- Email: [email protected]
Fundamentals of Edema Management
8 Aida E. Olvera-Dyckes
Fundamentals of Edema Management
E
dema (oedema) is a common condition after upper extremity injury or surgery. Dorsal hand edema causes the skin to tighten, forcing the metacarpophalangeal (MP) joints into hyperextension and the interphalangeal (IP) joints into flexion. As a consequence, the collateral ligaments of all the joints tighten and the volar plates of the proximal interphalangeal (PIP) joints shorten. The arches of the hand are lost and the thumb becomes adducted and extended. Clinical Pearl Without early intervention from a therapist, the anatomical response to hand edema can result in fixed contractures with fibrotic changes of tissues and shortening of musculotendinous units.
Edema versus Swelling Many people use the terms swelling and edema interchangeably, but they are not technically synonymous. Swelling is an enlargement of tissue that can occur for many reasons, for example a tumor, excess fluid, infection (pus), or inflammation. Edema refers specifically to an excessive amount of fluid in the interstitial space (space between the cells). So, edema manifests as swelling. Hand edema is not seen by the naked eye until interstitial fluid volume has increased over 30% beyond normal.1 Clinical Pearl Localized swelling due to hemorrhage or infection is not edema.
Edema is often described relative to its mechanism of injury, location, and pathogenesis. There are several classifications of edema, including acute, mild, brawny, pitting, and lymphedema. This chapter focuses on peripheral edema, which is the edema that occurs in the extremities.
Biological Mechanism of Edema Formation There is normally a balance of fluid moving into and out of the vessels on a cellular level. This balance is based on Starling’s equilibrium, which refers to the movement of fluid across capillary walls and which is affected by hydrostatic pressure and oncotic pressure in the capillaries and in the interstitium. The movement of fluid is usually balanced so that there is a steady state in the sizes of the intravascular and interstitial compartments. Edema occurs when the balance is disrupted.2 If either the capillary hydrostatic pressure increases and/or the oncotic pressure is reduced, more movement of fluid from the intravascular to the interstitial spaces will take place.
Edema Related to Wound Healing One of the most important tasks of managing wounds and edema is identifying inflammation. Inflammation may be a sign of infection and presents as a localized area of softtissue redness and swelling. The area is often warm to the touch and painful. When an infection is suspected, the therapist should alert the physician immediately. In the presence
Fundamentals of Edema Management CHAPTER 8
of infection, therapeutic intervention should be paused until the therapist has clearance from the physician to continue treating. Physical agent modalities, manual edema mobilization, and many other treatments are contraindicated when there is infection.
Types of Edema Pitting edema is present when the pressure of a finger makes an indentation that persists after the finger pressure is removed. The indentation is not permanent; the depression slowly refills with fluid from the surrounding tissues. Pitting edema may be related to problems with the kidneys, heart valves, and low protein levels.3 It can also be caused by trauma, localized problems with the veins, pregnancy, and certain medications. This type of edema is often simply due to an accumulation of water and is easily treated with movement, cold modalities, elevation, and light compression. Nonpitting edema (also known as brawny edema) is firm to the touch because the tissue is fibrotic. When chronic, the skin in the involved area can become thickened and brown in color. Nonpitting edema is composed of fluid that is more protein-rich and static––making this type of edema more difficult to treat. Lymphedema is a condition that occurs when lymph fluid has difficulty draining properly due to damage or a blockage in the lymphatic system. This type of edema can be either pitting or nonpitting. The lymphatic network can be altered by infection, radiation therapy, surgery, parasitic infection, and trauma. With lymphedema, protein-rich fluid accumulates in the interstitial spaces of the skin and subcutaneous tissue. This condition is incurable but it can be managed with appropriate treatment. Manifestations of chronic lymphedema are abnormal skin changes and an increased risk of infection. Complications are more common in clients who are unable to obtain proper medical care.
