Fundamentals of Hand Therapy || Edema Reduction Techniques

Unlike in the past, the treatment of hand edema no longer needs to be partly a guessing game. Modern treatment selections are more firmly grounded in ana-tomic and biologic principles and therefore are more successful. To treat edema

effectively, the therapist must know the difference between the lymphatic and venous systems, including the role these systems play in edema reduction. It also is essential that the therapist understand the different types of edema. This chapter describes acute, sub-acute, and chronic edema. It reviews vascular and lymphatic anatomy and biology, and it describes appropriate interventions for edema, including the technique of manual edema mobilization (MEM). Special emphasis is placed on the clinical reasoning involved in selecting the appropriate treatment.

Overview of Lymphatic Anatomy Related to Edema Reduction

An overview of the capillary vascular structures and their relationship to each other is a prerequisite for a more detailed discussion of these systems. The vascular structures include the interstitium, the arteriole, and the venule. The interstitium is the space between cells. It contains both the smallest arterial vessel, called an arteriole, and the smallest venous structure, called a venule.1, 2 Both the arteriole and the venule termi-nate in capillaries, which are joined histologically (Fig. 3-1). The heart is responsible for pumping blood through these structures.

3Sandra M Artzberger

Editor’s Note: Before the importance of Sandra Artzberger’s work on the treatment of edema was recognized, the edema techniques that hand therapists were taught were not specific to the lymphatic system and sometimes even damaged this delicate and amazing part of the body. Artzberger has done much to delineate the anatomy and physi-ology of post traumatic edema. She has changed our thinking and has overhauled the treatment repertoire, creating an approach that is based on science. Her technique of manual edema mobilization has resulted in much-improved management of edema in clients with upper extremity injuries.

Edema Reduction Techniques: A Biologic Rationale for Selection

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PART 1 Fundamentals36

The lymphatic system originates in the interstitium with the smallest of the lymphatic vessels, called the initial lym-phatic or lymphatic capillary, and culminates in the largest lymphatic structure, called the thoracic duct.2 The venous sys-tem has a continuous-loop pump system based on the heart pumping oxygenated blood to the arteries, arterioles, venules, veins and back to the lungs and heart. However, the lymphatic system does not have this continuous central pump system (see Fig. 3-1).3 Also, unlike with venous capillaries in the intersti-tium, molecules do not diffuse into the lymphatic capillary. Therefore the lymphatic system must be stimulated to activate a force pump, (external and internal vacuum stimulation that moves lymph), creating a vacuum and drawing the lymph prox-imally.3 Initial lymphatics, which are larger than venules, are finger-shaped tubes that are closed on the distal end and lined with overlapping, oak leaf–shaped endothelial cells. Anchor filaments extend from the endothelial cells to the connective tissue (Fig. 3-2). Movement of the connective tissue pulls on the anchor filaments. This, in turn, pulls on the overlapping flaps (junctions) of the endothelial cells, and water and large molecules are admitted into the initial lymphatic.1,2,4 Large molecules also enter the initial lymphatic when a change in the interstitial pressure causes the junctions of the endothelial cells

to spread apart. The initial lymphatic connection forms a net-like structure.1,3

The balance between fluid moving into and out of the vas-cular vessels on a cellular level, which was first described by Ernest Starling in the early 1900s, is called Starling’s equi-librium.1,2 This balanced movement of fluid functions as a gradient system from high to low pressure. On the capillary level, arteriole hydrostatic pressure (the pressure of the blood fluid exerted on the arteriole vessel wall) is 30 to 40 mm Hg, which is enough pressure to cause filtration of electrolytes, fluid, a few small plasma proteins, and other nutrients into the interstitium.1,2 The colloid osmotic pressure (also called the oncotic pressure) in the interstitium is determined by the con-centration of proteins in this intercellular space; this pressure is approximately 25 mm Hg.2 Tissue cells in the interstitium absorb the nutrients, electrolytes, and other substances filtered out of the arteriole. Of the remaining substances, 90% diffuse by osmosis into the venous system.1-3 The residual 10% of left-over substances are large molecules, which are absorbed by the lymphatic system.1-3 These large molecules consist of plasma proteins, minerals, ions, hormone cells, bacteria, fat cells, and fluid.1-5 Once the cells enter the initial lymphatic, they make up a substance called lymph.2

As lymph enters the initial lymphatic, it causes pressure changes that open the valve connected to the next lymphatic ves-sels, the three-celled collector lymphatics (Fig. 3-3). Clinically, the most important features of the tube-like collector lymphat-ics are a middle layer of muscle cell and the presence of valves every 6 to 8 mm along the tube.1,3 The chamber between two valves is called a lymphangion.3 As a bolus of lymph enters a lymphangion, the single layer muscle cell contracts against the expanding lymphangion and pushes the bolus proximally into the next lymphangion (see Fig. 3-3). This process continues until the bolus reaches the afferent lymphatic pathways of the lymph node.

The pumping movement of the lymphangions resembles the peristaltic movement of the small intestine. The lymphan-gions pump at a rate of 10 to 20 times per minute,3 and exer-cise can increase this pumping motion by 10 to 30 times.1 Recent theories hold that peristalsis also creates a negative pres-sure that opens the junctions of the endothelial cells, enabling large-molecule substances to move from the interstitium into the initial lymphatic.3

Eventually the bolus of lymph moves into the afferent lym-phatic pathways of the lymph nodes. Lymph nodes, which per-form several immunologic functions, are composed of a series of complex sinuses and therefore often are considered “dams” or “kinks in the hose” in the movement of lymph. Excessive swell-ing distal to the lymph nodes does not increase their rate of filtra-tion, but rather causes further congestion distally.4 Venous vessels do not connect to lymph nodes and therefore do not reflect this slowing of fluid movement. Also, venous vessels do not carry bacteria or tissue waste products and therefore do not pass these

FIGURE 3-1 Blood and lymph circulatory systems. (From Foldi M, Foldi E, Kubik S: Textbook of lymphology for physicians and lymphedema therapists, Munich, 2003, Urban & Fischer Verlag.)

Exercise moves lymph ten to thirty times faster through the collector lymphatics and increases the rate of lymphatic uptake from the interstitium.1

Clinical Pearl

Edema Reduction Techniques: A Biologic Rationale for Selection CHAPTER 3 37

substances through the lymph nodes for cleansing. Lymph nodes present significant resistance to the flow of lymph and must be massaged to facilitate a faster flow of the distal congested lymph.4 The MEM method of massaging healthy and uninfected nodes uses MEM pump point stimulation, which is a method of simul-taneously massaging two groups of nodes, bundles of lymphatic vessels, or watershed areas (anatomical drainage dividing areas), which theoretically speeds up the movement of lymph through the nodes.

From the nodes, lymph can enter the venous system directly, through lymphovenous anastomoses (areas where the small ves-sels of the lymphatic and venous systems join), or it can continue on in the lymphatic vessels and empty into either the right lym-phatic duct or the largest lymphatic vessel, the thoracic duct. The thoracic duct lies anterior to and parallel with the spinal cord from approximately L2 and empties into the left subclavian vein.2,3 The right lymphatic duct terminates in the right subclavian vein.

The movement of lymph in the thoracic duct is affected by changes in thoracic pressure. Diaphragmatic breathing expands the abdomen, causing changes in thoracic pressure that move the contents of the thoracic duct more proximally.1,3 This action creates a vacuum, drawing lymph from the more distal vessels toward the thoracic duct.1,3 Treatments such as MEM, therefore, begin with diaphragmatic breathing and trunk exercise. This is analogous to removing the plug from a drain or a clog from a backed-up sink. The clog must be removed before the water can flow out. In terms of clinical application, the vacuum created by

diaphragmatic breathing moves lymph more proximal in the tho-racic duct, creating a space into which the more distal peripheral edema can move.

