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Running head: BREAST CANCER RELATED LYMPHEDEMA

A Case Report: Breast Cancer Related Lymphedema


Kara Stedry
Saginaw Valley State University

BREAST CANCER RELATED LYMPHEDEMA

Client History
This case report is based on Martha, a 52-year old female who was diagnosed with stage III invasive
carcinoma of the left breast in September 2010. She found the cancer when she was performing a self breast
exam and discovered a lump under her arm. Chemotherapy was started in October 2010 and ended in February
2011. In March 2011, Martha underwent a bilateral mastectomy to remove both breasts. During the mastectomy,
she had lymph nodes removed from the left axillary area, three of which tested positive for cancer.
Approximately 3 months after her mastectomy, she experienced the onset of lymphedema in the left upper
extremity, starting in the hand for which she received occupational therapy for evaluation and treatment. In
November 2011, Martha also underwent a reconstruction of the breasts.
In December 2012, Martha was diagnosed with stage IV breast cancer due to metastases in the brain,
which was discovered through an MRI. After being diagnosed, she started receiving chemotherapy in January
2013 and is currently still undergoing treatments. In January 2013, M.P. experienced an exacerbation of her
lymphedema in her left upper extremity extending from hand up into axilla, in which she was referred back to
occupational therapy for evaluation and treatment.
There is a history of cancer in Marthas family shown through her paternal grandfathers diagnosis of
prostate cancer, paternal aunts diagnosis of breast cancer, and her nephews diagnosis of testicular cancer.
Martha has also been previously diagnosed with hypothyroidism.
Martha is a middle class, left-handed, Caucasian female who worked as a dental hygienist prior to being
diagnosed with cancer, but is now considered disabled. She is married and has two sons and one daughter. She
lives with her husband and youngest, high school aged son in a two-story, three-bedroom home in a
neighborhood in the township. Her bedroom is located on the first story of the home. Her bathroom contains a
walk in shower that has two grab bars. There is also a standard a toilet in the bathroom with no grab bars. Prior
to diagnosis, Martha was independent with all areas of occupation, but has been receiving moderate assistance

BREAST CANCER RELATED LYMPHEDEMA

from her family since diagnosis in 2010. She is also an active member of her church, where she attends every
Sunday. Martha frequently volunteers at her sons high school during his sporting events. She also enjoys
shopping, gardening, knitting, and spending time with her family.
Diagnosis
The diagnosis for which Martha is currently being treated is lymphedema of the left upper extremity and
breast cancer. In women, breast cancer is the most commonly diagnosed malignancy, with approximately
192,000 diagnoses in the United States in 2009 (Rourke, Hunt, & Cormier, 2010). It is estimated that
approximately one in eight women, about 12%, will develop breast cancer in their lifetime (Rourke, Hunt, &
Cormier, 2009). After lung cancer, breast cancer is the second most common cancer death (Quirion, 2009).
Recently, there has been a decline in deaths from breast cancer due to the increased ability to identify and
discover breast cancer in its earlier stages through quality screening, such as mammography. New and advanced
therapies have also been having a positive effect on patients with breast cancer, which has increased the survival
rate (Rourke, Hunt, & Cormier, 2010). Today, there are over 2.5 million breast cancer survivors in the United
States.
Lymphedema is the most common problem experienced after breast cancer treatment (Quirion, 2009).
Due to the increase in breast cancer survivors over the past few years, there is now a greater need for
lymphedema treatment. Lymphedema is a progressive, chronic, pathologic condition that can also be
disfiguring. A poorer quality of life has been reported by breast cancer survivors who suffer from lymphedema
compared to those that do not (Ridner, Dietrich, & Kidd, 2010). The decrease in quality of life has been
associated with some of the physical symptoms of lymphedema which include decreased physical activity,
changes in sensation of the limb, and fatigue (Rourke, Hunt, & Cormier, 2010). Lymphatic transport
dysfunction is the cause of lymphedema. The lack of movement on lymph causes protein-rich fluid to unusually
accumulate in the affected areas interstitium (Rourke, Hunt, & Cormier, 2010). Emotional distress, pain and

