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.