Before they reach the thoracic duct, the deep lymphatic trunks share a common vascular sheath with the venous and arte-rial structures.3 Therefore exercise increases the rate of arterial flow and passively stimulates the lymphatic vessels, increasing the rate of lymph flow. Also, at least 200 lymph nodes are located centrally and around deep venous and arterial structures. Exercise of the abdominal muscles increases the pumping of blood, which stimulates the lymph nodes, moving lymph through them more rapidly—a force pump action.

“Exercise is key to lymphatic activation” is a frequently heard statement. Yet therapists know that in most cases, simply exercis-ing the edematous hand or arm in the subacute phase does not significantly or permanently reduce edema. Lymphatic structures can exceed 30 times their normal capacity before edema becomes visible;1 this means that proximal to the visible edema is the beginning of non-visible edematous congestion.

FIGURE 3-2 Incorporation of the lymph capillary into the intersti-tium. 1, Arterial section of the blood capillary; 2, venous section of the blood capillary; 3, lymph capillary; 4, open intercellular groove-swinging tip; 5, fibrocyte; 6, anchor filaments; 7, intercellular space. Small arrows indicate the direction of blood flow; large arrows indicate the direction of intercellular fluid flow. (From Foldi M, Foldi E, Kubik S: Textbook of lymphology for physicians and lymphedema therapists, Munich, 2003, Urban & Fischer Verlag.)

A B CFIGURE 3-3 Structure and function of the valve segments in the collector lymphatics. A, Arrangement of the musculature. B, Normal function. C, Dilated lymph vessel with valvular insufficiency and reflux. (From Foldi M, Foldi E, Kubik S: Textbook of lymphology for physi-cians and lymphedema therapists, Munich, 2003, Urban & Fischer Verlag.)

The key to successful edema reduction is to “remove the plug” by starting proximally at the trunk with diaphragmatic breathing and proximal exercise.

Clinical Pearl


Exercise and light massage significantly proximal to the visible edema create a negative pressure, drawing lymph proximally and thus removing the “clog.” The results of research by Pecking and colleagues6 present a strong argument for stimulating lymphatic absorption and conduction significantly proximal to visible edema. In these researchers’ study, manual lymphatic drainage (MLD) (the manual decongesting of lymph through activating the lymph uptake through massage, low-stretch bandaging pro-grams, and so on) was performed exclusively to the contralateral, normal upper quadrant on 108 women with lymphedema caused by mastectomy; this resulted in a 12% to 38% lymph uptake in the hand, even without massage of the involved area.6 The con-tralateral massage created a negative pressure (vacuum), drawing the lymph from the involved to the uninvolved area, where it could be absorbed into the normal system.

If we synthesize these findings with the theory that changes in thoracic pressure move lymph proximally, and add the knowl-edge that muscle contraction stimulates lymphatic uptake on many levels, we arrive at a very strong rationale for beginning edema reduction at the trunk even if edema is visible only in the hand. Clinically, this means that therapists should not begin edema reduction treatment where edema is visible; rather, they must begin in a normal, uninvolved area significantly proximal to the visible edema. Appropriate treatments include diaphrag-matic breathing, trunk stretching and muscle contraction exer-cises and activities, and MEM massage that begins in the area of the uninvolved axilla. (MEM is discussed in more detail later in the chapter.)

Acute Edema Related to the Vascular Anatomy

The venous and lymphatic systems have many pump-like struc-tures that help propel the blood back to the heart. Because of the descending gradient of hydrostatic pressures from the arteriole capillary to the venule capillary, small-molecule substances dif-fuse easily and are reabsorbed into the venous capillary through its thin wall.2 Active muscle contraction acts as a pump as it com-presses and empties the large deep venous vessels. As this blood is propelled proximally toward the heart, a negative pressure is cre-ated, which draws blood from the periphery into the deep veins.

Edema develops when the descending gradient of Starling’s forces are disrupted by an interruption and an imbalance. The cas-cade of events that occurs after tissue laceration is a good example. Initially, an outflow of water and electrolytes (transudate edema) into the wound occurs. The mast cells then release histamines, which greatly increase capillary permeability, and plasma proteins, phagocytic cells, and other substances leak into the area. Plasma protein fibrinogen is converted to fibrin, which plugs the endothe-lial cells lining the lymphatics.7 This prevents the lymphatics from temporarily removing the large molecules as the various phagocyte cells perform their “cleanup” function.7 Edema results when excess fluid and plasma proteins are trapped in the interstitium. Star-ling’s equilibrium is disrupted, because the trapping of excess pro-teins in the interstitium increases the colloid osmotic pressure.

The immediate goal of treatment by physicians and therapists is to limit the amount of outflow into the wound bed, thereby preventing excessive swelling, accumulation of blood, and further tissue damage. After 2 to 5 days, the swelling begins to subside as the surrounding intact venous capillaries start to absorb the tran-sudate and the lymphatic vessels absorb the large-molecule plasma proteins not phagocytized by the macrophages.

Reduction Techniques for Acute Edema

Bulky Dressing

Several techniques can be used to reduce excessive fluid outflow (edema). For example, a bulky hand dressing applied at the time of surgery gives counterforce to the outflow (filtration) by chang-ing the tissue pressure. It is composed of appropriate wound care dressing, fluffy gauze sponges, and rolled-on gauze. After soft tissue trauma, immobilization for up to a week in a bulky dressing or plaster splint facilitates healing of involved structures by preventing stress on fragile tissue, which could cause microscopic rupture of vessels with resulting edema. The therapist should check the dress-ing or splint to make sure it is not too tight and should contact the physician immediately if this is a possibility. A bulky dressing that is too tight causes vascular changes, temperature changes, increased edema, or severe, painful compression of the fingers and can lead to tissue breakdown. The capillary refill test can be used to check vascular status (see Chapter 5). The therapist also must teach the client that any vascular changes (that is, changes in tissue color) or sensory changes must be reported immediately to the physician. Procedures, such as tenolysis and flexor tendon repair, involve min-imal or no immobilization in a bulky dressing. However, even with these diagnoses, limited motion can increase edema, therefore early motion must be balanced with rest to prevent this.

High Voltage Pulsed Current

In animal studies, high-voltage pulse current (HVPC) used on very acute edema was reported to retard the high capillary perme-ability outflow 8,9 but has not been replicated in human subjects. Clinically, it is a frequently used modality to reduce acute edema.

Elevation

Elevation of the hand above the heart, if not contraindicated, also reduces outflow because it reduces the arterial hydrostatic pressure.10 Elevation in the acute stage facilitates lymphatic flow because hydrostatic gradient pressure is increased along the lym-phatic trunks.4 Ideally, the involved extremity is elevated in a plus 45-degree “ski hill” position; this means that pillows are placed so that the elbow is above the shoulder, and the hand is above the elbow and wrist.

Keeping the arm elevated while sleeping can be difficult. Often clients use pillows on either side of them. A belt can be fastened around the pillows to keep them together. Also, the bed can be moved against the wall so that one set of pillows is pushed up against the wall, preventing them from falling. For clients with finger replantation, elevation no higher than the heart is recom-mended to avoid compromising arterial blood flow.11

Precaution. Extreme elevation of the right arm must be avoided in stroke clients with right-sided heart weakness. Extreme upper extremity elevation may cause fluid to flow too quickly into the right side of the heart, because the right upper quadrant is drained by the right lymphatic duct that empties into the right subclavian vein.

The anatomic differences between the lymphatic and venous systems determine the anatomically-based treatment of edema.

Clinical Pearl


Cold Packs

Cold packs, if not contraindicated for vascular and tissue ischemia reasons or diseases such as Raynauld’s, cause vasoconstriction and thus reduce the outflow of fluid in the acute stage. However, the temperature of the cold pack is a consideration. Research shows that when the temperature is lower than 59° F (15° C), proteins leak into the interstitium from lymphatic structures.12 Excess proteins in the interstitium cause edema.

