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Edema assessment and management practice patterns among hand therapists: Survey research
Journal of Hand Therapy xxx (2019) 1e7
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Journal of Hand Therapy journal homepage: www.jhandtherapy.org
Edema assessment and management practice patterns among hand therapists: Survey research Victoria Priganc PhD, OTR, CHT, CLT a, *, Jacqueline Reese Walter PhD, OTR, CHT b, Sandra H. Sublett PT, DPT, OCS, CLT c a
Occupational Therapy Department, Clarkson University, Clarkson Hall, Potsdam, NY, USA Department of Occupational Therapy, Nova Southeastern University, Fort Lauderdale, FL, USA c Advanced Therapy Specialists, Cedar Rapids, IA, USA b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 7 December 2018 Received in revised form 19 April 2019 Accepted 28 April 2019 Available online xxx
Study Design: Survey research. Introduction: Recently, the lymphatic system’s role in edema management has been reported; however, it is unclear how this evidence has translated into hand therapy practice. Purpose of the Study: Survey research was performed to explore edema education and management. Methods: A 22-question survey containing questions related to edema education and practice was administered to members of the American Society of Hand Therapists. Demographic data were obtained. Frequencies were examined using Chi-square and Fisher exact tests. Results: A total of 436 members responded to the survey (92% occupational therapists [OTs]; 6% physical therapists [PTs]). Most hand therapists received edema education through on-the-job training and, or continuing education. PTs were more likely to learn the difference between acute, subacute, chronic edema (P < .01; 36% PTs, 17% OTs) and the role of the lymphatic system in edema management (P < .002; 36% PTs, 14% OTs) in entry-level education compared to OTs. OTs with an MS or OTD were more likely to learn the difference between acute, subacute, chronic edema (P < .001; 23% OTD, 24% MS, 10% BS) and the role of the lymphatic system in edema management (P < .004; 19% OTD, 19% MS, 7% BS) in entry-level education than BS-trained OTs. Duration and feel were common ways therapists assessed and identified differences in edema. Many therapists acknowledged the role of the lymphatic system in edema reduction, but responses lacked specificity. Conclusion: The survey results suggest most hand therapists learn edema management outside of academic programs, although this may be changing in OT with advancement of the entry-level degree. Ó 2019 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.
Keywords: Lymphatic system Chronic edema Edema treatment Edema education
Introduction Hand therapists routinely work with clients with edema, as swelling often occurs following an injury.1,2 Sometimes, the edema dissipates quickly and easily and does not impede rehabilitation or engagement in daily function. At other times, the edema can be the most limiting variable in terms of regaining function and returning to desired activities. Although edema assessment and treatment is taught in entry-level programs and it is something every hand therapist treats, there is speculation that what is taught and actual treatment methods used vary.
Conflict of interest: The authors have no competing interests or conflict of interests. * Corresponding author. Occupational Therapy Department, Clarkson University, Clarkson Hall, 59 Main Street, Potsdam, NY 13699, USA. E-mail address: [email protected] (Victoria Priganc).
In the past 2 decades, there has been a proliferation of knowledge regarding the role of the lymphatic system in edema,3 particularly persistent edema,4 the importance of lymphatic stimulation to reduce edema,5-7 and the importance of altering treatment based on the type of edema.8 However, it is unclear if this information has made it into entry-level therapist education or current hand therapy practice. Current knowledge related to edema highlights the role of the lymphatic system in edema reduction,9 even for individuals with a normal and intact lymphatic system. After tissue has been damaged, plasma proteins infiltrate the interstitial spaces to start the healing process. Normally, these additional proteins are removed through a functioning lymphatic system.10 However, in some cases, these plasma proteins remain in the interstitial spaces, subsequently attracting fluid and perpetuating the edema. It is the role of the lymphatic system to remove these persistent proteins from the interstitial spaces.9,11 The primary structures to do this are
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the initial lymphatics,11 which are thin structures9 made up of a single but overlapping layer of endothelial cells located in the dermoepidermal layer of the skin.12 If stimulated, these initial lymphatics reduce the osmotic concentration of the interstitial space, thus preventing continued edema. However, because these initial lymphatics can easily collapse with pressure,13 it is hypothesized traditional edema reduction techniques that apply firm pressure to the tissue may collapse these delicate structures.7 If collapsed, fluid homeostasis of the tissues in that region is disrupted, contributing to persistent edema14; although the exact mechanism, as well as role, of the increased interstitial proteins in the development of brawny, fibrotic tissue is debated.15 Despite the current debate regarding the exact mechanism underlying the pathophysiology of persistent edema, there is acknowledgment that lymphatic stimulation is important to reduce edema.9,16 Addressing persistent edema is often a priority after an injury because it may delay an individual’s ability to resume desired activities1 due to stiffness, limited motion, or discomfort.17 However, to optimally treat edema, therapists must (a) understand the role of the lymphatic system, (b) recognize if edema is acute, subacute, or chronic, (c) tailor treatment techniques to the type of edema,8 and (d) move beyond thinking about engaging the lymphatic system exclusively for clients with lymphedema. Thus, the purpose of this survey was to understand the state of edema education and practice in hand therapy. It was designed to test the hypothesis that relationships exist between academic degrees and credentials, and edema practice and knowledge. Methods A survey was developed by the primary author with consultation from lymphatic experts to explore the edema education and management practices of hand therapists, primarily in the United States. The following goals guided the survey design: (1) gain an understanding of current edema assessment and treatment techniques used in hand therapy, (2) understand when and how hand therapists learn edema assessment and management techniques, (3) gain insight as to how hand therapists learn and incorporate lymphatic knowledge into edema assessment and management, and (4) understand if additional lymphatic training impacts edema management. Data related to demographics, credentials, education/training, and practice patterns were gathered. Once the survey questions were developed, the survey was sent to the Research Division of the American Society of Hand Therapists (ASHT), and revisions were made based on peer feedback. Upon receiving approval from the Research Division of the ASHT, the survey received final approval from the Institutional Review Board at Clarkson University, Potsdam, NY. Please refer to Appendix A for a copy of the survey. After Institutional Review Board approval, the survey was distributed to ASHT members with e-mail addresses on file through the Research Division of the ASHT during the month of May 2018, and participants completed the survey throughout the months of May and June 2018. The ASHT Research Division e-mailed the survey two times to ASHT members. Participation was voluntary, and participants were asked to click on a Survey Monkey link to complete the survey. Informed consent and estimated time to complete the survey were included in the introductory e-mail. In the introductory e-mail, participants were also invited to participate in a random drawing for a $50.00 Amazon Gift Card upon completion of the survey. All survey data were anonymous. Data analysis Descriptive statistics, frequencies, and percentages were calculated using Microsoft Excel (Microsoft). Quantitative data were
