edema management spaces - liveconferences.com · pitting edema 18 pitting edema. 4 19 edema

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Edema management

Exploring Hand Therapy

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Definition

Excessive fluid that is accumulated in the intracellular spaces

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Inflammatory response

Series of nonspecific events for protectionRedness, swelling, heat, pain & loss of function

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Edema

Affected by vascular and nonvascular process

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Anatomy

extracellular fluidFluid is subdivided into two main areas:

Interstitial fluidOutside the closed vascular system

Blood plasmaNon-cellular portion of the blood

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Arterial system and venous system

Arterial system Brings oxygen Venous system gets rid of waste and carbon dioxide

Oxygen and carbon dioxide are lipid-soluble substances (allowing diffusion through membrane)

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Diffusion and filtration

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Capillary – everywhere and close to every cell

Capillary wall is a single layer of high permeable Surrounded by a basement membraneDiameter is large enough for red blood cells and other blood cells to pass Blood enters the capillaries through the arteriolesBlood exists through the venules

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Transport

oxygen and glucose are in higher concentration in the blood stream vs the interstitial fluid interstitial fluidCarbon dioxide will diffuse in opposite directionProteins too large to diffuse easily through the capillary membrane --flow linear along the capillary

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Transport

small amounts of proteins leak out of the blood capillaries into the interstitium….balance … so the lymphatic system’s job is to return the proteins back into the venous system.

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Anatomy

Interstitium space between cells and the fluid between the cells)Constant exchange of fluid between the intercellular tissue and blood plasma across the capillary membrane.Fluid in the interstitium is trapped by proteoglycan filaments

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Tissue GEL

Similar to blood plasma Poor viscosity in the tissue gel

Water molecules, electrolytes, nutrients and cellular waste

Normally <1% of “free” fluid in gel

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When edema occurs 30% - 50% accommodates

Cannot accommodate additional fluidAmount of free fluid increases and may even expand to more than ½ of the interstitial fluidInterstitial fluid can increase to several hundered % above normal (severely edematous)

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Types of edema

Pitting (interstitial)Fluid that is “free” moving and can be displaced with pressure

Brawny (interstitium)Fluid becomes clotted with fibrinogenDifficult to move and firm to touch

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Lymph (extracellular) (Failure of lymphatics)

Protein rich fluid in the extracellularspace and subcutaneous tissue and a blockage of lymphatics and a failure to drain

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Edema

Pitting edema

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Pitting edema

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Edema

Brawny edema --interstitium becomes clotted with fibrinogenThe fibrinogen inhibits the fluid from moving easilyTissue cells will swell

Normally the interstitium will swell

Brawny edema is firm to the touch

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Healthy Capillary Filtration --

Net filtration across the capillary membrane is a balance b/w the forces that push fluid out into the interstitial spaces (filtration)And the force that moves fluid inward (resorption).

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Healthy Capillary Filtration (cont)

Filtration pressure is higher than the reabsorption pressureLymphatics balance

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Fluid Filtration and resorption depends on the capillary walls

Pressure acting on the capillary membraneCapillary permeability is selective

Affected by pressuresConcentrations Integrity of membraneCapillary pressure is increased

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4 pressures that effect capillary filtration

Capillary pressure (hydrostatic)Blood pressure in capillary –Pressure increased at arterial end vsvenous end of capillary

Interstitial fluid pressure (hydrostatic)

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4 Pressures continued

Plasma colloid osmotic pressureDissolved proteins causing osmosis of fluid

Interstitial fluid colloid osmotic pressure

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Edema in the Hand

Afferent blood flows on the volar surfaceControlled by arterial blood pressure

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Any constriction across the dorsum of the hand can damage vessels resulting in edema or lymphedema

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Circulatory system

ArteriesArteries are blood vessels that carry oxygen rich blood AWAY from the heart. Remember, A A Arteries Away, A A Arteries Away, A A Arteries Away.

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CapillariesCapillaries are tiny blood vessels as thin or thinner than the hairs on your head. Capillaries connect arteries to veins. Food substances (nutrients), oxygen and wastes pass in and out of your blood through the capillary walls.

