk  only short distances using a walker for support.  On two occasions he had been unable to get to the bathroom and was very concerned that he would soon be unable to manage his functions independently.

Precautions

I was concerned about the ability of the kidneys and heart to accept the added load of fluid which would result from lymph drainage work. I consulted with the nurse-practitioner who was in charge of his care, and she confirmed that his organs were failing.  However, she advised that his condition was terminal and the primary concern was to reduce pain and maintain function for as long as possible.

Goals of treatment

My client’s goals for treatment were to decrease the edema and maintain his ability to walk independently so that he could get to the bathroom and kitchen without assistance.

(Ref: 1. P. Clifford: Journal of Soft Tissue Manipulation: 2. D. Curties: Massage for Cancer:).

Treatment

For weekly treatments, the client was positioned supine on his hospital bed with his legs and feet elevated on pillows.

Treatment consisted of manual lymph drainage to both thighs, legs, feet and ankles, with thirty minutes spent on each leg.

I would like to briefly describe the techniques used for MLD.  While some therapists use a “feather-light” touch for lymph drainage, I use a more firm contact (Ref: P Clifford: Outcome Based Massage pg 158 - 159). Minimal pressure is used to engage the skin and sink slightly into the subcutaneous fat. The skin and superficial fascia are then stretched in the direction of lymphatic flow. The working surface of the therapist’s hand does not glide over the skin.  For large areas such as the thigh, two hands placed side by side create a larger contact area.  Oil is not usually applied for MLD work, however I did apply a small amount to my hands when working on the lower leg, to avoid pulling leg hair.

Because there was such significant edema in the client’s lower legs and feet, the lymph drainage techniques actually produced a visible “wave” of fluid that could be moved toward the inguinal lymph nodes.

In the left lower leg, it was necessary to direct lymphatic flow around the scarring, since all lymph ducts had been destroyed by the injury in this area.

In the first treatment I used heat at the inguinal lymph nodes, and performed a “pumping” technique over the lymph nodes and the cisterna chyli (Outcome Based Massage: Clifford pg 159).  Prior to the second treatment the client was put on portable chemotherapy, with the line inserted into the abdomen.  In all subsequent treatments I therefore avoided any manipulations in this area.

Treatment progression and results          

At the end of each treatment, there was a very noticeable and measurable decrease in the edema.  Measurements were taken at each treatment, which typically recorded a decrease in girth at the ankle of three- four cm. Bony landmarks of the ankle and foot were easily visible after treatment.  Active and passive range of motion of the ankle were increased after every treatment.

The client reported increased urination post-treatment, and was able to continue walking independently around the house until the last week of his life, using his walker for stability and balance. He was able to maintain independence for bathroom functions, and could go to the kitchen to get his lunch.

I treated this client a total of six times over a six-week period.  In the last two sessions I observed a rapid deterioration in his general condition.  He was losing weight rapidly, was very fatigued, and on my last visit he reported that he had developed pressure sores on his buttocks due to the loss of tissue mass on his buttocks and thighs. 

On that last treatment I also positioned him in sidelying and massaged his gluteal area to increase circulation to the area and decrease pressure sores.

Outcome

My client died at home four days after our sixth treatment.  I felt very saddened by the death of this very interesting and determined man. I also felt grateful that I had been able to use massage therapy techniques to give him some relief from pain, and to enable him to maintain function and independence to the end of his life.     

Note: Realistic treatment goals

The case study I just posted may seem to some therapists as a "failure"  since the client died of acute leukemia at the end of the story.  Unforunately, not all case studies have happy endings.

My goal with this particular patient was to keep him comfortable for as long as possible, to reduce pain, and most important of all, to enable him to maintain independent function to the end of his life. From this point of view the treatment was a success.

When treating cancer patients, or others with terminal illnesses, it is important to set realistic, achievable goals for our treatment. 

Lee Kalpin