BREAST CANCER RELATED LYMPHEDEMA

discomfort, and impaired function are all results of lymphedema. Martha experiences discomfort, pain,
emotional distress and impaired function due to her lymphedema. It impacted her daily life by decreasing her
performance in basic activities of daily living tasks, such as dressing and bathing.
There are two types of lymphedema: primary or secondary. Primary lymphedema is typically caused due
to morbid obesity or due to someone having a congenital anomaly in the lymphatic system (Quirion, 2009).
Primary edema can occur anywhere in the body. Trauma or some sort of insult caused to the lymphatic system
causes secondary lymphedema. Surgery for cancer is the most common cause of secondary lymphedema. Breast
cancer treatment frequently causes upper extremity lymphedema (Quirion, 2009). Typically breast cancer
related lymphedema develops within 36 months of treatment and occurs in the arm, shoulder, breast, or thoracic
area (Rourke, Hunt, Cormier, 2010). Martha suffers from secondary lymphedema because it was caused from
the removal of lymph nodes in her axillary area.
There are also four different stages that occur in lymphedema. The stage criteria allow professionals and
clinicians to communicate the level of damage caused by the lymphedema in the tissues and extremities. The
first stage is 0, which is when there are no physical identifiers of lymphedema, but the client reports
subjectively that they have been experiencing lymphedema symptoms in their extremity, such as heaviness
(Quirion, 2009). In stage I, is when unilateral swelling will occur in the limb. The edema will pit with pressure
and elevation will relieve the swelling (Ridner, Dietrich, & Kidd, 2010). At this stage, the lymphedema is still
considered to be reversible (Quirion, 2009). In stage II of lymphedema, the edema does not reduce with
elevation and the extremity may be firmer and no longer pit. There is also fibrosis present at this stage (Ridner,
Dietrich, & Kidd, 2010). Once stage III occurs, there are limited treatment options. This stage is also known as
lymphostatic elephantitis. There is a large amount of fibrosis present and the volume of the tissue increases
(Quirion, 2009). Also, skin folds and thick skin develops in this stage (Ridner, Dietrick, & Kidd, 2010). In

BREAST CANCER RELATED LYMPHEDEMA

Marthas case, she was evaluated in the 2nd stage of lymphedema. Her swelling was occurring for about 3-4
weeks before evaluation.
Frames of References
Frames of references are used in occupational therapy to illustrate the use of evidence based practice and
to further progress the profession. Clinicians are also able to understand and comprehend data in order to create
and develop efficient intervention plans through the use of frames of references (Krohn-Schultz & Pendleton,
2006).
Biomechanical Frame of Reference
The frame of reference utilized for Marthas treatment is the biomechanical frame of reference.
Occupational performance, the movement that is required in order to engage in occupation, is assessed when
applying the biomechanical frame of reference. Through the use of the biomechanical frame of reference the
clinician observes a persons limitations in performing their everyday occupations (Krohn-Schultz & Pendleton,
2006). Independence in occupation is promoted through stressing the importance in reducing physical deficits
(Jackson & Schkade, 2001). These physical limitations in occupational performance are addressed using activity
and exercises. Client factors, such as range of motion exercises, strengthening exercises, and mobility
activities, are included and addressed in intervention when utilizing the biomechanical frame of reference
(Jackson & Schkade, 2001). Splinting and other orthopedic techniques are used in biomechanical frame of
reference guided intervention (Krohn-Schultz & Pendleton, 2006)
Marthas evaluation and intervention plan were guided by the biomechanical frame of reference in order
to address the physical deficits that are affecting her occupational performance. In her case, the swelling in her
left upper extremity is severely affecting her independence in performing her daily occupations. The
biomechanical approach focuses her intervention on addressing and reducing the lymphedema with techniques,

BREAST CANCER RELATED LYMPHEDEMA


such as exercise, a special type of soft tissue mobilization, and a compression sleeve, in order to increase her
occupational performance.
Occupational Therapy Practice Framework: Domain
Areas of Occupation
Activities of Daily Living
Marthas areas of occupation were significantly impacted from her diagnoses of breast cancer and
lymphedema. The chemotherapy Martha was receiving at the time of treatment also affected her occupational
performance due to the amount of fatigue and neuropathy it caused. Her activities of daily living that were
impacted include bathing and showering, dressing, eating, and functional mobility.
Bathing/Showering: Bathing and showering activities were difficult to perform because of the
level of fatigue Martha was experiencing. It was also difficult for her to wash her hair and body
due to her left hand being so swollen and affecting her range of motion. She also required the
assistance of grab bars in order to get into and out of the bathtub. Martha also had to start taking
baths instead of showers because she tired too easily when she tried standing in the shower for
long periods of time.
Bowel and bladder management: Not applicable.
Dressing: Tasks for dressing were difficult because it was difficult for Martha to fit clothes over
her arm. She also experienced difficulty when trying to zip and button her clothing due to the
lymphedema affecting her fine motor abilities in her left hand.
Eating: Martha had difficulty eating due to the nausea from the chemotherapy
Feeding: Due to the fact that the swelling was in Marthas dominant upper extremity, it made it
difficult for her to hold feeding utensils.