Measuring Edema Edema can be measured using volumetry, figure-of-eight measurement, or circumferential measurement.1 Volumetry: This is a method of determining the volume of a hand or arm by immersing the limb in a container full of water and then measuring the amount of water that is displaced. Figure-of-Eight: This method of measuring edema utilizes a flexible tape measure. The therapist wraps the tape measure around the hand in a figure-of-eight pattern at specific anatomical landmarks. Circumferential Measurement: This method uses a flexible tape measure. The therapist wraps the tape measure once around the hand/limb in a circular pattern at specific anatomical landmarks. Volumetric measurement is considered the gold standard for measuring edema. Both the figure-of-eight and circumferential techniques are useful when it is not appropriate to immerse the limb in water (for example, if there is a wound). By placing a thin gauze covering over the wound, the therapist is able to obtain a measurement while protecting the wound. However, one of the problems with these two methods is that therapists use varying amounts of force when pulling the tape measure around the hand/limb. To address this problem, some therapists use a force gauge to standardize the force applied to the tape measure.
101
Clinical Pearl Edema can fluctuate due to factors such as activity level, time of day, and fluid retention. To most objectively measure changes in edema, try to have the same therapist measure the client at the same anatomical position, using the same measuring tool, at the same time of day.
Edema Management Edema can be treated using a variety of techniques including elevation, active range of motion (AROM), manual edema mobilization, compression, taping, and modalities. Elevation: Elevation of the limb is commonly recommended for individuals with upper extremity edema. Elevation helps because gravity assists with fluid drainage. The most effective position for upper extremity elevation is as follows: elbow higher than the shoulder, wrist higher than the elbow, and hand higher than the wrist. Additionally, the elbow should be more extended than flexed. This position for elevation should be used as long as it is not medically contraindicated. This sequential positioning pattern creates a pathway for fluid drainage. AROM: Active movement promotes fluid drainage and discourages the formation of adhesions. The type and frequency of AROM exercises should be customized to each client’s injury/ surgery and medical contraindications. Manual Edema Mobilization (MEM): This technique treats edema based on the anatomy and physiology of the lymphatic system. The lymphatic system is the only pathway for interstitial proteins to return to circulation and it is a key player in fluid homeostasis.4 Interstitial fluid persists due to protein molecules that attract water. At 6 to 12 days postinjury or surgery, these molecules are too large to be reabsorbed through the arteriovenous system. Therefore they must be returned through the lymphatic system. MEM includes light proximal-to-distal then distal-to-proximal mobilization of the skin done in specific patterns and segments, massaging over lymph node(s) proximal to the edema, and promoting flow in the anatomic direction of the lymphatic pathways. This facilitates the removal of excess fluid and interstitial protein molecules that continue to attract water if they are not recirculated.5 MEM can be very effective for clients with persistent edema following upper extremity trauma or surgery who have intact but overwhelmed lymphatic systems. It is not designed to be used with clients who have damaged lymphatic systems or for clients with primary lymphedema (a form of lymphedema not caused by another medical condition). Contraindications for MEM include infection, blood clots, congestive heart failure, renal failure, and cancer.6,7 Clinical Pearl When using hands-on techniques to reduce edema, use very light pressure (just enough pressure to gently move the skin). Deep or heavy massage pressure collapses the lymphatic network and is counterproductive or even injurious.
Compression: External compression provides counterpressure and compensates for the lack of elasticity in edematous tissues and thereby improves circulation. Compression helps
102
PART 1 Fundamentals
reinforce tissue hydrostatic pressure and facilitates venous and lymphatic flow. Using compression in the acute phase of healing is thought to limit the amount of space available for excess fluid to accumulate during the fibroblastic phase of healing. Compression is thought to decrease the fibroblastic synthesis of collagen by decreasing blood flood. This in turn causes local hypoxia, slowing down the development of scar tissue and fibrosis. In the later stages of healing, compression assists with edema management by reducing net filtration. Compression wrapping of brawny edema softens fibrotic connective tissue and scar tissue. Contraindications to the use of compression include severe arterial insufficiency, deep vein thrombosis, heart failure, uncontrolled hypertension, severe peripheral neuropathy, and active tuberculosis. Be aware that compression that is too tight actually damages the lymphatic system. A well-fitted compression garment promotes light skin traction during active movement, and this stimulates lymphatic flow. If creases are still visible in the skin 20 to 30 minutes after removing an edema glove or elastic tubular stockinette, then the compression is too tight and a looser-fitting garment should be used.
