Patient 2: Initially, this participant's affected left arm volume was 2,556 ml compared with a volume of 2,522 ml in her healthy right arm. After 14 months in ALT, she achieved a volume of 2,440 ml, which is a reduction of 116 ml. She began the ALT program with 1% edema in her affected left arm as compared to her healthy right arm. After 14 months, she demonstrated a -5% edema in the affected left arm as compared to her healthy right arm and the lymphedema under her axillary area was smaller and softer. Subjectively, she reported that her arm was stronger and that she was more confident in using her arm in functional tasks than before the self-treatment program. Additionally, this participant went on 2 long vacations of 1-month duration, using air travel and although she forgot to take her compression garment, her lymphedema did not return.
Patient 3: Initially, this participant's left arm volume was 3,548 ml compared with a volume of 3,148 ml in her healthy right healthy arm. After 14 months in the ALT program, she achieved a volume of 3,222 ml, which is a 326 ml reduction. This participant began the program with a 13% increase in edema in her affected arm as compared to her healthy right arm. After 14 months, her edema in the affected arm decreased to 2% in comparison to the healthy arm. Additionally, the lymphedema under her axillary area disappeared.
DISCUSSION
The ALT protocol described in this article provides women in the maintenance phase of lymphedema with an effective and pleasurable method to promote adherence to self-treatment methods. Aquatic lymphatic therapy provides women with the following benefits: first, ALT uses the properties of water, specifically the buoyant force, hydrostatic pressure, water viscosity, and water temperature, to maintain or improve lymphedema reductions achieved during the intensive treatment phase with CDT. The ALT method may be effective because the hydrostatic pressure of water has the potential to remove the fluid and then the self-massage and exercise promote protein removal using healthy lymphotomes. Second, ALT promotes self-efficacy by educating the participants to use the sequence and the slow rhythm of appropriate exercises so the participants can take responsibility for performing their individualized protocol.
Third, ALT provides women with a support group with all of its advantages.16 Fourth, this program includes monitoring by a physical therapist to address changes on an individualized basis, and the use of feedback charts to empower a woman to monitor her status and to develop appropriate self-treatment strategies. Finally, there is active self treatment as the participants use their muscles throughout the entire session, in contrast to conventional treatments using passive techniques.
The ALT was used in these cases as an effective tool during the maintenance phase of lymphedema when a woman is responsible for treating herself. The maintenance phase also may consist of daily compression with a low-stretch elastic sleeve, skin care, continued 'remedial' exercises, and repeated light massage as needed.7
All 3 women demonstrated good adherence with the ALT program. Two of the participants (Participant 2 and 3) were considered nonadherent with conventional maintenance phase treatments, since they did not wear their compression garments or perform the self massage and exercises. However, adherence to this method of maintenance was high for both of these participants.
Lastly, the summer temperature in Israel can reach up to 40°C with heat waves even in April and May. In spite of the changes in the climate through the 14 months, the amplitude of changes in the volume of the lymphedematous limbs were not acute. During April 2003 there were no sessions due to pool reconstruction, but as seen in Figures 10 and 11, the effect on the patients' conditions was a brief one and didn't last.
CONCLUSION
These case reports demonstrate the benefits that are typically derived from ALT by women in the maintenance phase of lymphedema treatment. During the 14 months of ALT none of these participants experienced exacerbations of their lymphedema and all of these women demonstrated further reductions in the volumes of their affected arm. These 3 women represent typical types of women that participate in the ALT program.
Participant 1 represents women who develop lymphedema even after receiving proper care and exhibiting good compliance to traditional maintenance techniques. Of interest was the fact that participant 1 experienced further marked improvements in her lymphedema with ALT treatments, as traditional techniques did not appear to adequately control her condition.
Additionally, women like participant 1 who develop lymphedema despite good care typically are required to wear a compression sleeves between self-treatment sessions as this participant was required to do.
Participant 2 represents women who achieve 100% reductions of their lymphedema after the initial intensive phase of the conventional treatment, or come for self-treatment to prevent the exacerbations of their lymphedema. Women like participant 2 are able to maintain good results with no further self treatment between sessions.
Participant 3 represents women who have lymphedema but struggle to adhere to traditional maintenance techniques. Participant 3 demonstrated good adherence to ALT and was able to show good improvements in her condition. This participant did not require a compression sleeve between sessions, like many women in the maintenance phase. For women similar to participant 3, ALT may be an additional tool in their maintenance phase for controlling lymphedema.
Further studies are needed to answer the following questions:
* What are the long-term and short-term physiological effects behind the ALT?
* Does ALT activate healthy lymphotomes or collateral vessels to take over the work for affected lymphotomes?
* How do the results of ALT compare to traditional land-based maintenance programs for lymphedema in terms of preventing exacerbations or further reducing lymphedema volumes?
* What are the differences in adherence between traditional maintenance protocols and ALT?
* Can this method be a successful alternative to the conventional methods for arm and leg lymphedema in places where conventional treatment is not available due to cost or availability or trained health care practitioners?
* What is the actual cost comparison between traditional maintenance protocols and ALT?
* Can ALT be used between phases one and two in order to improve outcomes in cases where a 100% reduction was not achieved by the CLT/CDT?
The ALT program has been successfully used at our facility for more than 2 years. We are continuing to gather additional data on the effects of aqua lymphatic therapy on patients.
However, further clinical research is required to modify, refine, and provide evidence for the utility of this approach in other groups of patients including those with lower extremity lymphedemas or lymphedema that is not the sequela of cancer treatments.
ACKNOWLEDGMENTS
We express our deepest gratitude to Prof Judith R. Casley-Smith, Chairman of the Lymphoedema Association of Australia, for her support in the development of the Aqua Lymphatic Therapy; and for Dr Anna Towers, Director, Palliative Care Division, McGill Department of Oncology; and Rachel Pritzker, President of the Lymphedema Association of Quebec (AQL/LAQ) for their helpful comments on an earlier draft of the manuscript.
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Dorit Tidhar, BPT, Aqua Lymphatic Therapist, Hydrotherapeutic Center of Shaar-Hanegev, Israel
Avi Shimony, MD, Soroka University Medical Center, Israel
Jacqueline Drouin, PT, PhD, Assistant Professor, Physical Therapy Department, The University of Michigan-Flint, USA
Copyright Rehabilitation in Oncology 2004 Provided by ProQuest Information and Learning Company. All rights Reserved
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