Precaution. To prevent “ice burn” to tissue, always place a dry towel between the skin and the cold pack. Cold packs should not be used on a client with a replanted hand or digit because of the effect of vas-cular compromise on tissue viability.13 A nerve repair may be injured by cold postoperatively. Clients should get explicit care instructions from their physicians, including precautions on the use of cold packs.

Retrograde Massage

Light retrograde massage with elevation facilitates diffusion of small molecules into the venous system. The elevation reduces capillary filtration (outflow) pressure, and the light pressure from the retrograde massage aids in venous absorption of the small molecules (not large plasma proteins).

Precaution. The pressure is kept light to avoid damaging the single-cell initial lymphatic structures in the dermal layer of the skin.

Compression

Light compression, such as from an elastic glove, Coban (or simi-lar type material) lightly spiral-layered on a digit, or low-stretch finger bandage wraps (see video/slides on the Evolve website), facilitates small molecule absorption by the venous system and absorption of large and small molecules by the lymphatic system. A loose but compressive elastic glove generally is one in which the glove material can be pulled away from the hand and simultane-ously on each side of finger at least ⅛ inch.

In the early post stroke stages, hand and arm edema is a tran-sudate swelling because fluid leaks into the interstitium as a result of lack of muscle pumping activity on the vascular vessels. Eleva-tion, light retrograde massage, and light compression from an elastic glove or elasticized arm stockinette are effective treatments that promote diffusion of leaked electrolytes and water back into the venous system.

Precaution. When using an elasticized garment, observe two important precautions: (1) make sure it is not too tight (that is, it does not cause color or temperature changes in the hand or digit) and (2) with elasticized stockinette, make sure it cannot roll down, caus-ing swelling distally.

A body garment glue can be used to prevent the elastic stocki-nette from rolling down on itself, which can cause distal swell-ing. Keep in mind that some body garment glues are latex based; therefore always make sure your client does not have a latex allergy before using this type of glue.

Precaution. An elastic glove should be fitted to give some compres-sion but should feel loose on the hand and fingers. If the compression is too tight, fluid flow is restricted, which increases edema.

Elastic Taping

Elastic taping is becoming the common generic term used to des-ignate a variety of tapes similar to the original Kinesio Tex tape

developed by a Japanese-born chiropractor, Dr. Kenso Kase, in the 1970s.14 The cloth-like tape has acrylic glue applied to one side in a wave-like pattern, such as a finger print swirl. When the tape is applied in a specific manner it is theorized that the edema reduces because patient movement pulls the skin in the opposite direction from where the tape was applied. This movement puts a stretch on the initial lymphatic structures facilitating congested lymphatic absorption.15 Increasing this space, creates a pull on the connec-tive tissue anchor filaments attached to the endothelial cells of the initial lymphatics; this separates the planted endothelial junctions, thereby increasing lymph and fluid flow.

Indications for Manual Edema Mobilization in the Acute Stage

Many wonder why MEM is not started in the acute stage. In 1989, Hutzschenreuter and Brummer16 did a research study on this point using sheep. They compared the results in two groups, one in which MLD was performed and one in which it was not over a defined period (that is, immediate postoperative to 3 weeks postoperative). They found that both groups showed minimal fluid reduction during the first week after surgery. However, after the first week, the MLD group had a significantly greater increase in fluid movement and edema reduction than the con-trol group.16 These results are not surprising because initially, acute edema is transudate that is changing to exudate edema as the plasma proteins invade and are contained. Only the lym-phatic vessels can remove excess proteins from the interstitium.1,2 MEM and manual lymphatic treatment* (MLT) programs are designed to activate lymphatic vessels.

Exercise

Some physicians prescribe proximal active motion of an extrem-ity or gliding of the involved structures, or both, during the acute stage of wound healing. Proximal trunk and shoulder motion is excellent. It decongests the lymphatic vessels and removes tissue waste products, resulting in better oxygenation to tissue and faster wound healing. However, movement must be balanced with rest of involved structures. This is done by progressively grading the exercise so as not to increase hand inflammation, pain, and swell-ing. Always respect the fragility of healing tissue and vascular structures. When moving the involved structures, start with lim-ited movement and check for signs of increased pain, swelling, or redness. If edema increases, rest the involved hand for a day (consider applying a static orthosis). Resume activity, but do less than previously and gradually increase the exercise over the next treatment sessions. I usually begin with the rule of three or five: three (or five) repetitions of an exercise three (or five) times a day. If this does not increase swelling, gradually increase repetitions or frequency, or both. Remember, edema and pain limit motion and retard progress.

* Manual lymphatic treatment is the generic term used to describe the massage prin-ciples common to all schools of lymphatic drainage.15

Reducing edema is almost always the first priority; do this, and the client will gain motion.

Clinical Pearl


Reduction Techniques for Subacute and Chronic Edema Based on the Lymphatic Anatomy

To review, the lymphatic system is an independent pump system that works on a negative pressure gradient. When lymph vessels fill (high pressure is created), lymph moves to an area of lower pressure.1-4

The two keys to activating the lymphatic system are as follows:• Key 1—Proximal, uninvolved lymphatic structures must be

stimulated (massaged), creating a lower negative pressure to draw the most proximal edema out of the involved area.

• Key2—Moleculesareabsorbedintothelymphaticsfromtheinterstitium because only changes in the interstitial fluid pres-sure (low to high) cause the endothelial cells lining the lym-phatics to open.Key 1 is based on the theory that negative pressure causes a

suction effect that moves the more distal lymph proximally in the trunk and extremities.1,3 Appropriate treatments to achieve this include MEM massage that starts at the uninvolved axilla, diaphragmatic breathing, trunk exercise, trunk exercise combined with breathing, proprioceptive neuromuscular facilitation (PNF) techniques combined with exhaling and inhaling, and easy yoga trunk stretching exercises. These are considered methods of inter-nal stimulation of the deep lymphatics.

Key 2 involves external stimulation of the lymphatics to facili-tate the uptake of lymph from the interstitium by creating changes in the interstitial pressure; by causing stretching of the anchor filaments attached to connective tissue; and by creating nega-tive pressure, which causes the opening of lymphatics through lymphangion pumping. Appropriate treatments to achieve this include MEM, elastic taping, gentle myofascial release (MFR), bombardment of tissue with fluidotherapy particles at a machine temperature no higher than 98° F (36.7° C), active and passive exercise and the light compression provided by elastic gloves, chip bags, and low-stretch bandaging.

Contrast Baths

Some therapists use contrast baths to reduce edema, although cur-rently no research is available that supports this practice.17 If con-trast baths are to be used, research findings on temperature need to be considered. Kurz18 states that lymph flows best at tempera-tures between 71.6° F (22° C) and 105.8° F (41° C).18 For therapy purposes, the hot temperature should not exceed 98° F (36.6° C) to avoid increasing capillary permeability (which is enhanced by heat) and thus edema. With regard to the cold temperature, as mentioned earlier, research has shown that the initial lymphatics actually leak protein into the interstitium at temperatures below 59° F (15° C).12 Therefore, to avoid the leakage of more plasma proteins into the interstitium (potentially increasing edema), the cold temperature should not be lower than 59° F (15° C).

Precaution. To avoid worsening the edema, set the temperatures for contrast baths between 71.6° F (22° C) and 98.6° F (37° C).

Therapy with contrast baths commonly is performed by hav-ing the client immerse the hand in warm water for 3 minutes and then in cold water for 1 minute. This sequence is repeated four times, ending on cold.