Types of Compression Edema Gloves: Edema gloves provide gentle compression. These gloves are typically fabricated from nylon and spandex. The glove should provide 15 to 25 mm Hg pressure in order to stimulate the superficial lymphatic system, promoting edema reduction. Custom and off-the-shelf gloves in various sizes are available. Gloves should be designed to extend only to the middle phalanges to allow sensory input and integration of the hand into activities of daily living. It is very important that gloves not be too tight, especially at the distal edges, as this can cause worsening of distal edema. Elastic Tubular Stockinette: Elastic tubular stockinette provides gentle compression. It is made of a cotton/rayon blend with rubber latex yarn. Caution should be used with clients who have latex allergies. The elastic tubular stockinette can be cut to size. Edema gloves and elastic tubular stockinette are reusable. Clients can wash the garments with warm soapy water and then air-dry them. These garments are often used for general edema, burns, strains, sprains, and soft-tissue injuries. Elastic tubular stockinette can be worn in combination with an edema glove. It is common practice to give the client two pairs of edema gloves and two sets of elastic tubular bandages, one to wash and one to wear. It is important to closely monitor the skin for marks indicating that the garments are too tight. A safe guideline is that therapists should be able to get their finger inside a tubular sleeve. If you can’t, it is too tight.6,8 String Wrapping: String wrapping is an outdated edema management technique that is still sometimes used and therefore deserves to be mentioned. It was originally thought to be a way of using distal to proximal compression to move edema out of the hand. However, we now know that the terminal portion of the lymphatic system is very delicate. Too much pressure, such as the pressure used with string wrapping, damages the lymphatic tissues. For this reason, string wrapping should not be used. Short-Stretch Bandaging: Short-stretch bandages stretch 20% of their original length. In this way they differ from ACE elastic bandages, which stretch 140% to 300% of their original
length. Short-stretch bandaging is a compression technique used to manage lymphedema. It is also used in manual edema mobilization. The techniques of use exceed the scope of this chapter, but readers are encouraged to pursue outside information about the use of short-stretch bandaging in the treatment of edema. Kinesiology tape: Kinesiology tape can be applied to increase lymphatic and vascular flow, thereby reducing edema and diminishing pain. The tape is thinner and more elastic than conventional tape and can be stretched 120% to 140% of its original length. Kinesiology taping is designed to raise the epidermis, reducing the pressure on the mechanoreceptors below the dermis. This is proposed to reduce pain. Kinesiology tape is reported to have a beneficial effect on lymphatic and venous circulation by raising the epidermis, thereby decreasing the pressure in the dermis and promoting lymphatic drainage through its mechanical action during movement. The theory is that when applied on stretch, kinesiology tape can lift the skin away from the muscle, creating space between the layers of fascia. Blood vessels, lymphatic vessels, and certain nerves are found in the fascia. By lifting the skin away from the muscle, kinesiology tape changes the pressure differential underneath the skin, allowing for improved perfusion of the area with ground substance, which includes the water and proteins responsible for the lubrication and nutrition of the connective tissue cells. Contraindications include allergic reactions to adhesive tape, open wounds, presence of a deep vein thrombosis, infection, peripheral neuropathy, and active cancer.9 Contrast Baths: It has been suggested that contrast baths produce a “pumping effect” contributing to edema reduction. The rationale provided is that contrast baths may help reduce pain and stiffness by activating vasodilation and vasoconstriction via muscle contraction.10 However, a randomized controlled study of contrast baths on patients with carpal tunnel syndrome did not find any significant effect on hand volume with use of contrast baths.11 A systematic review of the effectiveness of contrast baths concluded that although its use may increase the temperature of skin and blood flow superficially, there was conflicting evidence on its effect on edema.12 Contraindications for use of contrast baths include open wounds, poorly controlled epilepsy, hypertension, and diabetes. Intermittent Pneumatic Compression (IPC): IPC is often a modality of choice for treating lymphedema. It can also be effective for reducing posttraumatic edema, especially in the inflammatory phase of healing.13 The pump consists of a sleeve with multiple pressure compartments that encompass the entire