Assessing Lymphedema’s Seating & Mobility Challenges

Q&A with Stephanie Tanguay, OTR, ATP

Q: What are some possible scenarios in which a seating & mobility provider or clinician would work with a client with lymphedema? For example, what seating & mobility assistance/support would a lymphedema patient be likely to need?

Stephanie Tanguay: A patient with lymphedema in an upper extremity (if they are using wheeled mobility) would require an upper-extremity support that is wider than a standard armrest. Even some of the commercially available arm troughs might not be adequate; a custom upper-extremity support may be required.

Sometimes lower-extremity lymphedema can become so severe that ambulation is severely limited. When wheeled mobility becomes necessary, the shape of the involved tissue will infl uence the seat dimensions as well as the accessory components.

For example, a severely involved lower extremity can be double the circumference and weight of an uninvolved extremity. This is often the case with lymphedema that is characterized by asymmetrical or unilateral lower-extremity swelling. The size of one lower extremity may utilize two-thirds of the seat width. The size and/or shape of the lower extremity may cause asymmetrical seated postures, including rotation and obliquity.

Q: What challenges do patients with lymphedema present to the seating & mobility team? For instance, is pressure management a common concern? How about positioning or the ability to safely transfer?

ST: Distribution of tissue that shortens the possible seat depth is a frequent challenge. There may be pooled masses of lymphatic tissue on the posterior thigh that can cause this.

The seat pan may require modification to shorten and accommodate space for this tissue. Keep in mind that a mass like that should be supported, perhaps with a shelf or a “hammock” (I have seen both modifications on chairs for lymphedema patients).

A pannus can also require this accommodation. A pannus is a hanging flap of tissue. When the abdomen is involved, it is called a panniculus. This mass consists of skin, fat and sometimes contents of the abdominal cavity as part of a hernia.

A panniculus can become very large, even hanging down below the knees. When that happens, the mass contacts the front seat edge, which can limit the amount of functional seat depth.

It is imperative to pad all edges and sharp points of contact. If a tilting system is prescribed, plan for where gravity may displace tissue during the shift (front seat edge, etc.).

Q: Describe the seating & mobility evaluation process when working with lymphedema clients. What are important questions to ask regarding lifestyle, environment, medical histories, etc.?

ST: I frequently run into patients with lymphedema who were not diagnosed in a timely fashion. As a result, the condition has progressed unchecked for an extended period of time, resulting in extreme size and shape of the involved extremity (or extremities).

Ask if they are seeing a doctor who has experience in lymphatic conditions. Ask if they are seeing a therapist (OT or PT) who specializes in lymphedema — this is crucial.

Because of the asymmetrical nature of lymphedema, measurement for mobility devices can be challenging. The shape of tissue, especially in the lower body, can make it difficult to measure for Distribution of tissue that shortens the possible seat depth is a frequent challenge seat depth, seat width, back support and lower-leg position. It is never a good idea to take measurements of a consumer in a bed, and it is especially important to measure clients with lymphedema on a firm mat table — ideally, an elevating one to assist with the sit-to-stand assessment to determine seat-to-floor height parameters.

Q: What seating & mobility interventions can be helpful to these patients and why?

ST: Powered mobility is eventually necessary, as the anterior weight distribution and proportionate width requirements eventually make manual wheelchair mobility an impossibility. Tilt and recline in combination with lower-extremity elevation offer the best combination for repositioning and weight shift.

It is difficult for many consumers to shift their weight in a seated position, so “scooting” back onto a cushion may not be possible without repositioning of a powered seating system.

Q: What else about lymphedema is important for the seating& mobility team to know?

ST: The extra tissue of a hanging panniculus can make personal hygiene difficult; fungal infections are common in the deep folds of the skin, and cellulitis can also occur. Because of these risks, covers should be removable for washing or at least covered with a material that can be disinfected and wiped down.

The amount of edema that can develop with either of these diagnoses can make mobility base and seating system prescription very difficult. The anterior position of the edematous tissue — with the patient in a seated position, the involved lower extremities and genitalia orient the weight distribution forward — can result in anterior instability. This is a risk with prescription of both manual and power wheeled mobility systems for consumers with lymphedema.

Lymphorrhea is the seeping of lymph fluid through the skin. This condition can occur with lymphedema and impedes the use of compression garments and multi-layer bandaging. With regard to the seating & mobility system, porous fabric covers should be removable and/or easily cleaned. Risk of fungal infection and cellulitis is increased with lymphedema, and great care should be taken to utilize fabrics with moisture barriers to prevent draining fluids from permeating foam materials.

 

Stephanie Tanguay, OTR, ATP, is the clinical education specialist at Motion Concepts, and has given presentations on lymphedema at seating & mobility conferences. She is a member of Mobility Management's Editorial Advisory Board.

This article originally appeared in the June 2011 issue of Mobility Management.

About the Author

Laurie Watanabe is the editor of Mobility Management. She can be reached at lwatanabe@1105media.com.

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