analyzed for relationships between categorical values using Chisquare or Fisher's exact test if the frequency counts were less than 10, as the Fisher exact test is considered more reliable for small frequency counts.18 There were a total of four open-ended questions that gathered qualitative data. To analyze three of these openended questions (Q15, Q16, and Q22), answers were independently open-coded, categorized, and examined for common conceptual categories by the primary and secondary investigators (V.P. and J.R.W., respectively).19 Common conceptual categories were then reviewed until agreement was reached. Answers from the fourth open-ended question (Q19) were initially divided into acute and chronic categories. Within each of these categories, key words related to treatment were documented to obtain a count of the most common treatment words associated with acute edema treatment and chronic edema treatment. Subacute was not included in this analysis because some respondents likened it to acute edema, while others likened it to chronic edema; thus, it was hard to obtain a clear picture of these data. The primary and secondary investigators performed this analysis independently and then compared key words until agreement was reached and conceptual categories were identified. Results Demographic data A total of 436 people participated in the survey. The survey was successfully e-mailed to 2939 ASHT members. A total of 1025 ASHT members opened the initial e-mail, yielding a 43% response rate (436 of 1025). Most of the participants were occupational therapists (OTs) (92%; n ¼ 399), 28 (6%) were physical therapists (PTs), and 2 (0.5%) were occupational therapy assistants. A total of 360 (83%) participants were certified hand therapists (CHTs) and 43 (10%) were certified lymphedema therapists (CLTs). Related to educational background, 1 (0.2%) had an associate degree, 191 (44%) had a bachelor degree, 163 (37%) had a master degree (included MS, MA MOT), 49 (11%) had a clinical doctorate in occupational therapy, 12 (3%) had a clinical doctorate in physical therapy, 10 (2%) had a Ph.D., and 1 (0.2%) had an EdD. In the “other” category, people reported the following: MPH, MEd, MHS, DHS, DPS, MBA, and certificate of proficiency in occupational therapy. A total of 147 (34%) respondents have been or were in clinical practice for more than 30 years. Regarding years practicing as a CHT, respondents were relatively evenly distributed across all year categories (13% [n ¼ 55] to 17% [n ¼ 72]) with the exception of people practicing as a CHT for more than 30 years (6%; n ¼ 24). Most respondents reported working in an outpatient orthopedic or hand therapy clinic (68% and 60%, respectively). Table 1 highlights the demographic data. Edema education Six questions (Q10, Q11, Q13, Q14, Q20, and Q21) were focused on understanding how hand therapists receive edema education. A total of 374 respondents reported receiving edema management training, while 55 reported receiving no training. Of those who reported receiving edema management training, 373 respondents clarified when they learned this material, and most received this training through on-the-job training (76%; n ¼ 284) and, or continuing education (85%; n ¼ 319). A total of 338 respondents received training on the difference between acute, subacute, and chronic edema, while 89 reported receiving no such training. Of those who were taught the difference between acute, subacute, and chronic edema, 292 respondents clarified when they learned this material. Most reported learning this material through on-the-job training (67%; n ¼ 196) and, or continuing education (75%;
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Table 1 Demographic data Credentials Total 436a
OT 399
PT 28
CHT 360
CLT 43
OTA 2
Other 0
BS
MS
OTD
DPT
PhD
191
163
49
12
10
6-10 25
11-15 28
16-20 65
21-25 67
26-30 66
>30 147
6-10 56
11-15 62
16-20 56
21-25 55
26-30 68
>30 24
Inpatient hospital
Other (academia, physician practice, burn unit, private practice, hospital outpatient, public health, lymphedema clinic, management, outpatient orthopedics and neurology, occupational health, general outpatient, outpatient rheumatology, pediatrics, rehab agency, outpatient rheumatology and orthopedics) 28
Highest level of education Total
436
Associate
1
EdD
1
Other (MPH, MEd, MHS, DHS, DPS, MBA, certificate of proficiency in OT) 9
Years in clinical practice Total 436
0-5 38
Years practicing as a certified hand therapist Total 435b
0-5 72
n/a 44
Primary practice area Total
Outpatient orthopedics
Hand therapy clinic
417c
278
253
9
Other practice settings Total 16
c
Higher education 11
Consulting
Continuing education
2
1
Other (arthritis and hand specialist, home care, wellness, retired and semiretired) 6
OT ¼ occupational therapist; PT ¼ physical therapist; CHT ¼ certified hand therapist; CLT ¼ certified lymphedema therapist; OTA ¼ occupational therapy assistant. a Respondents can answer more than once. b 1 Person reported 0-5 & n/a; 1 person reported 26-30 & >30. c Some reported working in more than one setting.
Table 2 Edema education data broken down by years in practice and discipline When did you receive your edema management training? Years
OT of PT academic training OT
>30 26-30 21-25 16-20 11-15 6-10 0-5
47 of 137 27 of 60 23 of 59 32 of 57 11 of 26 18 of 25 14 of 35
(34%) (45%) (39%) (56%) (42%) (72%) (40%)
On-the-job PT
OT
4 of 9 (44%) 4 of 5 (80%) 2 of 6 (33%) 2 of 4 (50%) 0 of 2 (0%) 0 of 0 (0%) 2 of 2 (100%)
89 of 137 40 of 60 38 of 59 39 of 57 19 of 26 21 of 25 14 of 35
(65%) (67%) (64%) (68%) (73%) (84%) (40%)
Continuing education PT
OT
5 of 9 (56%) 4 of 5 (80%) 3 of 6 (50%) 2 of 4 (50%) 2 of 2 (100%) 0 of 0 (0%) 2 of 2 (100%)
113 of 137 49 of 60 42 of 59 46 of 57 20 of 26 16 of 25 10 of 35
PT (82%) (82%) (71%) (81%) (77%) (64%) (29%)
7 of 9 (78%) 3 of 5 (60%) 3 of 6 (50%) 2 of 4 (50%) 1 of 2 (50%) 0 of 0 (0%) 1 of 2 (50%)
When did you learn the difference between acute/subacute/chronic edema? Years
OT of PT academic training OT
>30 26-30 21-25 16-20 11-15 6-10 0-5
15 of 137 12 of 60 6 of 59 15 of 57 4 of 26 7 of 25 9 of 35
(11%) (20%) (11%) (26%) (15%) (28%) (26%)
On-the-job PT
OT
2 of 9 (22%) 2 of 5 (40%) 2 of 6 (33%) 1 of 4 (25%) 1 of 2 (50%) 0 of 0 (0%) 2 of 2 (100%)
67 of 137 28 of 60 28 of 59 26 of 57 8 of 26 14 of 25 12 of 35
Continuing education PT
(49%) (47%) (47%) (46%) (31%) (56%) (34%)
2 of 9 (22%) 2 of 5 (40%) 1 of 6 (17%) 1 of 4 (25%) 1 of 2 (50%) 0 of 0 (0%) 2 of 2 (100%)
OT 86 of 137 34 of 60 29 of 59 28 of 57 10 of 26 13 of 25 6 of 35
PT (63%) (57%) (49%) (49%) (38%) (52%) (17%)
4 of 9 (44%) 2 of 5 (40%) 1 of 6 (17%) 0 of 4 (0%) 1 of 2 (50%) 0 of 0 (0%) 1 of 2 (50%)
When were you trained about the role of the lymphatics and edema reduction? Years
OT of PT academic training
>30 26-30 21-25 16-20 11-15 6-10 0-5
14 of 137 6 of 60 3 of 59 11 of 57 4 of 26 8 of 25 9 of 35
OT (10%) (10%) (5%) (19%) (15%) (32%) (26%)
On-the-job PT
OT
2 of 9 (22%) 1 of 5 (20%) 4 of 6 (67%) 1 of 4 (25%) 0 of 2 (0%) 0 of 0 (0%) 2 of 2 (100%)
56 of 137 20 of 60 21 of 59 21 of 57 12 of 26 13 of 25 6 of 35
OT ¼ occupational therapist; PT ¼ physical therapist. Some reported learning this material through several different avenues.
Continuing education PT
(41%) (33%) (36%) (37%) (46%) (52%) (17%)
4 of 9 (44%) 3 of 5 (60%) 2 of 6 (33%) 1 of 4 (25%) 1 of 2 (50%) 0 of 0 (0%) 2 of 2 (100%)
OT 88 of 137 36 of 60 31 of 59 32 of 57 11 of 26 10 of 25 4 of 35
PT (64%) (60%) (53%) (56%) (42%) (40%) (11%)
5 of 9 (56%) 3 of 5 (60%) 5 of 6 (83%) 0 of 4 (0%) 1 of 2 (50%) 0 of 0 (0%) 0 of 2 (0%)
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Table 3 Chi-square test calculations highlighting differences in edema content taught in the academic program Credentials
OT PT
Overall
399 28
Difference between acute/subacute/chronic
Role of lymphatics
Yes
No
P-value (chi-square)
Yes
No
P-value (chisq)
68 (17.04%) 10 (35.71%)
331 (82.96%) 18 (64.29%)
.013
55 (13.78%) 10 (35.71%)
344 (86.22%) 18 (64.29%)
.002
OT ¼ occupational therapist; PT ¼ physical therapist. statistically significant at P < .05.
a
n ¼ 219). A total of 326 respondents reported learning about the role of the lymphatic system in edema reduction, while 40 respondents reported not learning this information. Of those respondents, 308 clarified when they learned this material: 168 (55%) through on-the-job training and, or 233 (76%) through continuing education. A higher percentage of OTs practicing as hand therapists in the past 10 years reported learning the role of the lymphatic system in edema management in the educational setting compared with OT hand therapists practicing for more than 30 years. Refer to Table 2 for a breakdown of how hand therapists acquire edema education training based on discipline and years in practice. A greater percentage of PTs learned the difference between types of edema (36% compared with 17%, respectively) (P < .01), as well as the role of the lymphatics in edema management (36% compared with 14%, respectively) (P < .002), in their academic programs compared with OTs. These findings indicate a statistically significant association between a discipline’s educational program and whether or not edema education is taught in the educational program Refer to Table 3. A statistically significant association was found between learning the difference between acute, subacute, chronic edema (P < .001) in an OT academic program as degrees advanced. A statistically significant association was also found between learning the role of the lymphatics (P < .004) in an OT academic program as degrees advanced, meaning that OTs with an MS or OTD were more likely to have received this information in their academic education than OTs with a BS degree. Refer to Table 4. This same difference was not found with hand therapists trained as PTs. Practice patterns Four quantitative questions (Q9, Q12, Q17, and Q18) were directed toward understanding current practice patterns related to edema assessment and treatment. Most of the respondents reported seeing clients daily where edema is impacting rehabilitation (n ¼ 308), and most reported altering treatment approaches based on the type of edema (n ¼ 335). Almost all respondents used circumferential measurements to assess edema (n ¼ 421), followed by volumeter (n ¼ 242) and figure-of-eight (n ¼ 154) measurements. Other assessment tools noted included visual inspection, photos, palpation, perometers, pitting, clinical judgment, and passive range of motion. The most common edema management treatment techniques used by CLTs and non-CLTs are depicted in Figure 1.
