Vol. 25 • Issue 12 • Page 28
I practice hand therapy in a small tourist town in the mountains, where a good share of the population is seasonal and from a variety of states. Three seasonal residents came to me with persistent hand edema ranging from one to three months post trauma or orthopedic surgery. A certified hand therapist had seen one of them; another had been seen by a generalist OT, and the third by an OT with lymphedema training. All the patients complained of having minimal edema reduction following discharge from therapy. They stated their hands were becoming more pained and stiffer; it was limiting their occupational performance.
Using the Manual Edema Mobilization (MEM) method of gentle stimulation of the lymphatics to reduce congested lymphatic edema for patients, I was able to reduce their edema by 50 percent and get them trained in their own edema-reduction home programs in just one or two sessions. This resulted in pain reduction and increased hand mobility for functional ADL and leisure usage. The amount of therapy time needed to reduce the edema was directly linked to how long the edema had been present; one month post onset reduced faster than three months post onset.
Manual Edema Mobilization techniques were specifically tailored to sub-acute and chronic edema seen in multiple diagnoses treated by OTs, PTs and hand therapists. Since 2001, two articles about Manual Edema Mobilization have been published in the Journal of Hand Therapy.
But there are five foundational guides for successful edema reduction that all therapists can consider, whether they know the MEM techniques or not.
Know the Etiology
Usually, edema post orthopedic surgery or tissue trauma will involve damage to the net-like initial lymphatics (the most superficial part of the lymph system), which are located in the dermis layer of tissue, and to deeper lymph structures depending upon the injury. Initially, this is a low-protein edema that decreases with elevation, icing, etc. But within a week or sooner, a high-protein edema develops because excessive plasma proteins become trapped in the interstitium and can't move out of the damaged lymphatics.
Usually, for patients post orthopedic surgery or tissue trauma, the edema presents as a thick, viscous consistency. When the tissue is indented (pitted) it takes 10 or more seconds to re-bound to normal tissue height.
Another low-protein edema is seen with malnutrition, liver disease and renal failure (i.e., nephrotic syndrome). Here there are too few proteins in the interstitium to absorb the water molecule and move it out. Initially this edema is generalized and quick to rebound. Low-protein edemas have to be managed by medication.
The third type of edema is a combination of the above two that, in later stages, can be slow to rebound. Combination edemas present in those post stroke, who are on kidney dialysis and have had arm-shunt surgeries, and those with osteoarthritis.
Therapists need to know specific precautions before treating any of these diagnoses with edema-reduction techniques that involve stimulating the lymphatic system. Thoroughly check medical charts for etiology of the patient's edema.
Also check the patient's medications because edema can be a secondary effect of some kinds of medicines.
Start at the Trunk
Only the lymphatic system can reduce high-protein edema. When stimulated, the system can absorb the large molecules, such as plasma proteins trapped in the interstitium post tissue trauma, surgery, etc.
The lymphatic system, in part, operates on hydrodynamic laws. Inhalation causes changes in tissue pressure, i.e. the thoracic duct, resulting in negative pressure (sucking effect) draining fluid from the periphery and bringing it proximal toward the trunk.1-3Thus in the lymphatic system, pressure changes in the large thoracic duct, located anterior to and parallel to the spine, create a vacuum (suction) pulling lymph from peripheral structures centrally. As a result, fluid from the periphery can move out of the area, and edema is reduced distally in a domino effect. Diaphragmatic breathing causes thoracic pressure changes, and so that is where treatment begins (Figure 1).
Pecking et al.4did a study in which they used manual lymphatic drainage (MLD) at the uninvolved axilla area in 108 women post mastectomy. A tracer element was placed in the involved hands. The result was a 12-percent to 38-percent reduction in hand edema. This further demonstrates that therapists must begin edema reduction in the trunk/axilla area, creating a vacuum effect that makes a space for the edema to move proximally (Figure 2).