limb. Once placed on the extremity, the chambers of the pump are sequentially inflated, working distal to proximal. This sequential compression moves the edematous fluid into the lymphatic system, which in turn pushes the venous blood proximally. The pumping motion encourages normal circulatory action by stimulating extracellular drainage and fluid clearance. Contraindications include congestive heart failure, deep vein thrombosis, inflammatory phlebitis, a history of pulmonary embolism, active infection, lymphangiosarcoma, and nonhealed fracture. Electric Stimulation: Muscle contractions are imperative for lymphatic flow. When a client is unable to perform effective active muscle contractions to assist in the drainage of the lymphatic and venous systems, electric stimulation can be helpful. Muscle contractions stimulate venous and lymphatic circulation. Current intensity must be high enough to elicit a muscle contraction. The client should be encouraged to actively contract their muscles simultaneously with the electrical stimulation. Treatment
Fundamentals of Edema Management CHAPTER 8
time is usually 20 minutes, with a cycle of 5 seconds on and 5 seconds off. High-voltage pulsed current and medium-frequency alternating current are commonly used. Contraindications are pregnancy, cancer, cardiac pacemaker or other implanted electrical stimulators, active tuberculosis, thrombophlebitis, thrombosis over the carotid sinus, and active hemorrhage.14 Cryotherapy: Cold therapy is often beneficial for the reduction of acute edema, especially in the inflammatory phase of healing. Cold therapy includes ice packs, gel wraps, and cold-water baths. Physiological exposure to cold activates vascular permeability, promotes vasoconstriction, and reduces local blood flow. This in turn decreases prostaglandin synthesis and histamines, thus reducing swelling and pain. Contraindications include but are not limited to
103
deep vein thrombosis, thrombophlebitis, impaired sensation, nerve regeneration, impaired circulation, and chronic wounds.1
Summary This chapter has presented a selection of techniques commonly used to treat edema. Elevation and appropriate active movement are very powerful methods to prevent and reduce edema. Edemareducing modalities are an adjunct to treatment and must be selected cautiously using sound clinical reasoning. Edema control is key to successful clinical outcomes and should be among the highest of priorities in the hand therapist’s plan of care.
References 1. Villeco JP: Edema: Therapist’s management. In Skirven TM, Osterman AL, Fedorczyk JM, Amadio PC, editors: Rehabilitation of the hand and upper extremity, ed 6, Philadelphia, PA, 2011, Elsevier Mosby, pp 845– 857. 2. Fauci AS et al: Harrison’s principles of internal medicine, ed 18, New York, NY, 2012, McGraw Hill. 3. Colditz JC: Therapist’s management of the stiff hand. In Skirven TM, Osterman AL, Fedorczyk JM, Amadio PC, editors: Rehabilitation of the hand and upper extremity, ed 6, Philadelphia, PA, 2011, Elsevier Mosby, pp 894–921. 4. Levick JR, Michel CC: Microvascular fluid exchange and the revised starling principle, Cardiovasc Res 87:198–210, 2010. 5. Artzberger SM: Hand manual edema mobilization: overview of a new concept in hand edema reduction, SAJHT 1:1–6, 2003. 6. Artzberger S: Edema reduction techniques: a biologic rationale for selection. In Cooper C, editor: Fundamentals of hand therapy: clinical reasoning and treatment guidelines for common diagnoses of the upper extremity, ed 2, St. Louis, MO, 2014, Mosby, pp 35–50. 7. Artzberger SM, Priganc VW: Manual edema mobilization: an edema reduction technique for the orthopedic patient. In Skirven TM, Osterman AL, Fedorczyk JM, Amadio PC, editors: Rehabilitation of the hand and upper extremity, ed 6, Philadelphia, PA, 2011, Elsevier Mosby, pp 868– 881.
8. Villeco JP: Edema: a silent but important factor, J Hand Ther 25(2):153– 162, 2012. 9. Bassett KT, Lingman SA, Ellis RF: The use and treatment efficacy of kinaesthetic taping for musculoskeletal conditions: a systematic review, N Z J Physiother 38(2):56–62, 2010. 10. Stanton DEB, Bear-Lehman J, Graziano M, Ryan C: Contrast baths: what do we know about their use? J Hand Ther343–346, 2003. 11. Janssen RG, Schwartz DA, Velleman PF: A randomized controlled study of cointrast baths on patients with carpal tunnel syndrome, J Hand Ther 22:200–208, 2009. 12. Stanton DEB, Lazaro R, MacDermid JC: A systematic review of the effectiveness of contrast baths, J Hand Ther 22:57–70, 2009. 13. Zaleska M, Olszewski WL, Jain P, et al.: Pressures and timing of intermittent pneumatic compression devices for efficient tissue fluid and lymph flow in limbs with lymphedema, Lymphat Res Biol 11(4):227– 232, 2013. 14. Shapiro S, Ocelnik M: Electrical currents for tissue healing. In Cameron MH, editor: Physical agents in rehabilitation: from research to practice, ed 4, St. Louis, MO, 2013, Elsevier Saunders, pp 267–272.