Electrical Modalities

Published research regarding the use of electrical modalities, such as transcutaneous electrical nerve stimulation (TENS), Low Intensity Laser Therapy (LILT), and non-thermal therapeutic ultrasound, to reduce peripheral subacute edema is inconsistent. Resende, et al.19 found that TENS did not reduce edema. For over 30 years, literature has been published regarding the mul-tiple applications for LILT. However because of the variety of parameters used with LILT, comparing outcomes is difficult. Studies showing the use of LILT for edema control of ankle sprains were not positive.20,21 In 2004, a post flexor tendon repair study using gallium arsenide (GaAs) laser therapy found edema reduced immediately and at 12 weeks post repair.22 Clini-cally non-thermal therapeutic ultrasound is often implemented to reduce upper extremity edema, yet a peer-reviewed literature search did not find any supporting evidence.

HVPC has been shown to reduce acute edema in the ani-mal model.8,9,23 It has also been a consideration for subacute and chronic edema. For instance, Griffin and colleagues24 found that HVPC did not reduce pre-existing edema.24 However, a subsequent study by Stralka and coworkers25 on employees with cumulative trauma disorders who wore an orthosis that incorpo-rated HVPC while working showed a reduction in edema. This raises the question of whether the HVPC was reducing the acute edema occurring while working, or reducing a combination of acute and subacute edema. Further study is needed.

The sooner lymphatic decongestion occurs, beginning at 1 week post-injury even with non-visible edema, the less the chances of developing tissue and scar thickening, fibrosis, and contractures.

Clinical Pearl

• Bulkyhanddressing(usuallyappliedbythesurgeonpostoperatively)

• High-voltagepulsecurrent(HVPC)(usedonlyforveryacute edema; benefit in humans not yet proven)

• Elevation • Lesserdegreeofelevationisneededforreplanted

digits and/or hands. • Extremeelevationiscontraindicatedifright-sided

heart weakness is present (that is, post stroke client).• Coldpacks(usedinthefirst24to48hoursonlyas

directed by physician) • Coldpacksshouldnotbeusedforreplantsbecause

cold causes vasoconstriction. • Precautionsshouldbeclarifiedwithphysicianifa

nerve is involved.• Lightretrogrademassage• Looseelasticgloveorelasticstockinette• Cobanorsimilarself-adherentmaterial(looselyplaced

on digit in spiral, distal-to-proximal pattern)• Fingerbandagewraps• Limitedactivemotionofuninvolvedareas(excessive

trunk/shoulder motion increases edema)• Balanceofactivityandrestforallstructurestoprevent

inflammation or increase in edema• Elastictaping(thatis,Kinesiotaping)

Summary of Reduction Treatment for Acute Edema


Thermal Modalities

Often with subacute edema the therapist additionally has to address joint and tissue stiffness and decreased range of motion (ROM). Heat will increase tissue elasticity. Heat between 71.6° F (21.9° C) and 105.8° F (41° C) will increase lymph flow18 and soften tissue due to decongestion of the lymph. However, too much heat will increase capillary permeability, increasing the swelling. Therefore, therapists are recommended to keep heat to tissue at body temperature or just slightly above.

Clinically, the author has been able to use well-padded hot packs for 12 minutes on the edematous indurated (dense thick-ened) tissue area, gain tissue elasticity, and soften this edematous indurated tissue without increasing edema. This has been accom-plished by doing a proximal MEM routine while the hot packs are on the extremity, followed by proximal to distal exercise after removal of the hot packs. Doing the MEM stimulates and decon-gests the proximal lymphatic system, creating the negative pres-sure vacuum to absorb and move the lymph from the area (see Case Study 3-1). A Fluidotherapy machine set at 98° F (36.6° C) to 100° F (37.7° C) will accomplish the same benefit.

Pneumatic Pump

Pneumatic pumps are rarely used by hand therapists. A com-bination of MEM, compression bandaging, elastic tapping on induration areas, and exercise will usually reduce the congested lymph. However, there might be rare instances where usage is needed, such as a temporary case of dependent edema from a neurological motor impairment, or extensive damage to the ini-tial lymphatics, such as a massive crush injury to the entire arm. This edema will not stay reduced unless a low-stretch bandag-ing or garment system is applied to the extremity after using the pneumatic pump. Description of this type of a bandaging or gar-ment program is beyond the scope of this chapter.

When using the pneumatic pump for post trauma/surgery chronic edema, the chamber pressures should never be greater than 40 mm Hg because of the potential to collapse the ini-tial lymphatics where absorption occurs “having a tourniquet effect”26 and because of potential calibration errors.4,27 A pneu-matic pump system was developed by Flexitouch in 2006, and research has shown it facilitates lymphatic uptake and moves lym-phatic fluid.28 This system mimics MLD by first decongesting trunk edema and then proceeding to the extremity(ies) with the sequence, a rolling light chamber pressure, and the timing used with MLD. The therapist must follow usage guidelines and pre-cautions for all pump usage.

Elastic Taping

Clinically I have found elastic tape to be an excellent adjunct to MEM to soften tissue and to keep the lymphatics stimulated for absorbing lymph throughout the day and night. There are many applications for taping, and formal course completion is recom-mended. See the Reduction Techniques for Acute Edema section for a complete description

Myofascial Release

MFR is a manual technique that entails sustaining a very light gentle pressure on soft tissue that in turn impacts the fascial

system directly below the therapist’s hands and throughout other parts of the body. The result is elongation or softening of the fascia and its ground substances. Clinically, I frequently use one of several MFR techniques on a specific muscle area to reduce the fascial restriction, and then I get a better lymphatic flow and edema reduction. Here, also, formal coursework is needed before doing the technique.

Exercise

Exercise should start at the trunk to facilitate the lymphatic pump. Even low-level aerobic exercise causes thoracic pressure changes on the thoracic duct. The pressure changes move the lymph proximally into the venous system at the subclavian veins creat-ing a vacuum drawing the lymph proximal from the periphery.3 Shoulder and elbow exercise, if not contraindicated, should be done next in the sequence. This draws and moves edema proxi-mal toward the thoracic duct, creating a space for the more distal edema to move proximally. Next, exercise is completed at the wrist and then at the hand/fingers.

Low-Stretch Bandages, Gloves, Massage, and Chip Bags

Massage or compression on tissue must be light to avoid collaps-ing the single-celled initial lymphatics in the dermal layer. Miller and Seale30 reported that the initial lymphatics began to collapse at a pressure of 60 mm Hg and that they closed completely at 70 mm Hg when tested on a flat surface. Eliska and Eliskova31 found that a 3 minute friction massage on edematous tissue at 75 to 100 mm Hg caused temporary damage to the endothelial linings of both the initial lymphatics and the collector lymphatics. Thus string wrapping should be avoided in all stages of edema because of the potential to damage fragile lymphatic structures and because fluid cannot be “pushed” into the lymphatic structures, but rather it has to be absorbed due to pressure changes. Applying this same information to the application of elastic gloves, finger and forearm wrapping, or massage means that the compression has to be light to cause interstitial pressure changes and lymphatic absorption. The movement and slight compression of a loose elas-tic glove or elastic stockinette causes interstitial pressure changes and lymphatic absorption. Clinically I have found that fingers of elastic gloves are most effective when they can be stretched simultaneously ⅛ of an inch on either side of the digit. An elastic stockinette must allow me to place my two hands on either side of the forearm when the patient is wearing it; otherwise it is too tight. MEM massage pressure is one half the weight of the hand,

Do not begin exercises at, or just, proximal to the edema because it has to have a proximal space (decongested area) for the fluid to move within the lymph system.

Clinical Pearl

When MEM is contraindicated (such as, for cardiac, pulmo-nary, kidney disease reasons), some edema will be reduced by doing diaphragmatic breathing. Then begin exercise at the trunk and proceed proximal to the edema and potentially add an elastic stockinette to the edematous area.

Clinical Pearl


or no heavier than required to feel tissue moving over muscle. (See Reduction Techniques for Chronic Edema and the Evolve website for a detailed description of bandaging and chip bags.)