Further analysis was performed to assess if lymphatic training factored into whether or not hand therapists used deep retrograde and light retrograde massage. CLTs were less likely to perform light retrograde massage than non-CLT OTs (P < .02). No relationship was found with deep retrograde massage. Refer to Table 5. Four open-ended, qualitative questions (Q15, Q16, Q19, and Q22) were designed to hear from the participants, in their own words, their thoughts related to edema knowledge and practice patterns. Three of these open-ended questions (Q15, Q16, and Q19) related to practice patterns. Coding of answers to the practice pattern questions associated with identification and assessment of edema (Q15 and Q16) revealed some similarities shared among hand therapists. Further review of these similarities resulted in the identification of conceptual categories (duration, feel, responsiveness to treatment, and appearance). Refer to Figure 2 to see the conceptual categories associated with how hand therapists describe and assess the difference between acute, subacute, and chronic edema. Duration Duration, meaning time elapsed since injury or surgery, was a common variable used by more than 50% of the respondents to differentiate and assess whether edema was acute, subacute, or chronic in nature. Some respondents solely used duration as a differentiating variable, whereas other respondents used duration in combination with other variables such as feel or observation to either classify or assess the type of edema. Therapists indicated that they not only described the difference between acute, subacute, and chronic edema by the amount of time since injury, but also used the amount of time since injury as an assessment tool. For example, therapists described acute edema as immediate or the initial response after an injury and described chronic edema to be present for a prolonged period of time. Words such as time, days, length, and immediate were identified as words associated with duration. Feel More than 50% of the respondents reported using tissue feel during clinical practice. Many used feel to help identify if the edema was acute, subacute, or chronic, indicating a pitting, brawny, or fibrotic feel was noticed as edema progressed from the acute, watery stage to more chronic edema. Feel was often used in combination with other variables such as duration, appearance, observation, and patient history when assessing the difference between
Table 4 Chi-square test and Fisher exact test calculations highlighting differences in edema education taught in OT educational program based on degree Credentials
Overall
OT BS MS OTD
178 156 48
OT ¼ occupational therapist. a statistically significant at P < .05.
Difference between acute, subacute, chronic
Role of lymphatics
Yes
No
P-value (chi-square)
Yes
No
P-value (Fisher exact)
17 (9.55%) 37 (23.72%) 11 (22.92%)
161 (90.45%) 119 (76.28%) 37 (77.08%)
.001
13 (7.30%) 29 (18.59%) 9 (18.75%)
165 (92.70%) 127 (81.41%) 39 (81.25%)
.004
V. Priganc et al. / Journal of Hand Therapy xxx (2019) 1e7
Percentage of respondents reporƟng edema treatment techniques uƟlized in clinic, categorized by CLT vs non-CLT 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
5
and lymphatic techniques. Numerous respondents reported moving away from elevation and ice to a lighter massage as the edema progresses into the chronic stages. The following statement depicts this transition to lighter techniques. “For chronic edema, I would use more manual lymphatic drainage techniques, for acute edema, I would use more compression, ice, and elevation.”
CLTs
non-CLTs
Fig. 1. Percent of respondents reporting edema treatment techniques used in clinic, categorized by CLT vs non-CLT *total respondents to this question (n ¼ 377); CLT (n ¼ 43); non-CLT (n ¼ 334). CLT ¼ certified lymphedema therapist.
acute, subacute, or chronic edema. Words such as pitting, thickness, brawny, and soft were identified as words associated with feel. Responsiveness to treatment How edema responds to treatment was a variable numerous hand therapists reported when describing methods to identify and assess the type of edema. Therapists indicated the manner in which edema responds or fails to respond to various treatment interventions served as a method to assess the type of edema. Words such as respond, resolves, change, and treatment were identified as words associated with responsiveness to treatment. Appearance and observation The appearance and observation of the tissue was often used in conjunction with other variables when assessing the difference between acute, subacute, and chronic edema. Words such as visual, appearance, color, and observation were identified as words associated with appearance and observation. The following statement highlights many of these conceptual categories. “Acute: 1 to 3 days following trauma, injury, surgery, sudden, painful, decrease range of motion and function, painful, red swollen, dark bruising. Subacute: 4-days e 3 wks, decrease pain and color of bruising changes. Less redness, increase range of motion and movement, soft, easily mobile, pitting edema with pressure. Chronic: Greater 3 to 4 wks to years. Decrease pain, patient complains of limb heaviness, skin and soft tissues firmer, edema does not decrease as easy with elevation but can respond (decrease) when combined with movement, compression, manual edema mobilization (MEM).” Coding of answers related to treatment for acute versus chronic edema (Q19) suggests elevation, movement, ice, and compression are the treatment techniques used most by hand therapists when treating acute edema. The most common treatment techniques used for chronic edema included compression, MEM, movement,
One open-ended question was related to lymphatic knowledge (Q22). Common concepts were not as evident as when reviewing the words of the respondents and their answers to the role of the lymphatic system in edema reduction. While numerous respondents used words such as protein, transport, remove, drain, interstitial, light, proximal, massage, and movement, many of the answers did not provide sufficient detail to determine the participant’s level of knowledge. The following statement is an example of an answer that lacked detail. “The lymph system is integral to edema reduction. It is a very delicate system. It responds well with proper techniques. Education of patient is important.” Although the majority of the answers lacked details, there were some common conceptual concepts gleaned from these data. First, some respondents reported light massage stimulates the lymphatic system, while deep massage can shut down this system. Second, some respondents reported the lymphatics are necessary to reduce higher protein edema, although the rationale for why varied. Third, some described the importance of light massage and proximal stimulation of the lymphatic system to reduce edema. Statements such as the following three highlight these conceptual concepts. “The lymphatic system is like a spider web with valves. Light pressure stimulates the system. Firm retrograde massage closes the valves. Also, lymph nodes must be stimulated to help drain the fluid out of the extremity.” “Stimulation of the lymphatic system is necessary to decrease subacute and chronic edema (high-protein edema)dtheoreticallydit removes the plasma proteins from edematous areas by enabling the proteins to leave the interstitial spaces and enter the lymphatic structures. By ridding the interstitial spaces of these proteins, the edema decreases.” “They are removing the 10% of fluid not taken up by veins and larger proteins not take by veins. When the system is overwhelmed we get edema, especially pitting edema. The lymphatics respond to gentle tissue pressure change (ie, gentle massage). Best to clear proximal then work down the hand and encourage movement proximally.”
Discussion The majority of hand therapists reported learning about edema management through continuing education courses or on-the-job training versus through their entry-level academic education. PTs were more likely than OTs to learn about the differences between
Table 5 Relationship of OTs and PTs performing deep and light retrograde massage based on lymphatic training Credentials
CLTs (OTs/PTs) OTs (non-CLT) PTs (non-CLT)
Overall
43 358 27
Deep retrograde
Light retrograde
Yes
No
7 (16.28%) 109 (30.45%) 10 (37.04%)
36 (83.72%) 249 (69.55%) 17 (62.96%)
P-value (Fisher exact)
Yes
No
P-value (chi-square)
.074 .084
25 (58.14%) 269 (75.14%) 18 (66.67%)
18 (41.85%) 89 (24.86%) 9 (33.33%)
.017
OT ¼ occupational therapist; PT ¼ physical therapist; CLT ¼ certified lymphedema therapist. a statistically significant at P < .05.
