Issue link: https://www.massageandbodyworkdigital.com/i/1128556
64 m a s s a g e & b o d y w o r k j u l y / a u g u s t 2 0 1 9 THREE CASE STUDIES | Patient 1 A 90-year-old female was recently placed in a skilled nursing facility. She presented with a terminal diagnosis of protein calorie malnutrition. She had a nonhealing gangrenous wound to the left foot, secondary to an injury sustained three months prior to her facility placement. The wound consisted of four sites, two proximal to the third toe and two proximal to the lateral malleolus, each weeping bloody lymphatic fluid. Her left lower extremity was edematous (abnormally swollen with fluid). Her personal physician recommended amputation of the leg, but the hospice physician believed that doing so would hasten her death: Either her heart would not survive the surgery or the emotional outcome of amputation would result in anguish. Otherwise, the patient was fairly strong for her age with tremendous motivation and a good appetite. The massage therapist received permission to engage the patient in manual therapy after making a request during a team meeting. Team members stated it was the patient's "last hope." The goal was to prevent systemic infection through complete wound healing by (1) increasing tissue nutrition through support of blood and lymph circulation; (2) decreasing lymphatic fluid stagnation, thereby decreasing tissue toxicity; (3) stimulating cell production for repair; (4) stimulating and supporting immune function; and (5) increasing the patient's sense of well-being. MLD and energy work were initiated, supported by exemplary nursing care. The hospice aide was trained in Swedish massage techniques to be applied in conjunction with MLD on alternating days. Foot soaks were also provided. The patient was encouraged to ambulate in her wheelchair and to be as active as possible. The process was complicated by the discovery of a deep vein thrombosis in her left thigh approximately five weeks into therapy. Permission was obtained to continue energy work during the acute period, and therapy was continued once the acute period had passed. After receiving a total of 28 MLD and 35 energy sessions—plus numerous Swedish massage sessions and foot soaks—she experienced complete wound healing. She was discharged from hospice and returned home with visiting nurse oversight. | Patient 2 An 80-year-old female had breast cancer with lung and liver metastasis. Secondary diagnoses included diabetes and congestive heart failure. Accompanying medical concerns were: left mastectomy with removal of 17 nodes; lymphedema of the left arm and edema of the lower extremities; and, most significantly, ascites (abnormal buildup of fluid in the abdomen) requiring paracentesis every 15 days with 4–5 liters removed each visit. Her weight fluctuated from a baseline of 125 pounds to 140–150 pounds, as the ascites worsened. She was placed in a residential hospice just prior to therapy intake. The referral was made by the hospice registered nurse, who wanted to administer MLD to the patient's left arm due to her complaints of swelling, discomfort, and decreased mobility. After the evaluation, a decision was made to recommend assistance with the ascites component instead, thus possibly lessening the need for paracentesis, especially since this seemed to be of greater value due to the accompanying problems affecting the patient's well-being: orthopnea (shortness of breath that occurs when lying flat); organ compression and related discomfort; diaphragmatic compression and shortness of breath; lymphatic fistulas (abnormal connection between two organs, such as blood vessels, intestines, or other hollow organs) and cellulitis (bacterial skin infection) of the left leg; ambulatory difficulties; and poor self-image. The patient also found it necessary to sleep in an upright position. The goals were to ease respiratory effort and decrease orthopnea, mobilize fluid to prevent infections and decrease occurrence of cysts/fistulas, decrease systemic discomfort, improve ambulation through weight control, improve self- image, and decrease the need for paracentesis. After the evaluation, a paracentesis was conducted. During that procedure, a total of four liters was evacuated. Her weight was 140 pounds. Daily MLD sessions were initiated upon her return from the hospital. The next scheduled paracentesis was delayed an additional 14 days, due to the effectiveness of MLD in slowing down the fluid accumulation. When the next paracentesis was performed, only three liters were removed. Her weight was 133 pounds. The patient survived another two and a half months after this final paracentesis. A routine MLD schedule eliminated her need for further procedures. Her weight remained under 130 pounds. Other benefits included decreased need for optimal