Fundamentals of Edema Management
E
dema (oedema) is a common condition after upper extremity injury or surgery. Dorsal hand edema causes the skin to tighten, forcing the metacarpophalangeal (MP) joints into hyperextension and the interphalangeal (IP) joints into flexion. As a consequence, the collateral ligaments of all the joints tighten and the volar plates of the proximal interphalangeal (PIP) joints shorten. The arches of the hand are lost and the thumb becomes adducted and extended. Clinical Pearl Without early intervention from a therapist, the anatomical response to hand edema can result in fixed contractures with fibrotic changes of tissues and shortening of musculotendinous units.
Edema versus Swelling Many people use the terms swelling and edema interchangeably, but they are not technically synonymous. Swelling is an enlargement of tissue that can occur for many reasons, for example a tumor, excess fluid, infection (pus), or inflammation. Edema refers specifically to an excessive amount of fluid in the interstitial space (space between the cells). So, edema manifests as swelling. Hand edema is not seen by the naked eye until interstitial fluid volume has increased over 30% beyond normal.1 Clinical Pearl Localized swelling due to hemorrhage or infection is not edema.
Edema is often described relative to its mechanism of injury, location, and pathogenesis. There are several classifications of edema, including acute, mild, brawny, pitting, and lymphedema. This chapter focuses on peripheral edema, which is the edema that occurs in the extremities.
Biological Mechanism of Edema Formation There is normally a balance of fluid moving into and out of the vessels on a cellular level. This balance is based on Starling’s equilibrium, which refers to the movement of fluid across capillary walls and which is affected by hydrostatic pressure and oncotic pressure in the capillaries and in the interstitium. The movement of fluid is usually balanced so that there is a steady state in the sizes of the intravascular and interstitial compartments. Edema occurs when the balance is disrupted.2 If either the capillary hydrostatic pressure increases and/or the oncotic pressure is reduced, more movement of fluid from the intravascular to the interstitial spaces will take place.
Edema Related to Wound Healing One of the most important tasks of managing wounds and edema is identifying inflammation. Inflammation may be a sign of infection and presents as a localized area of softtissue redness and swelling. The area is often warm to the touch and painful. When an infection is suspected, the therapist should alert the physician immediately. In the presence
Fundamentals of Edema Management CHAPTER 8
of infection, therapeutic intervention should be paused until the therapist has clearance from the physician to continue treating. Physical agent modalities, manual edema mobilization, and many other treatments are contraindicated when there is infection.
Types of Edema Pitting edema is present when the pressure of a finger makes an indentation that persists after the finger pressure is removed. The indentation is not permanent; the depression slowly refills with fluid from the surrounding tissues. Pitting edema may be related to problems with the kidneys, heart valves, and low protein levels.3 It can also be caused by trauma, localized problems with the veins, pregnancy, and certain medications. This type of edema is often simply due to an accumulation of water and is easily treated with movement, cold modalities, elevation, and light compression. Nonpitting edema (also known as brawny edema) is firm to the touch because the tissue is fibrotic. When chronic, the skin in the involved area can become thickened and brown in color. Nonpitting edema is composed of fluid that is more protein-rich and static––making this type of edema more difficult to treat. Lymphedema is a condition that occurs when lymph fluid has difficulty draining properly due to damage or a blockage in the lymphatic system. This type of edema can be either pitting or nonpitting. The lymphatic network can be altered by infection, radiation therapy, surgery, parasitic infection, and trauma. With lymphedema, protein-rich fluid accumulates in the interstitial spaces of the skin and subcutaneous tissue. This condition is incurable but it can be managed with appropriate treatment. Manifestations of chronic lymphedema are abnormal skin changes and an increased risk of infection. Complications are more common in clients who are unable to obtain proper medical care.
Measuring Edema Edema can be measured using volumetry, figure-of-eight measurement, or circumferential measurement.1 Volumetry: This is a method of determining the volume of a hand or arm by immersing the limb in a container full of water and then measuring the amount of water that is displaced. Figure-of-Eight: This method of measuring edema utilizes a flexible tape measure. The therapist wraps the tape measure around the hand in a figure-of-eight pattern at specific anatomical landmarks. Circumferential Measurement: This method uses a flexible tape measure. The therapist wraps the tape measure once around the hand/limb in a circular pattern at specific anatomical landmarks. Volumetric measurement is considered the gold standard for measuring edema. Both the figure-of-eight and circumferential techniques are useful when it is not appropriate to immerse the limb in water (for example, if there is a wound). By placing a thin gauze covering over the wound, the therapist is able to obtain a measurement while protecting the wound. However, one of the problems with these two methods is that therapists use varying amounts of force when pulling the tape measure around the hand/limb. To address this problem, some therapists use a force gauge to standardize the force applied to the tape measure.