P-value Fisher exact
.615
6
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Duration •Key words: time, days, length, immediate
Feel •Key words: pitting, thickness, brawny, soft
Responsiveness to treatment •Key words: respond, resolves, change, treatment
Appearance/observation •Key words: visual, appearance, color, observation Fig. 2. Conceptual categories and key words related to identification and assessment of acute, subacute, chronic edema (Q15 and Q16).
acute, subacute, chronic edema, as well as the role of the lymphatic system and edema in academic programs (Table 3). The likelihood of receiving edema education in academic programs related to types of edema and the role of the lymphatics increased with graduate training for OTs but not PTs (Table 4); however, this result may reflect the small number of PT responses. Although not statistically significant, when factored out by years in practice, a greater percentage of OTs practicing within 0 to 10 years reported learning about the lymphatic system in their primary academic programs than OTs practicing more than 30 years (Table 2). In a recent case report, the importance of incorporating edema and lymphatic education in an entry-level doctor of physical therapy curriculum was discussed and teaching strategies were suggested.20 No such studies examining occupational therapy curriculum and edema management or lymphatic education were found. Numerous authors report there is a knowledge translation lag between research and clinical practice.21,22 Thus, as a profession, it is important academic programs teach the importance of the lymphatic system, so future hand therapists are able to enter practice knowing the best ways to manage patients with edema. It is well documented the lymphatic system plays a crucial role in edema management,9,10,16,23 especially as the edema becomes more chronic in nature,8 thus understanding this system and how to stimulate it to effectively reduce higher protein edema is critical for best-practice edema management.20 Results from this survey suggest that newer practicing therapists and therapists with more advanced degrees are learning lymphatic knowledge in academic programs compared with therapists who have been practicing for a while. However, the majority still report that the primary method of obtaining edema education related to types of edema and lymphatic system knowledge is through on-the-job training or continuing education (Table 2). Understanding the differences between acute and chronic edema is also important for effective edema management because treatment should alter based on the type of edema.8 Both acute and chronic edema have a duration23 and quality component,17,24 and although most respondents acknowledged they utilize both of these variables when identifying if the edema is acute or chronic, many reported only using duration when differentiating between acute, subacute, and chronic edema. From a clinical perspective, the increased protein content associated with chronic edema presents with a different feel and texture17,24 and responds differently to treatment. Interestingly, few respondents used objective measurements to assist in differentiating between acute and chronic edema. We hypothesize because no reliable and valid tool is available to differentiate between acute and chronic edema, that clinicians rely primarily on duration, feel, patient history, and visual observation to make this clinical judgment. As a profession, there is a need to identify clinically applicable and objective methods of
differentiating between acute and chronic edema to inform appropriate hand therapy management strategies. Statistical analysis demonstrated CLTs were less likely to perform light retrograde massage than non-CLT OTs (P < .02), which can be explained by the fact that CLTs are taught the importance of proximal clearing and movement of fluid along lymphatic paths. Retrograde massage, whether light or deep, does not adhere to these lymphatic principles. Statistical analysis did not demonstrate a difference in performing deep retrograde massage between hand therapists with certified lymphatic training compared with their non-certified lymphatic trained OTs and PTs. This lack of significance is likely due to the low frequency numbers (Table 5). In addition, although not statistically significant, descriptive data reported a greater percentage of CLTs using lymphatic treatments such as MEM and low stretch bandaging than non-CLT hand therapists (Fig. 1). These findings partially confirm the hypothesis that edema practice differences in hand therapy are likely due to the increased knowledge CLTs have as it relates to the initial lymphatics, lymphatic pathways, and the knowledge that the proteins associated with chronic edema need to dissipate through the initial lymphatic system.25 Current clinical thinking as it relates to edema management includes avoiding deep pressure and instead using light pressure according to lymphatic pathways, along with light compression, to treat persistent edema.1,6,8 Ensuring hand therapists are taught these concepts in their educational programs can help to translate this knowledge to practice. When asked specifically to explain the role of the lymphatic system in edema reduction, most people indicated the lymphatic system played a role, but many of the answers were general and lacked specific details, making it difficult for the researchers to determine the participant’s understanding of lymphatic physiology. Despite current advances, there is acknowledgment that the lymphatic system and its role remain largely unknown among clinicians.3,26 Because the lymphatic system plays a role in all forms of edema,9,24 understanding concepts related to high-protein edema, lymphatic flow,9 and changes in oncotic and hydrostatic pressure in the capillaries and interstitial spaces12,24 are important if one is to really understand the crucial role of the lymphatics in edema reduction. Thus, understanding what is happening from a physiological perspective when edema becomes more chronic in nature may help to identify the best ways to manage this type of edema. Limitations Multiple limitations have been identified with this survey research. First, although the survey response was high, when broken out into subcategories such as PTs, CLTs, and years in practice, the numbers were low, which may have impacted some of the results, particularly results examining differences in deep and light retrograde massage between CLTs and non-CLTs. Second, this survey was not formally pilot tested. It was peer reviewed through the ASHT Research Division, and modifications were made based on feedback, but pilot testing may have revealed additional areas where clarity was needed. Third, the survey was only distributed to members of the ASHT and thus does not represent all OTs or PTs practicing in hand rehabilitation. Finally, two of the authors are CLTs and advocate the importance of the lymphatics in edema management. This perspective likely guided survey development. Conclusion These survey results provide insight into the current state of edema education and management among hand therapists practicing primarily in the United States. Most hand therapists rely on
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subjective measures such as duration and tissue feel when assessing acute, subacute, and chronic edema. Thus, additional research is recommended to identify an objective method of differentiating between acute and chronic edema so that hand therapists are equipped with the best assessment tools to guide treatment. Most hand therapists reported learning about edema education related to types of edema and lymphatic knowledge through on-the-job training and, or continuing education, although there appears to be a trend that newer therapists with more advanced degrees are learning this information in academic programs. The OT and PT professions can support bringing this knowledge into academic programs through practicums, casebased learning, and experiential learning opportunities that bridge science to clinical practice. Future survey research of OT and PT academic programs may provide additional insight as to how these topics are currently addressed in the academic setting. Ideally, all hand therapists will be taught the relationship between edema and the lymphatics in their academic programs and will be able to translate this knowledge to clinical practice when treating clients with edema. Acknowledgments The authors would like to thank Dr Ying He for the statistical support and Ms Kayla Lowman for her assistance in the initial design of the survey. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.jht.2019.04.005. References 1. Miller L, Jerosch-Herold C, Shepstone L. Effectiveness of edema management for subacute hand edema: a systematic review. J Hand Ther. 2017;30(4):432e 446. 2. Villeco, Edema J. A silent but important factor. J Hand Ther. 2012;25(2):153e 161. 3. Rockson SG. The unique biology of lymphatic edema. Lymphat Res Biol. 2009;7(2):97e100. 4. Vranova M, Halin C. Lymphatic vessels in inflammation. J Clin Cell Immunol. 2014;5(4):1e11.
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5. Haren K, Wibert M. A prospective randomized controlled trial of manual lymph drainage (MLD) for the reduction of hand oedema after distal radius fracture. Br J Hand Ther. 2006;11(2):41e47. 6. Vairo GL, Miller SJ, McBrier NM, Buckley WE. Systematic review of efficacy for manual lymphatic drainage techniques in sports medicine and rehabilitation: an evidence-based practice approach. J Man Manip Ther. 2009;17(3): E80eE89. 7. Knygsand-Roenhoej K, Maribo T. A randomized clinical controlled study comparing the effect of modified manual edema mobilization treatment with traditional edema treatment in patients with a fracture of the distal radius. J Hand Ther. 2011;24(3):184e194. 8. Majewski-Schrage T, Snyder K. The effectiveness of manual lymphatic drainage in patients with orthopedic injuries. J Sport Rehabil. 2016;25:91e97. 9. Breslin W, Yang Y, Scallan J, Sweat R, Adderley S, Murfee W. Lymphatic vessel network structure and physiology. Compr Physiol. 2019;9:207e299. 10. Cho S, Atwood JE. Peripheral edema. Am J Med. 2002;113(7):580e586. 11. Ohhashi T, Kawai Y. Proposed new lymphology combined with lymphatic physiology, innate immunology, and oncology. J Physiol Sci. 2015;65:51e66. 12. Wiig H, Swartz MA. Interstitial fluid and lymph formation and transport: physiological regulation and roles in inflammation and cancer. Physiol Rev. 2012;92:1005e1060. 13. Lynch PM, Delano FA, Schmid-Schönbein GW. The primary valves in the initial lymphatics during inflammation. Lymphat Res Biol. 2007;5(1):3e10. 14. Ly CL, Kataru RP, Mehara BJ. Review: inflammatory manifestations of lymphedema. Int J Mol Sci. 2017;18(171):1e13. 15. Markhus CE, Karlsen TV, Wagner M, et al. Increased interstitial protein because of impaired lymph drainage does not induce fibrosis and inflammation in lymphedema. Arterioscler Thromb Vasc Biol. 2013;33:266e274. 16. Mortimer P, Levick R. Chronic peripheral oedema: the critical role of the lymphatic system. Clin Med. 2004;5(4):448e453. 17. Villeco J. Edema: therapist’s management. In: Skirven T, Osterman L, Fedorczyk J, Amadio P, eds. Rehabilitation of the Hand and Upper Extremity. Philadelphia, PA: Elsevier; 2011:845e857. 18. Agresti A. An Introduction to Categorical Data Analysis. 2nd ed. Hoboken, NJ: John Wiley and Sons; 2007. 19. Patton M. Qualitative Research & Evaluation Methods. 3rd ed. Thousand Oaks, CA: Sage Publication Inc; 2002. 20. Sander A, Perdomo M. Integrating edema management into entry-level doctor of physical therapy curriculum: a case report. Rehabil Oncol. 2018;36:56e63. 21. Zidarov D, Thomas A, Poissant L. Knowledge translation in physical therapy: from theory to practice. Disabil Rehabil. 2013;35:1571e1577. 22. Hanney SR, Castle-Clarke S, Grant J, et al. How long does biomedical research take? Studying the time taken between biomedical and health research and its translation into products, policy, and practice. Health Res Policy Syst. 2015;13: 1e18. 23. Trayes KP, Studdiford JS, Pickle S, Tully AS. Edema: diagnosis and management. Am Fam Physician. 2013;88(2):102e110. 24. Doubblestein D. Manual Lymphatic Techniques for the Orthopedic Manual Therapist. Palm Beach Gardens. FL: Upledger Productions; 2016. 25. Keast DH, Despatis M, Allen JO, Brassard A. Chronic oedema/lymphoedema: under-recognised and under-treated. Int Wound J. 2015;12:328e333. 26. Zaleska M, Olszewski W. Imaging lymphatics in human normal and lymphedema limbs e usefulness of various modalities for evaluation of lymph and edema fluid flow pathways and dynamics. J Biophotonics. 2018;11: e201700132.