Manual Edema Mobilization

As mentioned in treatment for acute edema, MEM is used to reduce persistent subacute edema where proteins are congested and trapped in the interstitium because of extensive tissue damage to lymphatic structures, fibrotic scarring, and so on. The tech-nique reduces both visible and not yet visible edema when there is congestion of a normal, intact, but overloaded, lymphatic system.

MEM is a modification of MLT techniques used for lymph-adenectomy and/or lymph node irradiation, primary (congeni-tal) lymphedema, and lymphedema arising from filariasis. For those types of edemas, MLT very appropriately involves extensive rerouting of lymph flow around missing or permanently damaged nodes and lymphatic vessel areas.

I developed MEM after I became certified in lymphedema treatment and learned about the anatomic functioning of the lym-phatic system. As I studied lymphatic anatomy and physiology, I realized that the traditional treatments for upper extremity edema could be improved if they were based on this knowledge. Specifi-cally, I realized that the subacute edema that I struggled to reduce in my surgical, trauma, and stroke clients with hand edema was a lymphatic overloaded edema. In these cases, because the lymphatic system, although overloaded, was still intact, extensive rerouting wasn’t necessary, just decongestion, starting at the trunk.

I first taught MEM in 1995, and it continues to evolve. Since then, three peer-reviewed studies (one case study, a single-subject design study, and a randomized controlled study)32,33,34 have been published establishing the validity and showing outcomes of use of the MEM technique. There are no research-based articles for a “simple lymphatic” massage for subacute and chronic hand edema reduction. In other words, only MEM has been validated, and randomly modifying MLD has not been validated.

MEM is a significant modification of MLT in several ways: (1) it involves only one or two trunk rerouting techniques; (2) it requires exercise after each segment is massaged; (3) it has its own light hand massage patterns; (4) it includes scar rerout-ing patterns; (5) it relies heavily on client follow-through with a self-management program; and (6) it incorporates pump point stimulation, which is unique to MEM.

The full MEM program takes 30 minutes. The short version, consisting of trunk rerouting and pump point stimulation, takes 15 minutes. MEM can be combined with other edema reduction techniques, but it should be done before those techniques are per-formed. The reason for this is simple: MEM decongests the most proximal edema and moves that edema proximally, creating a space into which the more distal edema can move by means of a proximal negative pressure vacuum. The more traditional edema reduction techniques will be more effective after MEM, because then there is a space cleared to which the edema can be moved proximally.

Principles and Concepts

MEM is grounded in the following principles and concepts:35

1. Light massage is provided, ranging from 10 to 20 mm Hg, to prevent collapse of the lymphatic pathways and arterial capil-lary reflux.

2. When protocol allows, exercises are performed before and af-ter the MEM session; these exercises are done in a specific sequence, starting proximal to the edematous area or in the contralateral quadrant if possible.

3. Massage is performed in segments, proximal to distal, then distal to proximal. Massage ends in a proximal direction (that is, toward the trunk).

4. When possible, the technique includes exercise of the muscles in the segment just massaged.

5. Massage follows the flow of lymphatic pathways. 6. Massage reroutes around scar areas. 7. The method of massage and the types of exercise do not cause

further inflammation of the involved tissue. 8. A client home self-massage program is devised that is specific

to the pathologic condition of the hand. 9. MEM can be adapted to various diagnoses and stages of high

plasma protein edema. 10. Guidelines are included for incorporating traditional edema

control, soft tissue mobilization, and strengthening exercises without increasing edema.

11. Specific precautions are observed. 12. When necessary, low-stretch compression bandaging or other

compression techniques are used. 13. Pump point stimulation is used extensively. 14. MEM is beneficial in clients whose lymphatic vessels are in-

tact but overloaded from congestion.

Contraindications

The precautions and contraindications for MEM include those that are common to most massage programs and others that are specific to the movement of a large volume of fluid through the system. Always consult a physician if you are concerned about the client’s current or past cardiac and/or pulmonary status. For instance, if an 80 mL volumetric difference exists between the client’s two extremities, inform the physician that with MEM, that much fluid may be moved through the heart and lungs. Ask whether this would compromise the client’s cardiac status.

Therapists should not use MEM in the following circumstances:• Ifinfectionispresent,becausetheinfectionmaybespreadby

the technique.• Over areas of inflammation, because inflammation and pain

may be increased; MEM should be performed proximal to the inflammation to reduce the amount of congested fluid.

• Ifahematomaorbloodclotispresentinthearea,becausetheclot may be activated (that is, it may move).

• If active cancer is present. A controversial theory notes thepotential for spreading cancerous cells. MEM should abso-lutely never be done if the cancer is not being medically treated. The therapist should always seek the physician’s advice.

• If theclienthascongestiveheart failure, severecardiacprob-lems, or pulmonary problems, because the cardiac and pulmo-nary systems may be overloaded.

• In the inflammatory (acute) stage of acute wound healing(rationale explained previously).

• Iftheclienthasrenalfailureorseverekidneydisease,becausethe edema in these cases is a low-protein edema, and the renal system may be overloaded and/or the fluid may be moved to some other undesirable site.


• If the client has primary lymphedema or lymphedema aris-ing from a mastectomy. Successful treatment of this condition requires knowledge of ways to reroute lymph to other parts of the body, as well as specific techniques beyond the scope of this chapter.

Manual Edema Mobilization Massage, Drainage, and Definitions

U’s Hand Movement Pattern

U’s are a pattern of hand movement that involves placing a flat, but relaxed, hand lightly on the skin. The hand gently tractions (pulls) the skin slightly distal and then circles back up and around, ending in the direction of the lymph flow pattern. The movement is consistently a clockwise or counterclockwise motion in a U, or teardrop configuration. Very light pressure (10 mm Hg or less) is used to move just the skin, thereby stimulating the initial lymphat-ics. Clinically, this is taught by having the therapist first place the full weight of the hand on the client’s arm; then, while the entire palm and the digits remain in contact with the client’s skin, the hand is partly lifted so that only half of its weight rests on the arm. MEM massage proceeds at this very light pressure, moving in a U while tractioning (pulling), not sliding, the skin. This is a “skin” massage—just enough pressure to feel the skin move over muscles.

Clearing U’s Skin Tractioning Pattern

Clearing U’s is a pattern of skin tractioning (pulling) performed in segments. It starts proximally and moves to the designated dis-tal part of the trunk or arm segment (that is, upper arm, fore-arm, or hand). A minimum of five U’s are done in three sections for each segment. The purpose is to create interstitial pressure changes that cause the initial lymphatics to take up lymph.

Flowing U’s Lymph Movement Pattern

Flowing U’s is a pattern of sequential U’s that starts in the distal part of the segment being treated and moves proximally past the nearest set of lymph nodes. This could be described as “waltzing” up the arm. The process of moving one U after another from distal to beyond the proximal node is repeated five times. After the final repetition is completed, the flowing U motion is per-formed all the way to the contralateral upper quadrant. The pur-pose is to move the softened lymph out of the entire segment and facilitate its eventual return to the venous system and the heart (Fig. 3-4). In other words, the direction of “flow” follows the lymphatic pathways toward the heart (that is, flowing proximally, not distally). If not contraindicated by the diagnostic protocol, active muscle contraction is done in each segment after “flow.” This increases the rate of lymphangion contraction, which moves the lymph out of the area more quickly.

Pump Point Stimulation

Pump point stimulation involves simultaneous, synchronous movement of the therapist’s two hands in a U pattern over areas of lymphatic bundles (groups of initial and collector lymphat-ics), watershed areas, and/or lymph nodes.35 Because nodes pose resistance to the flow of lymph, pressure from the full weight of

the hand is used. Typically the therapist does 20 to 30 Us in one area before proceeding to the next area of pump points. After pump point stimulation is performed in an area, MEM flow is done followed by exercise either in that area or proximal to it (see the Evolve website)

Therapists should not attempt MEM unless they have been trained in the technique. One- and two-day courses are available and required for any therapist who would like to use MEM as a treatment.