101
Clinical Pearl Edema can fluctuate due to factors such as activity level, time of day, and fluid retention. To most objectively measure changes in edema, try to have the same therapist measure the client at the same anatomical position, using the same measuring tool, at the same time of day.
Edema Management Edema can be treated using a variety of techniques including elevation, active range of motion (AROM), manual edema mobilization, compression, taping, and modalities. Elevation: Elevation of the limb is commonly recommended for individuals with upper extremity edema. Elevation helps because gravity assists with fluid drainage. The most effective position for upper extremity elevation is as follows: elbow higher than the shoulder, wrist higher than the elbow, and hand higher than the wrist. Additionally, the elbow should be more extended than flexed. This position for elevation should be used as long as it is not medically contraindicated. This sequential positioning pattern creates a pathway for fluid drainage. AROM: Active movement promotes fluid drainage and discourages the formation of adhesions. The type and frequency of AROM exercises should be customized to each client’s injury/ surgery and medical contraindications. Manual Edema Mobilization (MEM): This technique treats edema based on the anatomy and physiology of the lymphatic system. The lymphatic system is the only pathway for interstitial proteins to return to circulation and it is a key player in fluid homeostasis.4 Interstitial fluid persists due to protein molecules that attract water. At 6 to 12 days postinjury or surgery, these molecules are too large to be reabsorbed through the arteriovenous system. Therefore they must be returned through the lymphatic system. MEM includes light proximal-to-distal then distal-to-proximal mobilization of the skin done in specific patterns and segments, massaging over lymph node(s) proximal to the edema, and promoting flow in the anatomic direction of the lymphatic pathways. This facilitates the removal of excess fluid and interstitial protein molecules that continue to attract water if they are not recirculated.5 MEM can be very effective for clients with persistent edema following upper extremity trauma or surgery who have intact but overwhelmed lymphatic systems. It is not designed to be used with clients who have damaged lymphatic systems or for clients with primary lymphedema (a form of lymphedema not caused by another medical condition). Contraindications for MEM include infection, blood clots, congestive heart failure, renal failure, and cancer.6,7 Clinical Pearl When using hands-on techniques to reduce edema, use very light pressure (just enough pressure to gently move the skin). Deep or heavy massage pressure collapses the lymphatic network and is counterproductive or even injurious.
Compression: External compression provides counterpressure and compensates for the lack of elasticity in edematous tissues and thereby improves circulation. Compression helps
102
PART 1 Fundamentals
reinforce tissue hydrostatic pressure and facilitates venous and lymphatic flow. Using compression in the acute phase of healing is thought to limit the amount of space available for excess fluid to accumulate during the fibroblastic phase of healing. Compression is thought to decrease the fibroblastic synthesis of collagen by decreasing blood flood. This in turn causes local hypoxia, slowing down the development of scar tissue and fibrosis. In the later stages of healing, compression assists with edema management by reducing net filtration. Compression wrapping of brawny edema softens fibrotic connective tissue and scar tissue. Contraindications to the use of compression include severe arterial insufficiency, deep vein thrombosis, heart failure, uncontrolled hypertension, severe peripheral neuropathy, and active tuberculosis. Be aware that compression that is too tight actually damages the lymphatic system. A well-fitted compression garment promotes light skin traction during active movement, and this stimulates lymphatic flow. If creases are still visible in the skin 20 to 30 minutes after removing an edema glove or elastic tubular stockinette, then the compression is too tight and a looser-fitting garment should be used.