Contents lists available at ScienceDirect
Journal of Hand Therapy journal homepage: www.jhandtherapy.org
Edema assessment and management practice patterns among hand therapists: Survey research Victoria Priganc PhD, OTR, CHT, CLT a, *, Jacqueline Reese Walter PhD, OTR, CHT b, Sandra H. Sublett PT, DPT, OCS, CLT c a
Occupational Therapy Department, Clarkson University, Clarkson Hall, Potsdam, NY, USA Department of Occupational Therapy, Nova Southeastern University, Fort Lauderdale, FL, USA c Advanced Therapy Specialists, Cedar Rapids, IA, USA b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 7 December 2018 Received in revised form 19 April 2019 Accepted 28 April 2019 Available online xxx
Study Design: Survey research. Introduction: Recently, the lymphatic system’s role in edema management has been reported; however, it is unclear how this evidence has translated into hand therapy practice. Purpose of the Study: Survey research was performed to explore edema education and management. Methods: A 22-question survey containing questions related to edema education and practice was administered to members of the American Society of Hand Therapists. Demographic data were obtained. Frequencies were examined using Chi-square and Fisher exact tests. Results: A total of 436 members responded to the survey (92% occupational therapists [OTs]; 6% physical therapists [PTs]). Most hand therapists received edema education through on-the-job training and, or continuing education. PTs were more likely to learn the difference between acute, subacute, chronic edema (P < .01; 36% PTs, 17% OTs) and the role of the lymphatic system in edema management (P < .002; 36% PTs, 14% OTs) in entry-level education compared to OTs. OTs with an MS or OTD were more likely to learn the difference between acute, subacute, chronic edema (P < .001; 23% OTD, 24% MS, 10% BS) and the role of the lymphatic system in edema management (P < .004; 19% OTD, 19% MS, 7% BS) in entry-level education than BS-trained OTs. Duration and feel were common ways therapists assessed and identified differences in edema. Many therapists acknowledged the role of the lymphatic system in edema reduction, but responses lacked specificity. Conclusion: The survey results suggest most hand therapists learn edema management outside of academic programs, although this may be changing in OT with advancement of the entry-level degree. Ó 2019 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.
Keywords: Lymphatic system Chronic edema Edema treatment Edema education
Introduction Hand therapists routinely work with clients with edema, as swelling often occurs following an injury.1,2 Sometimes, the edema dissipates quickly and easily and does not impede rehabilitation or engagement in daily function. At other times, the edema can be the most limiting variable in terms of regaining function and returning to desired activities. Although edema assessment and treatment is taught in entry-level programs and it is something every hand therapist treats, there is speculation that what is taught and actual treatment methods used vary.
Conflict of interest: The authors have no competing interests or conflict of interests. * Corresponding author. Occupational Therapy Department, Clarkson University, Clarkson Hall, 59 Main Street, Potsdam, NY 13699, USA. E-mail address: [email protected] (Victoria Priganc).
In the past 2 decades, there has been a proliferation of knowledge regarding the role of the lymphatic system in edema,3 particularly persistent edema,4 the importance of lymphatic stimulation to reduce edema,5-7 and the importance of altering treatment based on the type of edema.8 However, it is unclear if this information has made it into entry-level therapist education or current hand therapy practice. Current knowledge related to edema highlights the role of the lymphatic system in edema reduction,9 even for individuals with a normal and intact lymphatic system. After tissue has been damaged, plasma proteins infiltrate the interstitial spaces to start the healing process. Normally, these additional proteins are removed through a functioning lymphatic system.10 However, in some cases, these plasma proteins remain in the interstitial spaces, subsequently attracting fluid and perpetuating the edema. It is the role of the lymphatic system to remove these persistent proteins from the interstitial spaces.9,11 The primary structures to do this are
0894-1130/$ e see front matter Ó 2019 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jht.2019.04.005
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V. Priganc et al. / Journal of Hand Therapy xxx (2019) 1e7
the initial lymphatics,11 which are thin structures9 made up of a single but overlapping layer of endothelial cells located in the dermoepidermal layer of the skin.12 If stimulated, these initial lymphatics reduce the osmotic concentration of the interstitial space, thus preventing continued edema. However, because these initial lymphatics can easily collapse with pressure,13 it is hypothesized traditional edema reduction techniques that apply firm pressure to the tissue may collapse these delicate structures.7 If collapsed, fluid homeostasis of the tissues in that region is disrupted, contributing to persistent edema14; although the exact mechanism, as well as role, of the increased interstitial proteins in the development of brawny, fibrotic tissue is debated.15 Despite the current debate regarding the exact mechanism underlying the pathophysiology of persistent edema, there is acknowledgment that lymphatic stimulation is important to reduce edema.9,16 Addressing persistent edema is often a priority after an injury because it may delay an individual’s ability to resume desired activities1 due to stiffness, limited motion, or discomfort.17 However, to optimally treat edema, therapists must (a) understand the role of the lymphatic system, (b) recognize if edema is acute, subacute, or chronic, (c) tailor treatment techniques to the type of edema,8 and (d) move beyond thinking about engaging the lymphatic system exclusively for clients with lymphedema. Thus, the purpose of this survey was to understand the state of edema education and practice in hand therapy. It was designed to test the hypothesis that relationships exist between academic degrees and credentials, and edema practice and knowledge. Methods A survey was developed by the primary author with consultation from lymphatic experts to explore the edema education and management practices of hand therapists, primarily in the United States. The following goals guided the survey design: (1) gain an understanding of current edema assessment and treatment techniques used in hand therapy, (2) understand when and how hand therapists learn edema assessment and management techniques, (3) gain insight as to how hand therapists learn and incorporate lymphatic knowledge into edema assessment and management, and (4) understand if additional lymphatic training impacts edema management. Data related to demographics, credentials, education/training, and practice patterns were gathered. Once the survey questions were developed, the survey was sent to the Research Division of the American Society of Hand Therapists (ASHT), and revisions were made based on peer feedback. Upon receiving approval from the Research Division of the ASHT, the survey received final approval from the Institutional Review Board at Clarkson University, Potsdam, NY. Please refer to Appendix A for a copy of the survey. After Institutional Review Board approval, the survey was distributed to ASHT members with e-mail addresses on file through the Research Division of the ASHT during the month of May 2018, and participants completed the survey throughout the months of May and June 2018. The ASHT Research Division e-mailed the survey two times to ASHT members. Participation was voluntary, and participants were asked to click on a Survey Monkey link to complete the survey. Informed consent and estimated time to complete the survey were included in the introductory e-mail. In the introductory e-mail, participants were also invited to participate in a random drawing for a $50.00 Amazon Gift Card upon completion of the survey. All survey data were anonymous. Data analysis Descriptive statistics, frequencies, and percentages were calculated using Microsoft Excel (Microsoft). Quantitative data were