BREAST CANCER RELATED LYMPHEDEMA

Functional Mobility: Walking long distances was somewhat taxing for Martha due to her
increased fatigue from the chemotherapy, this intern affected her functional mobility.
Personal Device Care: Not applicable.
Personal hygiene and grooming: Martha has some difficulty brushing her teeth and applying
make-up because of the swelling in her dominant, left upper extremity. The swelling makes it
difficult for her to manipulate and grip the items in her hand.
Sexual Activity: Not applicable.
Toilet hygiene: Not applicable.
Instrumental Activities of Daily Living
Care of others: Not applicable.
Care of pets: Not applicable.
Child rearing: Not currently applicable. Martha has two older children who live on their own
and her youngest son who lives with her and her husband, but is able to care for himself.
Communication Management: Martha experiences difficulty writing with her dominant, left
hand due to the increased edema affecting her grip and prehension.
Community Mobility: Martha is no longer able to drive due to the stage of her cancer and the
fact that it has spread to her brain. Her husband drives her to all of her appointments; Martha has
stated that this sometimes makes her feel like a burden.
Financial Management: Marthas financial management has been affected due to her inability
to work and her husband recently losing his job. Martha is currently on disability and her
husband collects money through unemployment.

BREAST CANCER RELATED LYMPHEDEMA

Health management and maintenance: Martha has stated in therapy that she is not always
compliant with her home program. She is able to manage her own medications and take them as
prescribed.
Home establishment and management: Home establishment and management tasks have been
affected due to the fact that Martha is unable to work around the house because of her fatigue.
Meal preparation and cleanup: Martha also has a difficult time preparing meals for her family
due to her fatiguing so easily.
Religious Observance: Religious observance has also been affected because of Martha being
self-conscious about her swelling in her arm and due to her being so tired.
Safety and Emergency Maintenance: Not applicable.
Shopping: Prior to her diagnosis, Martha used to do all the grocery shopping, but now her
husband does it all due to her inability to walk around the store for a long period of time.
Rest and Sleep
Rest: Martha would rest frequently due to the chemotherapy that she was receiving at the time of
her treatment. She also stated that sometimes the nausea she would experience from the
chemotherapy would interrupt her being in a relaxed state during periods of rest. Martha now
takes a nap during the day since receiving chemotherapy.
Sleep: Martha was able to fall asleep, but she had some difficulty due to the chemotherapy that
she was receiving. Martha also stated that her arm would cause her pain that would interfere with
her sleep cycle.
Sleep preparation: Martha had difficulty determining the time of day and length of time desired
for sleeping due to the effects of the chemotherapy. Her sleeping patterns were also affected due
to the amount of fatigue, pain, and nausea she was experiencing.

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Sleep participation: Not applicable.


Education: Martha received a high school diploma and also a dental hygienist degree.
Work: Marthas ability to work was affected because after she was diagnosed and started treatments she
was put on disability. She could no longer perform the necessary tasks that were required for her job
because of her diagnoses. She had difficulty manipulating the tools needed to clean teeth and was ill
most of the time. Martha does try and volunteer in the community as much as she can.
Leisure
Leisure Exploration: Martha enjoys activities in which she can spend time with her family. She
enjoys traveling with her husband. A few months ago, Martha and her family had visited Disney
World in Orlando, Florida courtesy of the Jack and Jill Foundation. She was somewhat limited to
the activities she could take part in at the time of therapy due to her increased fatigue.
Leisure Participation: Martha is not able to take part in all of the activities that she was able to
prior to her diagnoses. She is unable to knit due to the decreased fine motor skills in her left
hand. Shopping is also difficult for her because of the increased fatigue from the chemotherapy.
Social Participation
Community: Prior to her diagnosis Martha loved volunteering in her community and being a
member of her church. Since her onset of lymphedema, she is somewhat self-conscious about the
swelling in her arm. She also is not able to participate as much because of her constant fatigue.
Family: Martha interacts with her family regularly, but has a difficult time participating in some
activities due to her feeling fatigued. Her family has supported her throughout her diagnosis.
Peer, Friend: Martha has many supportive friends, but since her diagnosis she has not been able
to spend much time with them because of her constantly feeling ill and tired.
Client Factors

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Values, Beliefs, and Spirituality: There are quite a few of Marthas client factors that were impaired.
Marthas values, beliefs, and spirituality have been affected because she is no longer able to provide for
her family, take care of her home, attend church, and participate in social events.
Body Functions: Body functions that were affected include mental functions, sensory functions and
pain, neuromusculoskeletal and movement-related functions, cardiovascular and immunological system
functions, and skin and related-structure functions. Specific mental functions were affected because her
self-esteem, body image, self-concept and her emotions about these factors. Marthas global mental
functions were also affected because she lacked motivation, energy, and drive. She also experienced
some pain in the left upper extremity due to the lymphedema, which is how her sensory and pain
functions were affected. Marthas joint mobility, joint stability, muscle power, muscle tone, and muscle
endurance were also affected through the lymphedema. The lymphedema also has an influence on the
cardiovascular and immunological functions. Due to the stretching of the skin on the left upper
extremity from the lymphedema, the skin functions are related.
Body Structures: Body structures that have been affected by Marthas diagnoses are structures of the
cardiovascular and immunological systems, structures related to movement, and skin and related
structures.
Activity Demands
Objects and their properties: During Marthas therapy there was a variety of different equipment and
materials used. Some of the equipment included in Marthas therapeutic activities were a hydraulic
powered massage plinth, a blue foam block, stockinette, Comprilan wrap, dermapore tape, and a roll of
gauze wrap. These materials and equipment were used to help decrease the swelling in Marthas arm
through several different specialized techniques.