Types of Compression Edema Gloves: Edema gloves provide gentle compression. These gloves are typically fabricated from nylon and spandex. The glove should provide 15 to 25 mm Hg pressure in order to stimulate the superficial lymphatic system, promoting edema reduction. Custom and off-the-shelf gloves in various sizes are available. Gloves should be designed to extend only to the middle phalanges to allow sensory input and integration of the hand into activities of daily living. It is very important that gloves not be too tight, especially at the distal edges, as this can cause worsening of distal edema. Elastic Tubular Stockinette: Elastic tubular stockinette provides gentle compression. It is made of a cotton/rayon blend with rubber latex yarn. Caution should be used with clients who have latex allergies. The elastic tubular stockinette can be cut to size. Edema gloves and elastic tubular stockinette are reusable. Clients can wash the garments with warm soapy water and then air-dry them. These garments are often used for general edema, burns, strains, sprains, and soft-tissue injuries. Elastic tubular stockinette can be worn in combination with an edema glove. It is common practice to give the client two pairs of edema gloves and two sets of elastic tubular bandages, one to wash and one to wear. It is important to closely monitor the skin for marks indicating that the garments are too tight. A safe guideline is that therapists should be able to get their finger inside a tubular sleeve. If you can’t, it is too tight.6,8 String Wrapping: String wrapping is an outdated edema management technique that is still sometimes used and therefore deserves to be mentioned. It was originally thought to be a way of using distal to proximal compression to move edema out of the hand. However, we now know that the terminal portion of the lymphatic system is very delicate. Too much pressure, such as the pressure used with string wrapping, damages the lymphatic tissues. For this reason, string wrapping should not be used. Short-Stretch Bandaging: Short-stretch bandages stretch 20% of their original length. In this way they differ from ACE elastic bandages, which stretch 140% to 300% of their original
length. Short-stretch bandaging is a compression technique used to manage lymphedema. It is also used in manual edema mobilization. The techniques of use exceed the scope of this chapter, but readers are encouraged to pursue outside information about the use of short-stretch bandaging in the treatment of edema. Kinesiology tape: Kinesiology tape can be applied to increase lymphatic and vascular flow, thereby reducing edema and diminishing pain. The tape is thinner and more elastic than conventional tape and can be stretched 120% to 140% of its original length. Kinesiology taping is designed to raise the epidermis, reducing the pressure on the mechanoreceptors below the dermis. This is proposed to reduce pain. Kinesiology tape is reported to have a beneficial effect on lymphatic and venous circulation by raising the epidermis, thereby decreasing the pressure in the dermis and promoting lymphatic drainage through its mechanical action during movement. The theory is that when applied on stretch, kinesiology tape can lift the skin away from the muscle, creating space between the layers of fascia. Blood vessels, lymphatic vessels, and certain nerves are found in the fascia. By lifting the skin away from the muscle, kinesiology tape changes the pressure differential underneath the skin, allowing for improved perfusion of the area with ground substance, which includes the water and proteins responsible for the lubrication and nutrition of the connective tissue cells. Contraindications include allergic reactions to adhesive tape, open wounds, presence of a deep vein thrombosis, infection, peripheral neuropathy, and active cancer.9 Contrast Baths: It has been suggested that contrast baths produce a “pumping effect” contributing to edema reduction. The rationale provided is that contrast baths may help reduce pain and stiffness by activating vasodilation and vasoconstriction via muscle contraction.10 However, a randomized controlled study of contrast baths on patients with carpal tunnel syndrome did not find any significant effect on hand volume with use of contrast baths.11 A systematic review of the effectiveness of contrast baths concluded that although its use may increase the temperature of skin and blood flow superficially, there was conflicting evidence on its effect on edema.12 Contraindications for use of contrast baths include open wounds, poorly controlled epilepsy, hypertension, and diabetes. Intermittent Pneumatic Compression (IPC): IPC is often a modality of choice for treating lymphedema. It can also be effective for reducing posttraumatic edema, especially in the inflammatory phase of healing.13 The pump consists of a sleeve with multiple pressure compartments that encompass the entire