FIGURE 3-4 Forearm: Clear A, B, C. Flow C, B, A. (From Mackin EJ, et al, editors: Rehabilitation of the hand and upper extremity, ed 5, St Louis, 2002, Mosby.)

• Startproximallywithdiaphragmaticbreathing,trunkstretches, trunk exercises, easy (appropriate) yoga trunk stretches

• MEM• Elastictaping• Gentlemyofascialrelease(MFR)• Fluidotherapymachine(setat98°F[36.6°C]orlower)• Activeandpassiveexercise(avoidexcessiveexercise,

which can cause re-inflammation of tissue)• Looseelasticglove;looseelasticstockinette;cotton

finger wrap bandages; Coban wraps• Pneumaticpumptosoftenlymph(setat40mmHg

or less)• Low-stretchbandages,gloves,massage,chipbags

Summary of Reduction Treatment for Subacute Edema

Starting proximal at the trunk is the key to lymphatic decon-gestion; this is the first technique that must be done so that the other edema reduction techniques are effective.

Clinical Pearl


Reduction Techniques for Chronic Edema

Chronic edema is persistent edema that lasts longer than 3 months and is indurated (hard) and difficult to pit.35 As a result of the long-term entrapment of plasma proteins in the interstitium, the tissue becomes fibrotic. In part, treatment is the same as for sub-acute edema, but it includes softening of the fibrotic tissue to facilitate uptake by the initial lymphatics. Softening of indurated tissue can be accomplished with low-stretch bandaging, chip bags (convoluted foam pieces of different densities placed in a stocki-nette bag), foam-lined orthoses, silicone gel sheets, and elastomer pads (see the Evolve website). Neutral warmth builds up under these inserts, causing an enzymatic reaction that softens the indu-rated tissue. The varying densities of the foam chips in a chip bag can result in tissue pressure differentiation, stimulating protein uptake.

Low-Stretch Bandaging

Low-stretch bandages are cotton, nonelastic bandages that have a 20% stretch because of the weave of the bandage. These bandages are rolled on rather than stretched on. When a muscle contracts, it bulks up under the bandages. Because the bandages stretch only 20%, they provide a light counterforce, which is not enough to collapse the initial lymphatics. When the muscle relaxes, the ban-dages only collapse 20%, again not enough to collapse the initial lymphatics. Thus variation in tissue pressure facilitates lym-phatic uptake and prevents refilling of stretched tissue. Research has shown that use of a combination of low-stretch and foam bandages on the forearm, along with exercise, increases protein uptake.36 (See the Evolve website for more information on low-stretch bandaging.)

Low-stretch finger wraps also soften lymph and facilitate lym-phatic absorption (see the Evolve website). These are often used when a client’s hand is so edematous that it does not fit into an elastic glove. Low-stretch finger wraps are not used to squeeze the edema out, because that would collapse the delicate lymphatic structures. The distal-to-proximal spiral pattern in which the wraps are applied, the neutral warmth maintained by the finger bandages, and the effect of finger movement all soften the indu-rated tissue, improving lymphatic flow and edema reduction.

Chip Bags

Chip bags vary in size, depending on the area they are to cover. They consist of stockinette bags filled with various densities and sizes of foam. The ends of the bag are either taped or sewn closed. Chip bags can be worn under low-stretch bandages, loose elas-tic gloves, or orthoses (see the Evolve website). Various types of commercially-fabricated chip bags made of foam or wheat hulls are also available for purchase.

Self-Adherent Wrap

Coban or similar self-adherent wrap material is used by many therapists on edematous fingers. When placed on the finger or digit circumferentially, it creates a squeezing effect, pushing fluid distal or proximal, or both. Lightly overlapping spirals of self-adherent wrap distal to proximal down a digit facilitates the absorption and movement of fluid proximally (see the Evolve website). This wrap also creates a buildup of neutral warmth.

A small stockinette or powder can be put on the wrap once it is on the finger so that the wrapped fingers do not stick together.

Other Types of Edema and Appropriate Treatment

Lymphedema

Lymphedema is a chronic, high-protein edema that results when a permanent mechanical obstruction of the lymphatic system creates a lymphatic overload.37 Permanent obstruction can be caused by surgical removal of the lymph nodes, irradiation of the nodes or skin, filariasis (an infestation of worms that destroys the lymph nodes), or a congenital deficit of the lymph nodes and lymphatic vessels. Clients with lymphedema must be treated with a full MLT program performed by a trained and credentialed therapist. Treatment includes multiple rerouting of lymphatic flow patterns around deficit areas. MEM is not appropriate for these clients.

Precaution. MEM is a treatment for clients with an overloaded but intact lymphatic system.

Therapists working with hand clients may see a perma-nent deficit of the lymphatic system, resulting in persistent, sustained swelling. This is seen with circumferential scars, as with a replanted digit. It may also occur with circumferential skin grafting. Primary (congenital) or secondary lymphedema (for example, from the removal of diseased nodes) causes lym-phatic congestion (slow outflow of lymph) in the subcutaneous, epifascial tissue space38 which means that only the superficial lymphatic vessels are affected. Therefore a client whose fingers are edematous as a result of this type of lymphedema does not develop joint contractures (Fig. 3-5). If surgical or traumatic invasion (that is, laceration) into the deeper lymphatic structures around joints has occurred, joint contractures may develop. Soft tissue contractures are caused by laceration of superficial and deep lymphatic capillaries, high capillary permeability that causes leakage of plasma proteins, and prolonged congestion of plasma proteins around these joint and tendon structures leading to fibrosis.

For chip bags, self-adherent wrap, or low-stretch bandaging to be successful, proximal MEM, or at least pump point stimula-tion (discussed earlier in the chapter), must be done first to de-congest the lymph (“pull the drain plug”) and move it proximal.

Clinical Pearl

• Alltechniqueslistedfortreatmentofsubacuteedema• Methodstosofteninduratedtissue(thatis,tissuethatis

hardening or already hard), including chip bags, convo-luted foam in stockinette, elastomer and elastomer-type products, silicone gel sheets, foam-lined orthoses low-stretch bandages, cotton finger wraps, and loose elastic stockinette and/or gloves (see the Evolve website).

Summary of Reduction Treatment for Chronic Edema


Complex or Combined Edema

Complex or combined edema is initially a transudate edema, such as acute flaccid stroke hand edema. With flaccidity, no muscle pump facilitates vascular flow, and water and electrolytes leak into the interstitium, resulting in a transudate edema. The treatment is the same as for acute edema. During this phase, night orthoses might be considered to prevent shortening of the extensor tendons. Three months later, the edema may have a viscous feel, but it is relatively fast to rebound, and it does not significantly or permanently reduce with elevation and/or the use of an elastic glove. The edema now has an exudate component. At this point, the lymphatic system, which initially was aiding in the removal of the excess fluid (transudate edema), has reached its maximum capacity. The lymphatic system is overloaded and has slowed down, resulting in lymphatic congestion. The congested plasma protein content of the fluid makes the edema feel viscous. The treatment is the same as for subacute and chronic edema. Often an orthotic program is needed to prevent or overcome joint contractures.

Precaution. Overexercising or forcing joints in a flaccid or hemiparetic hand can cause microscopic rupture of tissue, resulting in inflammation and increased hand edema. Therefore a balance must be attained between gentle, progressive motion and rest of structures.

Cardiac Edema

Cardiac edema occurs with a decline in the heart’s ability to pump blood completely through the circulatory system. As a result, fluid accumulates in the extremities, especially around the ankles. Often cardiac edema manifests as bilateral ankle swelling with a slight pinkish tone to the tissue. Hand therapists treating older adults need to look for this type of edema.