Clinically, while watching therapists using NDT trunk and scapular techniques on stroke patients, I have witnessed hand edema significantly reduce. The challenge then becomes maintaining the reduction when there is no active muscle pump in the involved extremity.
Guyton and Hall point out that exercise increases lymphatic pumping speed 10 to 30 fold.5Therefore, for those therapists trained in lymphatic massage techniques such as MEM, exercise of muscles in the segment just massaged is essential before continuing with the massage. In general, it is effective to follow the theory of emptying (stimulating) the trunk first by beginning exercise at the trunk and then continuing to the shoulders, down the arm to the edematous area. This technique makes space for the edema to move into by creating a vacuum.
Keep Compression Light
A study done by Miller and Seale found that 60mmHg pressure begins to collapse the initial lymphatics and that 75mmHg pressure totally collapses them.6Often heavy retrograde massage done by therapists
who were taught they had to "push" the edema from the area or heavy scar massage can produce pressures of 75mmHg or greater. Because of the anatomy and physiology of the lymphatic system, the large molecules that cause persistent swelling cannot be "pushed" into the lymphatic net. The lymphatic net has to be stimulated to absorb the molecules.
Casley-Smith and Gaffney, in another research study, found that when plasma proteins stay in the interstitium for 64 days or longer, they cause chronic inflammation,7which leads to tissue fibrosis. Thus the therapist's goal is to get the plasma proteins into the lymphatic system as soon as possible. Only stimulating the lymphatics can do this.
MEM courses teach how to do this stimulation and minimize the risk of developing persistent edema. However, there are very specific things that every therapist can do to avoid collapsing the initial lymphatics. For example, Spandex-type gloves, which are frequently used in clinics, should give light, not tight, compression. I use the guide of being able to pull the glove fingers 1/8th inch away from each side of the finger simultaneously. When using an elastic/cotton stockinette to prevent edema return after treatment, I use the guide of being able to get my two hands into the tube after it has been applied on the patient's arm. Light compression with a little movement of the skin stimulates uptake by the initial lymphatics. If the compression is too heavy, the result is just the opposite, and the initial lymphatics collapse.
Lymph is most mobile between the temperatures of 71.6 and 105.8 degrees Fahrenheit (F).3Therapists know not to treat an edematous hand with heat because that would increase blood supply to the area and increase swelling.
However, body-temperature, neutral warmth of 98 to 99 degrees F will not increase swelling. Thus the heat produced from wearing an elastic/cotton stockinette, or chip bags made of different densities of 1-inch foam pieces placed in a stockinette bag on the affected area for a prolonged period of time, creates neutral warmth and softens congested tissue.
Kubik, S. Anatomy of the Lymphatic System in Foldi, M, Foldi E, Kubik, S. editors: Textbook of lymphology for physicians and lymphedema therapists, 2003, Elsevier.
Casley-smith JR, Casley-Smith JR: Modern Treatment for Lymphoedema, ed. 5, Adelaide, Australia, 1997, The Lymphoedema Associaton of Australia.
Kurz I: Textbook of Dr. Vodder's manuallLymph drainage, vol 2, ed 4, Heidelberg, 1997, Haug.
Pecking A, et al: Indirect lymphoscintigraphy in patients with limb edema, Progress in Lymphology, Proceedings of the Ninth International Congress of Lymphology, pp. 201-206, 1985.
Guyton A, Hall J: Textbook of medical physiology, ed 9, Philadelphia, 1996 WB Saunders.
Miller GE, Seale J: Lymphatic clearance during compressive loading. Lymphology 14:161, 1981.
Casley-Smith JR, Gaffney RM: Excessive plasma proteins as a cause of chronic inflammation and lymphedema: quantitative electron microscopy, J Pathol 133:242, 1981
Sandy Artzberger, MS, OTR, CHT, CLT, works at Rocky Mountain PT in Pagosa Springs, CO, is a national and international lecturer on lymphedema and Manual Edema Mobilization and has authored of several articles and chapters on these topics. Reach her at firstname.lastname@example.org.