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Space Demands: For Marthas therapy there was adequate space for her activities. The therapy room in
the clinic had enough room to perform her manual lymph drainage and her lymphedema exercises. The
room also provided privacy in order to perform Marthas therapeutic tasks and activities.
Social Demands: It is important for Martha to be able to communicate with her family, friends, and
therapists. In therapy she needs to communicate if she understands the instructions given to her for the
home program. She also has to communicate how she is feeling and if she is experiencing any pain.
Sequence and Timing: Martha does not show any impairment in sequencing or taking direction for any
of her tasks, but she does need extra time due to her constant feeling of fatigue. It takes her more time to
perform activities because of her labored movements and difficulty using her left upper extremity.
Required Actions and Performance Skills: Martha requires motor and praxis skills in order to be able
to perform her home program and the exercises given to her in therapy. She will need adequate grip in
order to squeeze the blue foam block to try and pump the lymphedema out of her hand. She will need to
coordinate body movements to complete the exercises and the home program. Martha will need
cognitive skills in order to perform her exercises and home program. This is due to the fact that she will
have to prioritize her time in order to be sure she is performing her home program. She will have to
sequence the different steps required in the exercises for her home program. Communication and social
skills are also required for Martha to participate in therapy. These are required because she will have to
be able to verbalize her understanding of the home program and exercises to the occupational therapists.
Martha will have to be able to verbalize any pain that she is experiencing during therapy.
Required Body Functions: Martha requires mental functions such as attention, memory, perception,
thought, mental functions of sequencing complex movement, and an adequate experience of self and
time. Martha will require these in order to understand and carry out the activities that the occupational
therapist gives her to perform. Martha will also require global mental functions such as consciousness,

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orientation, temperament and personality, and energy and drive in order to carry out the tasks given to
her. Through having these areas Martha will remain focused, motivated, and emotionally stable during
her therapy sessions making them more beneficial. Sensory functions and pain are also required by
Martha, such as visual acuity, visual stability, visual field functions, hearing functions, proprioceptive
functions, touch, pain, and pressure. Through the use of visual acuity, visual stability, visual field
functions, and hearing functions, Martha will be able to see the task or skill that she is performing, and
she will also be able to hear the directions for it. Touch, pain, and pressure can help Martha localize her
pain or discomfort. Martha also requires adequate neuromusculoskeletal and movement-related
functions such as joint mobility, joint stability, muscle power, muscle tone, muscle endurance, and
control of voluntary movement. These skills are necessary for Martha to perform her exercises and the
home program. Voice and speech functions are also required by Martha to participate in therapy in order
for her to communicate with the occupational therapist.
Required Body Structures: There are a variety of body structures required by Martha in order to
engage in her therapeutic activities. Martha must have eyes in order to see and visualize what she is
doing during his therapeutic activities, for example she needs to see the directions to each exercise
before she actually performs them. She also needs her ears in order to here directions given to her by the
occupational therapist. Also required by Martha are voice and speech in order to communicate with the
therapist and let her know if she is in any pain or if she needs to ask a question. She also needs her
respiratory system in order to control her breathing during her exercises. Two upper extremities and two
lower extremities are also required by Martha.
Performance Skills

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Motor and Praxis Skills: Marthas range of motion has been affected due to the amount of swelling her
left upper extremity. Her grip and fine motor coordination has also been affected. She also has a difficult
time manipulating items in her hand.
Sensory-Perceptual Skills: Martha is aware of her surroundings and responds to sensations
appropriately. She is able to feel pain and discomfort in her left upper extremity. She is also able to
localize and communicate her pain and discomfort to the occupational therapist.
Emotional Regulation Skills: Martha displays emotions that are appropriate for each situation. She
remains calm and composed when she discusses her prognosis and the way that her chemotherapy has
affected her life.
Cognitive Skills: Martha is able to sequence her tasks needed to perform her activities throughout the
day. She is able to organize her activities, but has trouble with time because of the amount of fatigue that
she experiences. She also has trouble multitasking because of her fatigue and lack of motivation.
Communication Skills and Social Skills: Martha is able to communicate her feelings to her family,
friends, and occupational therapist. She is also able to ask and answer questions when she necessary. She
acknowledges others opinions when they are talking and appropriately takes turns during conversations.
Performance Patterns
Habits: A habit of Marthas is always checking her wig before leaving home to be sure it is on correctly.
Martha also has to be sure that she has an adequate amount of warm clothing because the chemotherapy
makes her feel cold all the time.
Routines: Martha takes her medication at the same time every day. She follows the same routine in the
morning, but some days it can get interrupted by her feelings of nausea or fatigue.
Rituals: Martha goes to church every Sunday with her husband, but has difficulty doing this now that
she has been receiving chemotherapy.