Precaution. MEM and many of the edema-reduction tech-niques are contraindicated for clients with cardiac edema, because movement of more fluid can further overload the already compro-mised cardiac system.

Low-Protein Edema

Low-protein edema can manifest as extremity swelling caused by liver disease, malnutrition, or kidney failure (for example, nephrotic syndrome).1,5 Edema results because too few plasma proteins are present in the interstitium to bond with the water molecule and bring fluid back into the vascular systems.

Precaution. Low-protein edema has a systemic cause and must be treated with medication. MEM and many of the edema reduction techniques are contraindicated because they may overload the kidneys or liver. Also, even if these edema control techniques are used, this type of edema will return because of its systemic cause.

Evaluation of Edematous Tissue

Edema reduces ROM both actively and passively because it increases the size of the fingers or hand. This, in turn, can reduce functional use and coordination of the hand. Once the edema has been reduced, if decreased ROM persists, the therapist can effectively evaluate and treat joint and/or soft tissue limitations. The sooner the edema is reduced, the less the buildup of plasma proteins in soft tissue, the less the fibrosis of the tissue, and the less the thickening of scar tissue.

Precaution. Reducing edema does not reverse existing joint contractures.

By taking circumferential measurements, the therapist can determine where on the hand specifically the edema is prevalent. For consistency, always use the same measuring device; also, take measurements at the same time of day and after the same amount of hand activity.

Edema rebound tests (see Chapter 5) can help determine whether treatment has reduced some of the viscous congested edema. For instance, if the edema rebound time was 65 seconds before treatment and 40 seconds after treatment, this indicates that lymph was moved out. To make this subjective test more consistent, devise a protocol for how much pressure is used and for how long it is applied.

Volumeters have been shown to provide reliable, valid edema measurements.39 These measurements indicate whether volume reduction has occurred; they do not specify the location of the reduction.

The criteria for tissue quality assessment, another evaluation method, are as follows:• Acute edema: Tissue pits deeply, rebounds rather quickly, and

can be easily moved around.• Subacute edema or early stage chronic edema: Tissue pits, is very

slow to rebound, and has a viscous quality.• Chronic edema: Tissue pits minimally and has a hard feeling.• Severe edema: Tissue has no elasticity and is shiny, taut, and

cannot be lifted.• Lymphorrhea: Weeping of tissue occurs with an extremely con-

gested edematous hand or arm. Lymph, a clear, yellowish fluid, escapes from the interstitium to the outside of the skin. Tech-nically, weeping tissue is considered an open wound and must be treated as such. MEM techniques can rapidly decongest the lymph and stop the lymphorrhea.

FIGURE 3-5 Lymphedema of the hand with no loss of mobility.


Note: Always perform the capillary refill test if the client’s hand has a bulky dressing or if the client is wearing finger bandages.

Precaution. Color, temperature, and sensory changes may be signs of a problem. A purple color often indicates pooling of venous blood, and a whitish color means that arterial blood flow to the tissue is compromised. Immediately notify the physician of these signs.

The therapist must be able to distinguish between congestion and infection. With an open wound, the classic signs of infec-tion are redness, warmth, pain to the touch, odor, and/or cloudy drainage. With a closed wound, the signs of a subclinical infec-tion are a pinkish red color and slight warmth; also, the wound may be painful to the touch and the tissue may be hard.40 This is often seen with a very edematous extremity or hand if the first course of antibiotics hasn’t fully resolved the infection. Extremely edematous hands often need a second course of antibiotics as determined by the treating physician.

Precaution. If infection is suspected, MEM should not be started before a full course of antibiotics has been completed and the physi-cian has assessed the status of the infection.

The signs of congestion frequently are the same as those of a subclinical infection. The client’s history can help determine whether the condition is congestion or infection (or both). Often congestion (and, possibly, infection) can be prevented if the ther-apist begins treatment of an uninfected extremity early, before visible edema is present, with the short version of MEM. Pro-longed tissue congestion can lead to infection because congestion reduces oxygen delivery to tissue, diminishing the effectiveness of the phagocytic cells.

Both old and new scars can create a barrier to lymph flow. Check for proximal scars (for example, on the shoulder, back, or axilla). Soften both old and new scars with gentle MFR tech-niques, silicone gel sheets, paper tape, and/or elastic taping. Instruct the client in MEM techniques to reroute edema around scars and to soften scars.

Sensory testing is very important for an edematous extremity because edema often reduces sensation. As edema is reduced, the degree of sensation usually improves. Sensory testing, therefore, becomes an objective test that shows limitations and improve-ments that can be related to function.

Coordination often is diminished by edema in the hand. A nine-hole peg test can become a repeated, scheduled test for assessing hand function. Reducing hand edema should improve coordination, unless an underlying problem exists.

Pain assessment is very important. As edema declines, pain usually diminishes. Clinically, pain reduction often is noticed before ROM shows improvement. Keep in mind that pain can have many sources. For example, in a client with a Colles fracture, edema reduction can relieve the pain caused by the pressure of edema on the nerve receptors; however, the client still may have chronic pain specifically related to the fracture site. Therefore other, appropriate methods must be used to reduce that pain, which differs from edema-related pain. Even during treatment for a different cause of pain, the client should follow a MEM home program twice daily to eliminate any new, not yet visible congested edema.

CASE STUDY

CASE STUDY 3-1 n

Marlene is a 58-year-old white woman from Texas who sustained a right complex distal radius fracture, abrasions and facial fractures, plus bruising to her right shoulder when she slipped off a chair hit-ting her granite countertop as she climbed down from cleaning overhead light fixtures. An orthopedic surgeon and plastic surgeon saw her in the emergency room and appropriate surgery was per-formed on all fractures during the next week. The complex distal ra-dius fracture was treated with open reduction and internal fixation (ORIF), casting for 4 weeks, and then a soft wrist brace for 2 weeks.

At 6 weeks, Marlene saw a hand therapist for the first time. The therapist gave her the standard forearm, wrist, and hand active range of motion (AROM) exercises plus an elastic edema glove. Marlene ex-plained they were leaving for Colorado for the summer in 2 days and would continue hand therapy there. It was another week before Mar-lene saw me for treatment in Colorado. An assessment revealed in part: significant decreased and painful shoulder ROM; forearm supination of 40 degrees and pronation 50 degrees; both wrist flexion and extension 20 degrees; radial deviation 10 degrees and ulnar deviation 5 degrees; active composite finger/thumb ROM was 25% of normal range and passive 50% of normal range. Forearm through fingers were extremely edematous with a total of 3½ inches greater than the circumference of the uninvolved left forearm/fingers. Sensation was impaired one grade overall in all fingers. The patient was extremely anxious about moving her dominant right upper extremity and guarded it.

Problem: I had only three visits that week to treat Marlene before going away for a week.

Thus treatment priorities had to be determined for hand therapy including that the patient needed to be competent with a home edema reduction and exercise program, patient psychological fears needed to be addressed, and she needed to be beginning to func-tionally use her right upper extremity. I requested physical therapy (PT) for shoulder issues so that I had adequate time to address the hand deficit areas.

After the evaluation, she was shown how to apply heat packs to her shoulder and perform traditional Codman’s shoulder exercises to do until her PT visit. Knowing protein-rich, subacute edema is “glue” causing pain and decreased ROM, my first priority became to reduce the edema. I did the basic short MEM home program (Fig 3-6). Note that MEM and exercises are begun at the trunk and shoulder to re-duce hand edema. For Marlene if MEM was just started at the elbow, the distal edema would have had no proximal lymphatic space for congested forearm edema to move into and out of the area. Also, the shoulder exercises as part of the MEM treatment facilitate prox-imal muscle pumping of the lymphatic system. I chose to do the MEM home program on the patient rather than a full therapist treat-ment, because I could teach the patient her home program while I was doing it. It was imperative for her to follow through three to five times a day. This also got her used to using and touching the right upper extremity. The AROM program previously given to Mar-lene was reviewed and incorporated into her daily routine. I loaned Marlene a 3½ inch ball to use for wrist/arm ROM exercises (see the Evolve website).