VeinsVeins carry blood back toward your heart.

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Hand Position

15mmHg with elevated hand35mmHg dependent position

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EdemaActive motion -- “retrograde” venous and lymphatic flow.

augment the return flow by moving the elbow and shoulder (proximal)AROM and compression

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Edema treatment depends on the stage of wound healing

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Inflammatory response -3 to 5 daysGoal is for body to protect

Vasoconstriction followed by Vasodilation(dilation of blood vessels)Stimulated by histamine & bradykinin(other chemicals as well) (increases capillary permeability)Increase blood supply to damaged areaCausing the redness, increased temperature increasing white blood cells, increasing vascular permeability

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Inflammatory response

The body protects itself and the blood, clotting factors, fluids move into the injured area And EDEMA or swelling occurstransudate

Water and dissolved electrolytes

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Treating Edema (tranudate)

ElevationCold – pain control and to help balance system

To decrease vasodialtion and membrane permeability, control capillary infiltration, and arterial blood flow

Active motion (Gentle)Minimal –

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Pain controlrestGoal minimize the pooling of blood in injured areaExcessive edema can slow wound healing by decreasing arterial, venous and lymphatic flow

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Edema

Pain is caused by:Swelling on never endingsNerve endings exposed to bacteria

Aspirin decreases pain by inhibiting the production of prostaglandins).

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Lymphatic system

Draining fluid, proteins, lipids, microorganisms and debris from tissueReturn proteins to bloodvolume of interstitial fluidbalance of protein and fluid pressure

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Edema

increased volume of lymph, and it may accumulate in the tissues and distend them. This condition is known as edema. The lymphatics are intact therefore most edema is temporary

As tissue heals the blood vessels do not excessively leak controlling edema

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Edema

Although edema is temporary the overload may produce fibrosis causing the edemaprevent the lingering edemaMacrophages help to eliminate protein as well

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Edema: Proliferative stage (2 -6 weeks)

Viscous due to increased protein contentExcessive fluid is referred to as EXUDATEFibrosis and thickening of tissueShortening of structuresVicious cycle resulting in Dense Fibrous Tissue

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Fibroplasia phase (concern for us)

ongoing problemFluid is more viscous (increased protein)Edema is now referred to as exudatewhich protein rich excessive fluidfibrosis & thickening of tissues

Reduced nutrition and inelasticity

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Treatment in proliferation phase

Decrease fluid accumulationCompression accompanied with elevation, AROM

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Brawny edema

Occurs in this phase of wound healing especially if the colloid osmotic pressure is increased (due to increase in proteins) resulting in higher capillary pressureClotting occurs preventing expulsion of fluid

Resulting in brawny edema

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Edema: Maturation Phase ( up to 2 years)begins when fibroplasia subsides

Remodeling is accomplished by STRESS being placed on collagen fibersFibrosis may occur (persistent – stagnant edema)Elevated protein contentStretching of tissue spacesMay become hard, thick and brawnyLasting longer than 3 months is chronic

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Maturation phase

Persistent edema requires continued use of compression garments as Worst case scenario arterial flow is impaired as well as metabolic circulation and cellular nutrition… necrosis of tissue can occur

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Prevention

Begin as soon as you see your patientYou cannot see the beginning of edema30% of interstitial fluid volume is not visible50 ml of fluid in hand may accumulate before seen

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Preventing EDEMADressing

Post surgery: BulkyCold

Inflammatory stage: Vasoconstriction, reducing metabolic rate, arteriolar blood flow, capillary infiltrationGood control for painCAUTION: do not use if arterial compromise

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PreventingElevation

Inflammatory phase or immediately after injury or surgeryEasy, cheap, controls painHelps prevent dependent edemaCombines w/gentle AROM increases pumping and decreases fluid accumulation assisting lyphatics and venous systemsReplant limb must NOT be elevated above heart

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Goal of Elevation

Facilitating venous and lymphatic drainageDecreases hydrostatic pressure in blood vDecreases capillary pressure