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Roles: The roles that Martha has in her life are being a wife, mother, mother-in-law, daughter, aunt,
sister, patient, client at an outpatient rehabilitation clinic, friend, and member of a church congregation.
Contexts and Environments
Cultural: Martha is a 52 year old, Caucasian female. Prior to her diagnosis she was a dental hygienist.
She and her husband are middle class citizens. The cultural contexts involved in Marthas interventions
are the ability to regain AROM in her affected upper extremity, grasp, and fine motor coordination in
order to engage in gardening, knitting, writing, feeding, dressing, and home tasks. These activities are
important to her cultural context due to her participating in them with her family, friends, and other close
members of the community.
Personal: Martha is a 52 year old disabled dental hygienist. She has a high school diploma and a dental
hygienist degree. Martha and her husband often volunteered at their church and are active members of
their community. She enjoys performing home establishment and maintenance tasks like working in her
garden. She also enjoys knitting, shopping, and watching her youngest son play sports. Martha also
enjoys traveling and taking vacations with her family.
Temporal: Marthas therapy was focused on having her return to her leisure, home maintenance, social
participation, independence in areas of occupation, and decreasing her discomfort due to the prognosis
of her diagnosis. During her therapy sessions, Martha tends to be fatigued from the chemotherapy that
she was undergoing at the time. The exercises that Martha performs in therapy can be graded depending
on the repetitions and duration in which she can tolerate.
Virtual: Martha uses a computer to communicate with friends and family through e-mail and social
networks, such as Facebook. Martha also uses a computer to look up research on her diagnoses. Martha
also has a cell phone that she uses frequently to communicate with friends and family. She takes her cell
phone everywhere she goes.

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Physical: Martha currently lives a two-story, three-bedroom home in a neighborhood in the township.
She lives with her husband and high school aged son. Her bedroom is located on the first story of the
home. Her bathroom contains a walk in shower that has two grab bars. There is also a standard a toilet in
the bathroom with no grab bars. Martha could benefit from a shower chair in her shower and a hand held
showerhead to help with energy conservation. In the clinic where she receives her therapy, Martha
typically performs and receives her therapeutic interventions in a private room that meets all of her
space requirements. When Martha goes into the community she is typically driven by her husband or a
friend in their vehicle.
Social: Marthas social context consists of her family and friends. Her family consists of her husband,
daughter, sons, son-in-law, siblings, and her parents. She has many friends from the community, through
being involved in her sons school, and through her church. She also enjoys shopping with friends and
spending time with her family.
Occupational Therapy Practice Framework: Process
Evaluation
Occupational Profile: In her initial evaluation Martha was interviewed in order to build her
occupational profile. She is currently seeking occupational services for her recent exacerbation of
lymphedema in her left upper extremity. Through decreasing her lymphedema, it will increase her
performance when performing her activities of daily living and social participation.
Analysis of Occupational Performance: Martha was assessed and evaluated by performing different
tests. Her strength of her extremities was tested through the use of manual muscle testing. Her range of
motion was tested through the use of goniometry. Her edema was circumferentially measured using a
measuring tape on the left upper extremity and cross tested with the right upper extremity. Martha was
able to subjectively communicate her difficulties when performing her occupations at home.

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Intervention
Intervention Plan: Martha stated during her evaluation that her goal for therapy is to reduce the
lymphedema in her left upper extremity. In order to achieve this goal she will have to be compliant with
performing a home program for lymphedema in order to try and pump the fluid out of her left upper
extremity. Exercises will be used to increase range of motion and flexibility. Martha will have to be
taught risk reduction techniques in order to reduce the risk of an exacerbation once her treatment is over.
Intervention Implementation: Martha receives manual lymph drainage, which is deep, circular soft
tissue mobilization from distal to proximal on the affected extremity. She is also involved in performing
range of motion exercises for her upper extremities. Martha also squeezes a blue foam block in order to
try and pump the fluid out of her hand. Bandage compression is also done with comprilan wrap,
dermapore tape, a roll of gauze wrap, and a stockinette.
Intervention Review: Martha will be reevaluated every 6 sessions in order to measure her progress. If
the therapeutic activities being used to treat Marthas lymphedema are not helping her reach her goals,
they will be changed in order to better accommodate her condition.
Outcomes: Having an effect on Marthas lymphedema, it will increase her quality of life and improve her
performance in her areas of occupation. Therapy sessions should relate to her interests and her overall goal of
reducing the lymphedema in her left arm in order to motivate her to perform to her fullest potential in her
sessions.
Types of Occupational Therapy Interventions
Therapeutic Use of Self: Through the therapeutic use of self, the occupational therapist will use their
knowledge of lymphedema in order to evaluate and treat Martha. The occupational therapist will also
use a positive and kind attitude and demeanor while working with Martha. They will also engage Martha
in conversation in which they will discuss Martas interests and her family. The occupational therapist