analyzed for relationships between categorical values using Chisquare or Fisher's exact test if the frequency counts were less than 10, as the Fisher exact test is considered more reliable for small frequency counts.18 There were a total of four open-ended questions that gathered qualitative data. To analyze three of these openended questions (Q15, Q16, and Q22), answers were independently open-coded, categorized, and examined for common conceptual categories by the primary and secondary investigators (V.P. and J.R.W., respectively).19 Common conceptual categories were then reviewed until agreement was reached. Answers from the fourth open-ended question (Q19) were initially divided into acute and chronic categories. Within each of these categories, key words related to treatment were documented to obtain a count of the most common treatment words associated with acute edema treatment and chronic edema treatment. Subacute was not included in this analysis because some respondents likened it to acute edema, while others likened it to chronic edema; thus, it was hard to obtain a clear picture of these data. The primary and secondary investigators performed this analysis independently and then compared key words until agreement was reached and conceptual categories were identified. Results Demographic data A total of 436 people participated in the survey. The survey was successfully e-mailed to 2939 ASHT members. A total of 1025 ASHT members opened the initial e-mail, yielding a 43% response rate (436 of 1025). Most of the participants were occupational therapists (OTs) (92%; n ¼ 399), 28 (6%) were physical therapists (PTs), and 2 (0.5%) were occupational therapy assistants. A total of 360 (83%) participants were certified hand therapists (CHTs) and 43 (10%) were certified lymphedema therapists (CLTs). Related to educational background, 1 (0.2%) had an associate degree, 191 (44%) had a bachelor degree, 163 (37%) had a master degree (included MS, MA MOT), 49 (11%) had a clinical doctorate in occupational therapy, 12 (3%) had a clinical doctorate in physical therapy, 10 (2%) had a Ph.D., and 1 (0.2%) had an EdD. In the “other” category, people reported the following: MPH, MEd, MHS, DHS, DPS, MBA, and certificate of proficiency in occupational therapy. A total of 147 (34%) respondents have been or were in clinical practice for more than 30 years. Regarding years practicing as a CHT, respondents were relatively evenly distributed across all year categories (13% [n ¼ 55] to 17% [n ¼ 72]) with the exception of people practicing as a CHT for more than 30 years (6%; n ¼ 24). Most respondents reported working in an outpatient orthopedic or hand therapy clinic (68% and 60%, respectively). Table 1 highlights the demographic data. Edema education Six questions (Q10, Q11, Q13, Q14, Q20, and Q21) were focused on understanding how hand therapists receive edema education. A total of 374 respondents reported receiving edema management training, while 55 reported receiving no training. Of those who reported receiving edema management training, 373 respondents clarified when they learned this material, and most received this training through on-the-job training (76%; n ¼ 284) and, or continuing education (85%; n ¼ 319). A total of 338 respondents received training on the difference between acute, subacute, and chronic edema, while 89 reported receiving no such training. Of those who were taught the difference between acute, subacute, and chronic edema, 292 respondents clarified when they learned this material. Most reported learning this material through on-the-job training (67%; n ¼ 196) and, or continuing education (75%;
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3
Table 1 Demographic data Credentials Total 436a
OT 399
PT 28
CHT 360
CLT 43
OTA 2
Other 0
BS
MS
OTD
DPT
PhD
191
163
49
12
10
6-10 25
11-15 28
16-20 65
21-25 67
26-30 66
>30 147
6-10 56
11-15 62
16-20 56
21-25 55
26-30 68
>30 24
Inpatient hospital
Other (academia, physician practice, burn unit, private practice, hospital outpatient, public health, lymphedema clinic, management, outpatient orthopedics and neurology, occupational health, general outpatient, outpatient rheumatology, pediatrics, rehab agency, outpatient rheumatology and orthopedics) 28
Highest level of education Total
436
Associate
1
EdD
1
Other (MPH, MEd, MHS, DHS, DPS, MBA, certificate of proficiency in OT) 9
Years in clinical practice Total 436
0-5 38
Years practicing as a certified hand therapist Total 435b
0-5 72
n/a 44
Primary practice area Total
Outpatient orthopedics
Hand therapy clinic
417c
278
253
9
Other practice settings Total 16
c
Higher education 11
Consulting
Continuing education
2
1
Other (arthritis and hand specialist, home care, wellness, retired and semiretired) 6
OT ¼ occupational therapist; PT ¼ physical therapist; CHT ¼ certified hand therapist; CLT ¼ certified lymphedema therapist; OTA ¼ occupational therapy assistant. a Respondents can answer more than once. b 1 Person reported 0-5 & n/a; 1 person reported 26-30 & >30. c Some reported working in more than one setting.
Table 2 Edema education data broken down by years in practice and discipline When did you receive your edema management training? Years
OT of PT academic training OT
>30 26-30 21-25 16-20 11-15 6-10 0-5
47 of 137 27 of 60 23 of 59 32 of 57 11 of 26 18 of 25 14 of 35
(34%) (45%) (39%) (56%) (42%) (72%) (40%)
On-the-job PT
OT
4 of 9 (44%) 4 of 5 (80%) 2 of 6 (33%) 2 of 4 (50%) 0 of 2 (0%) 0 of 0 (0%) 2 of 2 (100%)
89 of 137 40 of 60 38 of 59 39 of 57 19 of 26 21 of 25 14 of 35
(65%) (67%) (64%) (68%) (73%) (84%) (40%)
Continuing education PT
OT
5 of 9 (56%) 4 of 5 (80%) 3 of 6 (50%) 2 of 4 (50%) 2 of 2 (100%) 0 of 0 (0%) 2 of 2 (100%)
113 of 137 49 of 60 42 of 59 46 of 57 20 of 26 16 of 25 10 of 35
PT (82%) (82%) (71%) (81%) (77%) (64%) (29%)
7 of 9 (78%) 3 of 5 (60%) 3 of 6 (50%) 2 of 4 (50%) 1 of 2 (50%) 0 of 0 (0%) 1 of 2 (50%)
When did you learn the difference between acute/subacute/chronic edema? Years
OT of PT academic training OT
>30 26-30 21-25 16-20 11-15 6-10 0-5
15 of 137 12 of 60 6 of 59 15 of 57 4 of 26 7 of 25 9 of 35
(11%) (20%) (11%) (26%) (15%) (28%) (26%)
On-the-job PT
OT
2 of 9 (22%) 2 of 5 (40%) 2 of 6 (33%) 1 of 4 (25%) 1 of 2 (50%) 0 of 0 (0%) 2 of 2 (100%)
67 of 137 28 of 60 28 of 59 26 of 57 8 of 26 14 of 25 12 of 35
Continuing education PT
(49%) (47%) (47%) (46%) (31%) (56%) (34%)
2 of 9 (22%) 2 of 5 (40%) 1 of 6 (17%) 1 of 4 (25%) 1 of 2 (50%) 0 of 0 (0%) 2 of 2 (100%)
OT 86 of 137 34 of 60 29 of 59 28 of 57 10 of 26 13 of 25 6 of 35
PT (63%) (57%) (49%) (49%) (38%) (52%) (17%)
4 of 9 (44%) 2 of 5 (40%) 1 of 6 (17%) 0 of 4 (0%) 1 of 2 (50%) 0 of 0 (0%) 1 of 2 (50%)
When were you trained about the role of the lymphatics and edema reduction? Years
OT of PT academic training
>30 26-30 21-25 16-20 11-15 6-10 0-5
14 of 137 6 of 60 3 of 59 11 of 57 4 of 26 8 of 25 9 of 35
OT (10%) (10%) (5%) (19%) (15%) (32%) (26%)
On-the-job PT
OT
2 of 9 (22%) 1 of 5 (20%) 4 of 6 (67%) 1 of 4 (25%) 0 of 2 (0%) 0 of 0 (0%) 2 of 2 (100%)
56 of 137 20 of 60 21 of 59 21 of 57 12 of 26 13 of 25 6 of 35
OT ¼ occupational therapist; PT ¼ physical therapist. Some reported learning this material through several different avenues.