During the first treatment visit, we reviewed her MEM program that she had done two of the five recommended times a day. I took 30 minutes and did the entire therapist version of MEM to her right upper extremity and reduced the hand edema by 50%. Marlene

Macrophages are less effective in edematous tissue because it has less oxygen; phagocytic activity therefore is diminished.4

Clinical Pearl


was excited to see the edema reduction, plus her pain reduced from 6/10 at rest to 3/10 at rest. She also had a slight increase in active and passive ROM. During the last 15 minutes of the MEM treatment, I placed her forearm/hand between two hot packs in an effort to facilitate induration softening and elongation of tis-sue to increase ROM. I added a 6 oz weight hammer for supina-tion/pronation exercises and wrist flexion/extension to her home program. She was also given sponges to carry around to do fin-ger/wrist exercises multiple times a day. The use of a heat pack for 10 minutes four times a day was encouraged along with continu-ing the ball exercises, which she like to do because “it makes my wrist and arm feel good.”

During the second treatment visit, Marlene was in full compli-ance with her home program because she experienced decreased pain and had started to use her hand for assistive light tasks, such as folding clothes and dusting. MEM was again 30 minutes as noted above with the hot pack placed 15 minutes on hand/forearm indu-rated tissue. Edema was reduced about 15% further. This was fol-lowed up by forearm/wrist MFR, grade one wrist joint mobilization, and instruction in scar massage. The forearm and wrist were elastic taped for edema reduction. Marlene loved to do color pencil sketch-ing. She was asked to bring her tools to the next session.

During the third treatment visit, Marlene continued to be com-pliant with MEM and the exercise part of her home program, but she still was apprehensive about using her right upper extremity for routine light activities of daily living (ADLs), and so on. Between visits, the patient’s hand edema had reduced another 10%. MEM with the usage of the hot pack was only 15 minutes during this treatment

session with a slight edema reduction noted. I performed MFR and joint mobilization. This session began with the use of mirror therapy to improve her hand/wrist ROM exercises and improve patterns of composite and spontaneous movement. Marlene was instructed in a simple mirror therapy home program to do two times daily. Her colored pencils were also built up for easier gripping, and I encour-aged her to do sketching activities.

While I was on vacation, Marlene continued her home pro-gram but apprehension on her and her husband’s part limited the frequency. There was neither further loss nor gain in edema. The remaining 25% of the increased edematous girth compared to the uninvolved extremity was reduced by my treatment in two subsequent 15 minute MEM sessions. More vigorous progressive strengthening exercises were started after the edema reduced (If started too soon and vigorously, this will cause an inflammatory response and increased edema.) and her upper extremity ROM started to significantly increase. It took a few more sessions for Mar-lene to lose her apprehension of using the right hand, and then she began again doing and enjoying her volunteer activity at a thrift store sorting and marking. She also felt she could safely enjoy long mountain hikes again.

Post note: Ideally I would have preferred seeing Marlene for treat-ment the first week post casting for a shoulder ROM program and an edema or preventative edema reduction program. If there were no complications (such as, blood clots or other MEM contraindications), then I would have begun shoulder/elbow ROM, dealt with patient psychological apprehension and ADL issues, and started a MEM home program addressing trunk to cast.


Breathing - 2 Diaphragmatic

Inhale through nose making navel move out towards hands.Exhale through puckered lips, hands follow navel in.

Repeat ______ times. Rest ______ seconds between repeats.

Do ______ times per day.

Axillary - 1 One at a Time

Using full weight of flat hand with flat fingers at centerof uninvolved armpit, make ______ in-place circles.

Repeat at involved armpit. Do ______ times per day.

Shoulder - 5 Chicken Wings

With thumbs in armpits and elbows at sides, lift elbowstoward ears then lower to sides.

Repeat ______ times. Do _____ times per day.

Arm/Hand - 2 Elbows: Cubital Crease Nodes

Repeat ______ times.


Arm/Hand - 4 Arm Anterior Elbow to Should ñ Sweep

On involved arm, sweep______ times from elbowcrease over biceps, totop of shoulder.

Inhale and bringshoulders up, back,then exhale and relax shouldersdown.


Shoulder - 1 Roll



Palm across involvedelbow’s crease, pressingslightly harder on inside ofelbow make ______ in-placecircles.

3

5

5 5

5

5

5

5

5

10 20

20

20

2

FIGURE 3-6 Marlene’s manual edema mobilization (MEM) home program. (From Visual Health Information (VHI) kits, used with permission.)


Arm/Hand - 6 Arm: Volar Elbow to Wrist ñ Clear

10

10



Involved hand palm side up,make _____ in-place circlesat elbow crease proceedingin sections to wrist.

Sweep _____ times frominvolved arm wrist creaseto elbow crease.

Arm/Hand - 7 Arm: Volnar Wrist to Elbow ñ Sweep

Do ______ times per day

Wrist/Finger - 3 Wrist: Curl to Shoulder

Palm side of arm up, bend wrist toward elbow, bend elbowso hand rest on shoulder.

Repeat _____ times. Do _____ times per day.

Arm/Hand - 3 Hand: Dorsum of Hand to Axilla Sweep

Involved palm down, fingers in web spaces, sweep______ times over top of hand and forearm, back ofupper arm, shoulder, chest front to uninvolved armpit.

Do _____ times per day.

Arm/Elbow - 1 Upper Arm: Make Fist Overhead

With involved armabove head and straight,open and close hand_____ times.



2

5

2

5

5

5

5

5 5

20

FIGURE 3-6, cont’d


References

1. Guyton A, Hall J: Textbook of medical physiology, ed 9, Philadelphia, 1996, WB Saunders.

2. Hole JW: Human anatomy and physiology, ed 4, Dubuque, IA, 1987, William C Brown.

3. Kubik S: Anatomy of the lymphatic system. In Foldi M, Foldi E, Kubik S, editors: Textbook of lymphology for physicians and lymphedema therapists, Munich, 2003, Urban & Fischer Verlag.

4. Casley-Smith JR: Modern treatment for lymphedema, ed 5, Adelaide, 1997, The Lymphoedema Association of Australia.

5. Chikly B: Silent waves: theory and practice of lymph drainage therapy with applications for lymphedema, chronic pain, and inflammation, Scottsdale, AZ, 2001, International Health & Healing Publishing.

6. Pecking A, et al: Indirect lymphoscintigraphy in patients with limb edema: progress in lymphology, Proceedings of the Ninth International Congress of Lymphology201–296, 1985.

7. Bryant WM: Wound healing, Clin Symp 29(3):1–36, 1977. 8. Reed BV: Effect of high voltage pulsed electrical stimulation on microvas-

cular permeability to plasma proteins, Phys Ther 68(4):491–496, 1988. 9. Snyder AR, Perotti AL, Lam KC, et al: The influence of high voltage

electrical stimulation on edema formation after acute injury: a systematic review,, J Sport Rehabil 19:436–451, 2010.

10. Vasudevan SV, Melvin JL: Upper extremity edema control: rationale of treatment techniques, Am J Occup Ther 33(8):520–523, 1979.

11. Buncke HJ, et al: Surgical and rehabilitative aspects of replantation and revascularization of the hand. In Hunter JM, Schneider LH, Mackin EJ, et al: Rehabilitation of the hand: surgery and therapy, ed 4, St Louis, 1995, Mosby.

12. Lievens P, Leduc A: Cryotherapy and sports, Int J Sports Med 5(Supplement):37–39, 1984.

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Fundamentals of Hand Therapy || Edema Reduction Techniques

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