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will attempt to build a therapeutic relationship through the use of therapeutic use of self. Through this
relationship the therapist will have an adequate rapport with Martha, in which she will trust her therapist.
Therapeutic Use of Occupations and Activities
Occupation-Based Intervention: An occupation-based intervention for Martha would be
completing her morning routine of dressing with the aid of adaptive devices. Completing her
shower through the use of a hand held shower head and a shower chair would also be an
occupation based intervention.
Purposeful Activity: A purposeful activity for Martha would be picking out her clothing and
manipulating the fasteners in order to regain fine motor coordination. Martha practicing
stitches for knitting to increase fine motor coordination is also an example of an appropriate
purposeful activity.
Prepatory Methods: A prepatory method for Martha would be to perform active range of
motion exercises in order to increase range of motion in her left upper extremity. Another
prepatory method for Martha would be to squeeze the blue foam block in order to pump the
fluid from left upper extremity back to the rest of the body.
Consultation Process: The occupational therapist can advise Marthas family, such as her husband and
children, on what the purpose of occupational therapy is and how it will help her with her lymphedema.
The therapist can also advise the family on different things that can be done at home in order to prevent
the lymphedema from occurring again.
Education Process: The occupational therapist can advise Marthas family, such as her husband and
children, about the things that Martha needs to do at home in order to manage her lymphedema and

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reduce the risk of it returning. The therapist can also discuss with them how long Martha will be in
therapy and her progress with Marthas consent.
Advocacy: The occupational therapist can give information about lymphedema to Martha and tell her
where she can find support for the condition. The therapist could give Martha information on support
groups in the area for people with cancer and lymphedema.
Occupational Therapy Intervention Approaches
Create/Promote: Understanding energy conservation techniques and promoting participation in the
home program provided to her will help Martha perform her areas of occupation efficiently.
Establish/Restore: The goal of Marthas therapy is to establish and restore her participation in her daily
life by decreasing her lymphedema in her left upper extremity. Also, through increasing her range of
motion and flexibility Martha will be able to effectively participate in her daily tasks.
Maintain: Martha will be educated in lymphedema self management techniques in order to decrease the
risk of her having another exacerbation of the condition. Martha also has a compression garment and a
compression pump in order to decrease swelling in her upper extremity.
Prevent: Through lymphedema self-management education Martha will learn about the things that she
needs to do in order to decrease her risk of another exacerbation.
Types of Outcomes
Occupational Performance: Martha would like to improve her ability to dress herself independently.
She would also like to be able to shower with more ease. Martha would also like to be able to write with
no difficulty.

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Adaptation: Through the use of grab bars, a shower chair, and hand held shower head Martha will be
able to increase her ability to shower and bathe herself independently. Martha also could feed herself
with a built-up feeding utensil in order to grip it easier with her affected dominant hand.
Health and Wellness: Martha can attend a support group for people with cancer and lymphedema in
order to have ongoing support and encouragement. This will also increase her social participation.
Participation: Martha will be able to participate in her meaningful occupations, such as activities of
daily living, effectively. Also, Martha will be able to participate in social participation without being
self-concious about her lymphedema.
Prevention: Prevention of Martha having an exacerbation of lymphedema will be addressed through
educating her on lymphedema self-management techniques.
Quality of Life: Martha values her ability to perform her activities of daily living, such as bathing and
dressing, independently. She also values being able to spend time with friends and family. She also
values being able to take part in her leisure activities, such as traveling, gardening, and shopping.
Role Competence: Martha values her role of being a mother and wife and would like to be able to
effectively perform in the tasks required by these roles.
Self-advocacy: Martha can advocate for herself by expressing to her therapist when she is in pain or
when she feels that something isnt working for her so the therapist can accommodate accordingly.
Occupational Justice: Marthas family will respect her diet and lifestyle changes that need to be made
in order for her to manage her lymphedema.
Pharmacological Assessment and Impact on Therapeutic Intervention
Current Medication
Levothyroxin: This medication is used to treat hypothyroidism and is a thyroid hormone. It is
typically used for hypothyroidism due to the fact when a person has the condition their thyroid

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gland is unable to produce enough of the hormone. Side effects from this medication include:
weight loss; tremors; headaches, nausea, diarrhea, nervousness, irritability, insomnia, excessive
sweating, etc (Medline drug information, 2013). This medication can impact therapeutic
intervention by causing Martha to feel uncomfortable and ill during therapeutic activities, which
would affect her occupational performance. It could also cause her to become irritable during
therapy.
Capecitabine: This medication is used to treat breast cancer that has come back after other
medications have been used to treat it. Side effects from capecitabine include: stomach pain or
upset stomach, constipation, loss of appetite, increased thirst, unusual tiredness or weakness,
dizziness, headache, skin rash, hair loss, etc (Medline drug information, 2013). This medication
could impact Marthas therapeutic intervention by causing her to be fatigued and uncomfortable
while trying to perform her therapeutic activities. It could also cause her to be nauseated and
dizzy, which could have an effect on her performance.
trimethobenzamide: This medication is used to treat nausea and vomiting, typically after
surgery. Side effects that can occur from taking trimethobenzamide include: drowsiness,
dizziness, headache, depression, and diarrhea (Medline drug information, 2013). This medication
could potentially cause Martha to become dizzy during therapy which could affect her
performance. She could also become depressed which could have an effect on her motivation to
take part in therapy.
Zofran (ondansetron): This medication is used to treat nausea and vomiting. It is typically
prescribed to patients receiving chemotherapy, radiation therapy, or surgery. Side effects that it
can cause include: diarrhea, headache, constipation, weakness, tiredness, and dizziness (Medline