Continuing education PT
(41%) (33%) (36%) (37%) (46%) (52%) (17%)
4 of 9 (44%) 3 of 5 (60%) 2 of 6 (33%) 1 of 4 (25%) 1 of 2 (50%) 0 of 0 (0%) 2 of 2 (100%)
OT 88 of 137 36 of 60 31 of 59 32 of 57 11 of 26 10 of 25 4 of 35
PT (64%) (60%) (53%) (56%) (42%) (40%) (11%)
5 of 9 (56%) 3 of 5 (60%) 5 of 6 (83%) 0 of 4 (0%) 1 of 2 (50%) 0 of 0 (0%) 0 of 2 (0%)
4
V. Priganc et al. / Journal of Hand Therapy xxx (2019) 1e7
Table 3 Chi-square test calculations highlighting differences in edema content taught in the academic program Credentials
OT PT
Overall
399 28
Difference between acute/subacute/chronic
Role of lymphatics
Yes
No
P-value (chi-square)
Yes
No
P-value (chisq)
68 (17.04%) 10 (35.71%)
331 (82.96%) 18 (64.29%)
.013
55 (13.78%) 10 (35.71%)
344 (86.22%) 18 (64.29%)
.002
OT ¼ occupational therapist; PT ¼ physical therapist. statistically significant at P < .05.
a
n ¼ 219). A total of 326 respondents reported learning about the role of the lymphatic system in edema reduction, while 40 respondents reported not learning this information. Of those respondents, 308 clarified when they learned this material: 168 (55%) through on-the-job training and, or 233 (76%) through continuing education. A higher percentage of OTs practicing as hand therapists in the past 10 years reported learning the role of the lymphatic system in edema management in the educational setting compared with OT hand therapists practicing for more than 30 years. Refer to Table 2 for a breakdown of how hand therapists acquire edema education training based on discipline and years in practice. A greater percentage of PTs learned the difference between types of edema (36% compared with 17%, respectively) (P < .01), as well as the role of the lymphatics in edema management (36% compared with 14%, respectively) (P < .002), in their academic programs compared with OTs. These findings indicate a statistically significant association between a discipline’s educational program and whether or not edema education is taught in the educational program Refer to Table 3. A statistically significant association was found between learning the difference between acute, subacute, chronic edema (P < .001) in an OT academic program as degrees advanced. A statistically significant association was also found between learning the role of the lymphatics (P < .004) in an OT academic program as degrees advanced, meaning that OTs with an MS or OTD were more likely to have received this information in their academic education than OTs with a BS degree. Refer to Table 4. This same difference was not found with hand therapists trained as PTs. Practice patterns Four quantitative questions (Q9, Q12, Q17, and Q18) were directed toward understanding current practice patterns related to edema assessment and treatment. Most of the respondents reported seeing clients daily where edema is impacting rehabilitation (n ¼ 308), and most reported altering treatment approaches based on the type of edema (n ¼ 335). Almost all respondents used circumferential measurements to assess edema (n ¼ 421), followed by volumeter (n ¼ 242) and figure-of-eight (n ¼ 154) measurements. Other assessment tools noted included visual inspection, photos, palpation, perometers, pitting, clinical judgment, and passive range of motion. The most common edema management treatment techniques used by CLTs and non-CLTs are depicted in Figure 1.
Further analysis was performed to assess if lymphatic training factored into whether or not hand therapists used deep retrograde and light retrograde massage. CLTs were less likely to perform light retrograde massage than non-CLT OTs (P < .02). No relationship was found with deep retrograde massage. Refer to Table 5. Four open-ended, qualitative questions (Q15, Q16, Q19, and Q22) were designed to hear from the participants, in their own words, their thoughts related to edema knowledge and practice patterns. Three of these open-ended questions (Q15, Q16, and Q19) related to practice patterns. Coding of answers to the practice pattern questions associated with identification and assessment of edema (Q15 and Q16) revealed some similarities shared among hand therapists. Further review of these similarities resulted in the identification of conceptual categories (duration, feel, responsiveness to treatment, and appearance). Refer to Figure 2 to see the conceptual categories associated with how hand therapists describe and assess the difference between acute, subacute, and chronic edema. Duration Duration, meaning time elapsed since injury or surgery, was a common variable used by more than 50% of the respondents to differentiate and assess whether edema was acute, subacute, or chronic in nature. Some respondents solely used duration as a differentiating variable, whereas other respondents used duration in combination with other variables such as feel or observation to either classify or assess the type of edema. Therapists indicated that they not only described the difference between acute, subacute, and chronic edema by the amount of time since injury, but also used the amount of time since injury as an assessment tool. For example, therapists described acute edema as immediate or the initial response after an injury and described chronic edema to be present for a prolonged period of time. Words such as time, days, length, and immediate were identified as words associated with duration. Feel More than 50% of the respondents reported using tissue feel during clinical practice. Many used feel to help identify if the edema was acute, subacute, or chronic, indicating a pitting, brawny, or fibrotic feel was noticed as edema progressed from the acute, watery stage to more chronic edema. Feel was often used in combination with other variables such as duration, appearance, observation, and patient history when assessing the difference between
Table 4 Chi-square test and Fisher exact test calculations highlighting differences in edema education taught in OT educational program based on degree Credentials
Overall
OT BS MS OTD
178 156 48
OT ¼ occupational therapist. a statistically significant at P < .05.
Difference between acute, subacute, chronic
Role of lymphatics
Yes
No
P-value (chi-square)
Yes
No
P-value (Fisher exact)
17 (9.55%) 37 (23.72%) 11 (22.92%)
161 (90.45%) 119 (76.28%) 37 (77.08%)
.001
13 (7.30%) 29 (18.59%) 9 (18.75%)
165 (92.70%) 127 (81.41%) 39 (81.25%)
.004
V. Priganc et al. / Journal of Hand Therapy xxx (2019) 1e7
Percentage of respondents reporƟng edema treatment techniques uƟlized in clinic, categorized by CLT vs non-CLT 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
5
and lymphatic techniques. Numerous respondents reported moving away from elevation and ice to a lighter massage as the edema progresses into the chronic stages. The following statement depicts this transition to lighter techniques. “For chronic edema, I would use more manual lymphatic drainage techniques, for acute edema, I would use more compression, ice, and elevation.”
CLTs
non-CLTs
Fig. 1. Percent of respondents reporting edema treatment techniques used in clinic, categorized by CLT vs non-CLT *total respondents to this question (n ¼ 377); CLT (n ¼ 43); non-CLT (n ¼ 334). CLT ¼ certified lymphedema therapist.
acute, subacute, or chronic edema. Words such as pitting, thickness, brawny, and soft were identified as words associated with feel. Responsiveness to treatment How edema responds to treatment was a variable numerous hand therapists reported when describing methods to identify and assess the type of edema. Therapists indicated the manner in which edema responds or fails to respond to various treatment interventions served as a method to assess the type of edema. Words such as respond, resolves, change, and treatment were identified as words associated with responsiveness to treatment. Appearance and observation The appearance and observation of the tissue was often used in conjunction with other variables when assessing the difference between acute, subacute, and chronic edema. Words such as visual, appearance, color, and observation were identified as words associated with appearance and observation. The following statement highlights many of these conceptual categories. “Acute: 1 to 3 days following trauma, injury, surgery, sudden, painful, decrease range of motion and function, painful, red swollen, dark bruising. Subacute: 4-days e 3 wks, decrease pain and color of bruising changes. Less redness, increase range of motion and movement, soft, easily mobile, pitting edema with pressure. Chronic: Greater 3 to 4 wks to years. Decrease pain, patient complains of limb heaviness, skin and soft tissues firmer, edema does not decrease as easy with elevation but can respond (decrease) when combined with movement, compression, manual edema mobilization (MEM).” Coding of answers related to treatment for acute versus chronic edema (Q19) suggests elevation, movement, ice, and compression are the treatment techniques used most by hand therapists when treating acute edema. The most common treatment techniques used for chronic edema included compression, MEM, movement,
One open-ended question was related to lymphatic knowledge (Q22). Common concepts were not as evident as when reviewing the words of the respondents and their answers to the role of the lymphatic system in edema reduction. While numerous respondents used words such as protein, transport, remove, drain, interstitial, light, proximal, massage, and movement, many of the answers did not provide sufficient detail to determine the participant’s level of knowledge. The following statement is an example of an answer that lacked detail. “The lymph system is integral to edema reduction. It is a very delicate system. It responds well with proper techniques. Education of patient is important.” Although the majority of the answers lacked details, there were some common conceptual concepts gleaned from these data. First, some respondents reported light massage stimulates the lymphatic system, while deep massage can shut down this system. Second, some respondents reported the lymphatics are necessary to reduce higher protein edema, although the rationale for why varied. Third, some described the importance of light massage and proximal stimulation of the lymphatic system to reduce edema. Statements such as the following three highlight these conceptual concepts. “The lymphatic system is like a spider web with valves. Light pressure stimulates the system. Firm retrograde massage closes the valves. Also, lymph nodes must be stimulated to help drain the fluid out of the extremity.” “Stimulation of the lymphatic system is necessary to decrease subacute and chronic edema (high-protein edema)dtheoreticallydit removes the plasma proteins from edematous areas by enabling the proteins to leave the interstitial spaces and enter the lymphatic structures. By ridding the interstitial spaces of these proteins, the edema decreases.” “They are removing the 10% of fluid not taken up by veins and larger proteins not take by veins. When the system is overwhelmed we get edema, especially pitting edema. The lymphatics respond to gentle tissue pressure change (ie, gentle massage). Best to clear proximal then work down the hand and encourage movement proximally.”