limb. Once placed on the extremity, the chambers of the pump are sequentially inflated, working distal to proximal. This sequential compression moves the edematous fluid into the lymphatic system, which in turn pushes the venous blood proximally. The pumping motion encourages normal circulatory action by stimulating extracellular drainage and fluid clearance. Contraindications include congestive heart failure, deep vein thrombosis, inflammatory phlebitis, a history of pulmonary embolism, active infection, lymphangiosarcoma, and nonhealed fracture. Electric Stimulation: Muscle contractions are imperative for lymphatic flow. When a client is unable to perform effective active muscle contractions to assist in the drainage of the lymphatic and venous systems, electric stimulation can be helpful. Muscle contractions stimulate venous and lymphatic circulation. Current intensity must be high enough to elicit a muscle contraction. The client should be encouraged to actively contract their muscles simultaneously with the electrical stimulation. Treatment
Fundamentals of Edema Management CHAPTER 8
time is usually 20 minutes, with a cycle of 5 seconds on and 5 seconds off. High-voltage pulsed current and medium-frequency alternating current are commonly used. Contraindications are pregnancy, cancer, cardiac pacemaker or other implanted electrical stimulators, active tuberculosis, thrombophlebitis, thrombosis over the carotid sinus, and active hemorrhage.14 Cryotherapy: Cold therapy is often beneficial for the reduction of acute edema, especially in the inflammatory phase of healing. Cold therapy includes ice packs, gel wraps, and cold-water baths. Physiological exposure to cold activates vascular permeability, promotes vasoconstriction, and reduces local blood flow. This in turn decreases prostaglandin synthesis and histamines, thus reducing swelling and pain. Contraindications include but are not limited to
103
deep vein thrombosis, thrombophlebitis, impaired sensation, nerve regeneration, impaired circulation, and chronic wounds.1
Summary This chapter has presented a selection of techniques commonly used to treat edema. Elevation and appropriate active movement are very powerful methods to prevent and reduce edema. Edemareducing modalities are an adjunct to treatment and must be selected cautiously using sound clinical reasoning. Edema control is key to successful clinical outcomes and should be among the highest of priorities in the hand therapist’s plan of care.
References 1. Villeco JP: Edema: Therapist’s management. In Skirven TM, Osterman AL, Fedorczyk JM, Amadio PC, editors: Rehabilitation of the hand and upper extremity, ed 6, Philadelphia, PA, 2011, Elsevier Mosby, pp 845– 857. 2. Fauci AS et al: Harrison’s principles of internal medicine, ed 18, New York, NY, 2012, McGraw Hill. 3. Colditz JC: Therapist’s management of the stiff hand. In Skirven TM, Osterman AL, Fedorczyk JM, Amadio PC, editors: Rehabilitation of the hand and upper extremity, ed 6, Philadelphia, PA, 2011, Elsevier Mosby, pp 894–921. 4. Levick JR, Michel CC: Microvascular fluid exchange and the revised starling principle, Cardiovasc Res 87:198–210, 2010. 5. Artzberger SM: Hand manual edema mobilization: overview of a new concept in hand edema reduction, SAJHT 1:1–6, 2003. 6. Artzberger S: Edema reduction techniques: a biologic rationale for selection. In Cooper C, editor: Fundamentals of hand therapy: clinical reasoning and treatment guidelines for common diagnoses of the upper extremity, ed 2, St. Louis, MO, 2014, Mosby, pp 35–50. 7. Artzberger SM, Priganc VW: Manual edema mobilization: an edema reduction technique for the orthopedic patient. In Skirven TM, Osterman AL, Fedorczyk JM, Amadio PC, editors: Rehabilitation of the hand and upper extremity, ed 6, Philadelphia, PA, 2011, Elsevier Mosby, pp 868– 881.
8. Villeco JP: Edema: a silent but important factor, J Hand Ther 25(2):153– 162, 2012. 9. Bassett KT, Lingman SA, Ellis RF: The use and treatment efficacy of kinaesthetic taping for musculoskeletal conditions: a systematic review, N Z J Physiother 38(2):56–62, 2010. 10. Stanton DEB, Bear-Lehman J, Graziano M, Ryan C: Contrast baths: what do we know about their use? J Hand Ther343–346, 2003. 11. Janssen RG, Schwartz DA, Velleman PF: A randomized controlled study of cointrast baths on patients with carpal tunnel syndrome, J Hand Ther 22:200–208, 2009. 12. Stanton DEB, Lazaro R, MacDermid JC: A systematic review of the effectiveness of contrast baths, J Hand Ther 22:57–70, 2009. 13. Zaleska M, Olszewski WL, Jain P, et al.: Pressures and timing of intermittent pneumatic compression devices for efficient tissue fluid and lymph flow in limbs with lymphedema, Lymphat Res Biol 11(4):227– 232, 2013. 14. Shapiro S, Ocelnik M: Electrical currents for tissue healing. In Cameron MH, editor: Physical agents in rehabilitation: from research to practice, ed 4, St. Louis, MO, 2013, Elsevier Saunders, pp 267–272.