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drug information, 2013). Marthas therapeutic interventions could be affected and impacted by
this medication because it could cause her to be dizzy during therapy. She could also feel tired
and weak, which would cause her to not want to participate in her exercises.
topotecan: This medication is used to treat small cell lung cancer that has returned. It is the
current form of chemotherapy that Martha is taking. Side effects that it can cause include:
nausea, vomiting, diarrhea, loss of appetite, and hair loss (Medline drug information, 2013).
Marthas chemotherapy has caused her to lose her hair and it causes her a large amount of
fatigue. This has an effect on the way she performs her therapeutic activities because she is often
tired and weak.
Treatment Plan
Assets/Strengths:

Martha is able to understand instructions for her home program when they are given to her by the
occupational therapist.

Martha is motivated to attend all of her therapy appointments unless there is an emergency.

Martha also has a good attitude about her prognosis and is pleasant during her sessions.

Martha has no infection or cellulitis in her left upper extremity preventing treatment for her
lymphedema.

She has a history of lymphedema and has knowledge of the causes and treatment for it.

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Problems:

Martha has admitted to not being compliant with wearing her compression pump for her left
upper extremity while at home.

She has a history of hypothyroidism.

Martha has decreased strength in her left upper extremity as a result of her lymphedema which is
affecting her performance in her activities of daily living.

There is decreased range of motion in her left upper extremity as a result of the lymphedema
which is affecting her performance in her activities of daily living.

There is increased edema in her left upper extremity which is affecting her performance in her
activities of daily living.

Martha has decreased fine motor control in her left hand due to her lymphedema in her left upper
extremity.

She also has decreased grip in the left hand due to her lymphedema.

Martha has increased pain in her left upper extremity due to her lymphedema, she stated it was a
4 out of 10, where 0 is no pain.

The chemotherapy that Martha has been receiving has been causing her a large amount of
fatigue, which affects her performance during her activities of daily living.

Lymphedema puts Martha at risk for infections, such as cellulitis.

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Short Term Goals

Client will demonstrate a pain level of 3 where 0 is no pain to increase performance in basic
ADL tasks within 2 weeks.

Client will express verbal knowledge of home program for lymphedema within 2 weeks.

Client will demonstrate decreased edema in the left upper extremity to 1333 ml. to increase
independence with dressing tasks within 2 weeks.

Long Term Goals

Client will demonstrate a pain level of 2 where 0 is no pain to increase performance in basic
ADL tasks within 4 weeks.

Client will be independent and compliant with home program for lymphedema within 4 weeks.

Client will demonstrate decreased edema in the left upper extremity to 1233 ml. to increase
independence with ADL tasks within 4 weeks.

Current Treatment Methods and Interventions


The primary evidence based treatment modality for lymphedema according to the National Lymphedema
Network and the Oncology Nursing Society is a method called Complete Decongestive Therapy (CDT)
(Quirion, 2009). In CDT there are two phases. The first phase of CDT is considered to be the reductive phase
and is typically every day for 3-8 weeks. This stage is intense with the goal being to reduce the limb to the

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smallest possible size. The second phase is focused on maintenance and preventing infection. This phase in
individualized to the clients specific needs (Chang & Cormier, 2013).
Marthas interventions were all components of CDT. Some of the components of Complete Decongestive
Therapy used in Marthas treatment to reduce her edema in her left upper extremity include:

Manual Lymph Drainage: Manual lymph drainage is performed by an occupational therapist that is
specially trained in lymphedema. It is a hands-on therapy that uses a light massage technique from distal
to proximal on the limb. This method is used to jump start the flow of lymph out of the limb and into
other areas of the lymphatic system (Quirion, 2009). Martha received MLD on her left upper extremity
at the beginning of her therapy sessions in order to accelerate the lymph flow.

Skin Care and Nail Care: Clients with lymphedema must be educated on proper techniques for skin
and nail care in order to prevent infection from occurring in the limb (Dayna, 2009). Clients are taught
to use nonabrasive soaps when cleaning their limbs and to pat the limb completely dry. In order to
protect the integrity of the skin, low pH moisturizers are used (Dayna, 2009). The nails should be kept
clean and trimmed and they should not cut their cuticles.