Discussion The majority of hand therapists reported learning about edema management through continuing education courses or on-the-job training versus through their entry-level academic education. PTs were more likely than OTs to learn about the differences between
Table 5 Relationship of OTs and PTs performing deep and light retrograde massage based on lymphatic training Credentials
CLTs (OTs/PTs) OTs (non-CLT) PTs (non-CLT)
Overall
43 358 27
Deep retrograde
Light retrograde
Yes
No
7 (16.28%) 109 (30.45%) 10 (37.04%)
36 (83.72%) 249 (69.55%) 17 (62.96%)
P-value (Fisher exact)
Yes
No
P-value (chi-square)
.074 .084
25 (58.14%) 269 (75.14%) 18 (66.67%)
18 (41.85%) 89 (24.86%) 9 (33.33%)
.017
OT ¼ occupational therapist; PT ¼ physical therapist; CLT ¼ certified lymphedema therapist. a statistically significant at P < .05.
P-value Fisher exact
.615
6
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Duration •Key words: time, days, length, immediate
Feel •Key words: pitting, thickness, brawny, soft
Responsiveness to treatment •Key words: respond, resolves, change, treatment
Appearance/observation •Key words: visual, appearance, color, observation Fig. 2. Conceptual categories and key words related to identification and assessment of acute, subacute, chronic edema (Q15 and Q16).
acute, subacute, chronic edema, as well as the role of the lymphatic system and edema in academic programs (Table 3). The likelihood of receiving edema education in academic programs related to types of edema and the role of the lymphatics increased with graduate training for OTs but not PTs (Table 4); however, this result may reflect the small number of PT responses. Although not statistically significant, when factored out by years in practice, a greater percentage of OTs practicing within 0 to 10 years reported learning about the lymphatic system in their primary academic programs than OTs practicing more than 30 years (Table 2). In a recent case report, the importance of incorporating edema and lymphatic education in an entry-level doctor of physical therapy curriculum was discussed and teaching strategies were suggested.20 No such studies examining occupational therapy curriculum and edema management or lymphatic education were found. Numerous authors report there is a knowledge translation lag between research and clinical practice.21,22 Thus, as a profession, it is important academic programs teach the importance of the lymphatic system, so future hand therapists are able to enter practice knowing the best ways to manage patients with edema. It is well documented the lymphatic system plays a crucial role in edema management,9,10,16,23 especially as the edema becomes more chronic in nature,8 thus understanding this system and how to stimulate it to effectively reduce higher protein edema is critical for best-practice edema management.20 Results from this survey suggest that newer practicing therapists and therapists with more advanced degrees are learning lymphatic knowledge in academic programs compared with therapists who have been practicing for a while. However, the majority still report that the primary method of obtaining edema education related to types of edema and lymphatic system knowledge is through on-the-job training or continuing education (Table 2). Understanding the differences between acute and chronic edema is also important for effective edema management because treatment should alter based on the type of edema.8 Both acute and chronic edema have a duration23 and quality component,17,24 and although most respondents acknowledged they utilize both of these variables when identifying if the edema is acute or chronic, many reported only using duration when differentiating between acute, subacute, and chronic edema. From a clinical perspective, the increased protein content associated with chronic edema presents with a different feel and texture17,24 and responds differently to treatment. Interestingly, few respondents used objective measurements to assist in differentiating between acute and chronic edema. We hypothesize because no reliable and valid tool is available to differentiate between acute and chronic edema, that clinicians rely primarily on duration, feel, patient history, and visual observation to make this clinical judgment. As a profession, there is a need to identify clinically applicable and objective methods of
differentiating between acute and chronic edema to inform appropriate hand therapy management strategies. Statistical analysis demonstrated CLTs were less likely to perform light retrograde massage than non-CLT OTs (P < .02), which can be explained by the fact that CLTs are taught the importance of proximal clearing and movement of fluid along lymphatic paths. Retrograde massage, whether light or deep, does not adhere to these lymphatic principles. Statistical analysis did not demonstrate a difference in performing deep retrograde massage between hand therapists with certified lymphatic training compared with their non-certified lymphatic trained OTs and PTs. This lack of significance is likely due to the low frequency numbers (Table 5). In addition, although not statistically significant, descriptive data reported a greater percentage of CLTs using lymphatic treatments such as MEM and low stretch bandaging than non-CLT hand therapists (Fig. 1). These findings partially confirm the hypothesis that edema practice differences in hand therapy are likely due to the increased knowledge CLTs have as it relates to the initial lymphatics, lymphatic pathways, and the knowledge that the proteins associated with chronic edema need to dissipate through the initial lymphatic system.25 Current clinical thinking as it relates to edema management includes avoiding deep pressure and instead using light pressure according to lymphatic pathways, along with light compression, to treat persistent edema.1,6,8 Ensuring hand therapists are taught these concepts in their educational programs can help to translate this knowledge to practice. When asked specifically to explain the role of the lymphatic system in edema reduction, most people indicated the lymphatic system played a role, but many of the answers were general and lacked specific details, making it difficult for the researchers to determine the participant’s understanding of lymphatic physiology. Despite current advances, there is acknowledgment that the lymphatic system and its role remain largely unknown among clinicians.3,26 Because the lymphatic system plays a role in all forms of edema,9,24 understanding concepts related to high-protein edema, lymphatic flow,9 and changes in oncotic and hydrostatic pressure in the capillaries and interstitial spaces12,24 are important if one is to really understand the crucial role of the lymphatics in edema reduction. Thus, understanding what is happening from a physiological perspective when edema becomes more chronic in nature may help to identify the best ways to manage this type of edema. Limitations Multiple limitations have been identified with this survey research. First, although the survey response was high, when broken out into subcategories such as PTs, CLTs, and years in practice, the numbers were low, which may have impacted some of the results, particularly results examining differences in deep and light retrograde massage between CLTs and non-CLTs. Second, this survey was not formally pilot tested. It was peer reviewed through the ASHT Research Division, and modifications were made based on feedback, but pilot testing may have revealed additional areas where clarity was needed. Third, the survey was only distributed to members of the ASHT and thus does not represent all OTs or PTs practicing in hand rehabilitation. Finally, two of the authors are CLTs and advocate the importance of the lymphatics in edema management. This perspective likely guided survey development. Conclusion These survey results provide insight into the current state of edema education and management among hand therapists practicing primarily in the United States. Most hand therapists rely on
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subjective measures such as duration and tissue feel when assessing acute, subacute, and chronic edema. Thus, additional research is recommended to identify an objective method of differentiating between acute and chronic edema so that hand therapists are equipped with the best assessment tools to guide treatment. Most hand therapists reported learning about edema education related to types of edema and lymphatic knowledge through on-the-job training and, or continuing education, although there appears to be a trend that newer therapists with more advanced degrees are learning this information in academic programs. The OT and PT professions can support bringing this knowledge into academic programs through practicums, casebased learning, and experiential learning opportunities that bridge science to clinical practice. Future survey research of OT and PT academic programs may provide additional insight as to how these topics are currently addressed in the academic setting. Ideally, all hand therapists will be taught the relationship between edema and the lymphatics in their academic programs and will be able to translate this knowledge to clinical practice when treating clients with edema. Acknowledgments The authors would like to thank Dr Ying He for the statistical support and Ms Kayla Lowman for her assistance in the initial design of the survey. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.jht.2019.04.005. References 1. Miller L, Jerosch-Herold C, Shepstone L. Effectiveness of edema management for subacute hand edema: a systematic review. J Hand Ther. 2017;30(4):432e 446. 2. Villeco, Edema J. A silent but important factor. J Hand Ther. 2012;25(2):153e 161. 3. Rockson SG. The unique biology of lymphatic edema. Lymphat Res Biol. 2009;7(2):97e100. 4. Vranova M, Halin C. Lymphatic vessels in inflammation. J Clin Cell Immunol. 2014;5(4):1e11.
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