Compression Bandaging: After the client receives MLD, they will be wrapped with multiple layers of
bandages that have short stretch and limited extensibility to keep the area from accumulating with fluid
again (Rourke, Hunt, & Cormier, 2010). These garments are typically worn about 24 hours and are used
in order to create a pressure gradient to pump the lymph from the limb (Quirion, 2009). Martha was
wrapped with stockinette, artiflex, Comprilan, and durapore tape after she received her MLD.

Compression Garment: In the second phase of lymphedema, compression garments are used for longterm control. These compression garments are typically worn throughout the day. The bandages are

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easier to apply than the bandages and typically need to be replaced every 6 months (Quirion, 2009) Due
to Martha having had previous treatment for lymphedema, she already owned and wore a compression
garment on her left upper extremity. During her therapy sessions during her recent exacerbation she was
educated on the wear and care of the garments again.

Lymphedema self-management education: Clients with lymphedema are educated on the long term
nature of the condition. They are taught the signs and symptoms of lymphedema and cellulitis so they
can recognize when they need to seek treatment. They are also trained to perform self-MLD and
lymphedema exercise programs. Clients are also educated on the wear and care of compression
garments. They are also educated on having a specific diet that will help decrease the risk of another
lymphedema exacerbation (Rourke, Hunt, Cormier, 2010). Martha was taught lymphedema selfmanagement techniques when she was treated for lymphedema the first time, but has admitted to being
non-compliant with them. Martha was re-educated on the different techniques and the importance of
them in reducing her risk of having lymphedema again.

Exercise: Remedial exercise is used in lymphedema treatment to move the fluid from the extremities.
The clients compression garment should be worn during their exercises (Chang & Cormier, 2013).
Martha was given a home exercise plan that included exercises working on increasing her range of
motion and improving her posture.

Recommended Treatment Methods and Interventions


Key Hole Peg: By using the key hole peg board as an intervention, Martha can work on her fine motor
coordination that has been decreased due to the lymphedema in her left upper extremity.

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Clothes Pins: Martha could use the different colored clothes pins as an intervention in order to work on
pinch and prehension that was decreased due to her lymphedema.
Other Services Involved and Referrals Recommended

Oncologsit: Martha sees an oncologist for her cancer. The oncologist explains her diagnosis and stage of
the cancer to her and her family. He also discusses the treatment options and helps hers manage cancer
related pain by providing her with the correct medications and treatments.
Recommended Services
Social Worker: Martha could see a social worker to learn more techniques for coping with her
diagnosis. She could also see a social worker for follow up care to be sure that she isnt developing any
depression.
Psychological and Social Impact on Intervention
Martha has a positive and friendly attitude during therapy and remains calm and collected when she
discusses her prognosis. Her level of depression was evaluated using the Beck Depression Inventory, which is a
self-evaluation questionnaire, and she scored herself as 0, which means she was not depressed at all. Martha has
been educated on coping mechanisms that are essential for dealing with stress of having cancer. Martha could
potentially become depressed because of her poor prognosis, which could affect her performance during her
therapeutic interventions. The medications that Martha is on could also affect the way she feels during therapy
because many of them have depression or the feeling of being ill as a side effect. Participation in support groups
was a suggestion give to Martha so she can interact with others going through the same experiences as her.

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Discharge and Transition Plan


Martha was discharged with decreased edema, but she has not been vigilant about maintaining her
lymphedema reduction and therefore is fluctuating. Martha has been taught and educated on all of the
lymphedema self-management techniques in order to decrease her risk of having another exacerbation. Her
compression garment is worn daily and she also has a pneumatic compression pump that she wears throughout
the day. She has a good understanding of the home program and has been instructed to contact the occupational
therapist if she has any questions or problems.

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References
Chang, C.J. & Cormier, J.N. (2013). Lymphedema interventions: exercise, surgery, and compression devices.
Seminars in Oncology Nursing, 29, 28-40.
Dayna, G.E. (2009). Lymphedema diagnosis and management. Journal of the American Academy of Nurse
Practitioners, 19, 72-78.
Jackson, J. & Schkade, J. (2001). Occupational adaptation model versus biomechanical-rehabilitation model in
the treatment of patients with hip fractures. American Journal of Occupational Therapy, 55, 531-537.
Krohn-Schultz, W. & Pendleton, H. (2006). Application of occupational therapy practice framework to physical
dysfunction. In Pendleton, H. & Schultz-Krohn, W. (7th ed.), Pedrettis occupational therapy: Practice
skills for physical dysfunction (28-54). St. Louis: Mosby-Elsevier.
Medline drug information. (2013). The American Society of Health-System Pharmacists, Inc., Retrieved from
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a681004.html

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Quirion, E. (2009). Recognizing and treating upper extremity lymphedema in postmastectomy/lumpectomy
patients: a guide for primary care providers. Journal of the American Academy of NursePractitioners,
20, 450-459.
Rourker, L., Hunt, K., & Cormier, J. (2010). Breast cancer and lymphedema: a current overview from the
healthcare provider. Womens Health, 6, 399-406.

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