Peripheral venous and arterial pressure affected by gravity (pressure decreased if above the heart)Dependent edema:

Increases intravascular pressure and capillary pressure

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Edema/ elevate with finger ext

Plumbing

Photo from Interactive Hand: Primal 2001 54

Active Motion

Pumping, soft tissue movement, compression of veins and lymphatic vStrong muscle action assist in drainage of venous and lymphatic vCaution

Excessive exercise and no isometric

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AROM entire limb

Prevent adhesionInclude proximal muscles to increase distal drainageTENDON gliding

Heat

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Compression

Proliferation & Maturation stageMaintain gains made in edema reduction by reducing capillary filtrationReinforce tissue hydrostatic pressure and increases venous and lymphatic flowContraindicated with arterial compromise, new skin grafts or unhealed burn woundsMust teach patient to monitor for capillary flow (color, cool, numb)

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Compressive bandages – important in fibroplastic phase

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DEMO

JunoJobstCoban/CowrapOff the shelfWrap

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Compression therapyLight support – Fashion hosiery, Jobst, Sigvarus

8-14mmHg Antiembolism compression

16-18 mmHgLow compression – venous insufficiency

18-24 mmHg – dependent edema – not very active

Low to moderate – venous insufficinecy25-35 mmHg able to participate in rehabilitation

Moderate compression30-40 mmHg

High compression – pumps, jobst (vairox jobst)40-50 mmHg (edema from 60

Compression therapy

Decrease fibroblast synthesis of collagen

Decreasing blood flow and causing local hypoxiaGoal is for the compression to apply pressure to mechanically FORCE fluid out of the tissue

Fibroplastic PhaseIn the maturation phase goal is to help maintain the gains achieved in clinic with edema reduction by reducing capillary filtration.

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Isotoner gloves

Therapeutic glovesControl edema

Arthritis, injury, CRPS, raynoids,

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Isotoner®Really nice– lightweight spandex and nylon allows for an even gentle compression in the moderate compression range : 23-32mmHgWhat is really nice is the soft, seamless construction and this is nice because it minimizes or eliminates the pressure marksThis glove is designed without a seam at the base of the thumb.A regular glove always has that seam circle around the bottom ofthe thumb which can cause pressure marks. You can see the Isotoner glove extends the seam down to avoid this area. I have never seen any other gloves that are designed this way -Edema -- wear all day & night and the Isotoner are comfortable and effective

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Isotoner® ORDERING information

Therapist ordering Info:Sammons Preston- 800-228-3693

www.sammonspreston.com

North Coast Medical- 877-231-9300www.ncmedical.com

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Isotoner®Patient/consumer Ordering info

Patient’s may order direct from Isotoner513-682-8240

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Compression for edema

Using bandagesDown side is bulky and limits the NORMAL use of the hand

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Retrograde Massage

Goal: Remove edema from the limbMay help with removal of lymphatic fluidContinuous pressure of massage can decrease interstitial fluidHelp decrease adhesionMobilize tissue fluid

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Vibration

To soften scars and the formation of scarsMinimize adhesions

Soften tissue

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CPM

Post op patientsStiff hand

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Electrical Modalities

HVPC

Maturation phaseStralka et el Avoid or be very careful in inflammatory phase as the muscle contraction can increase vasodialation and clotting time

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NMS

Research has shown to decrease edema even in flaccid hands

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LASER

The effects of LLLT are photochemicalRed and near infrared light can affect cell membrane permeability and aid the production of ATP thereby providing the cell with more energy Cell will be at a better or an optimum condition to begin the natural healing process.

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LASER

When using LLLT for edema we usually treat it locally… meaning Laser light irradiates the local affected areaThe treatment technique depends on the depth of the tissue.

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LASER

Improved microcirculationDilation of lymphatic vesselsReduction in the permeability of blood vesselsTreat proximal to the edema first to open the blood flow –

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LASER

If edema present 2-4 J to the effected area and proximal to area and somethimes up to 10-15 J with a GaAlAs laser

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Intermittent compression

Help remove by products

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Instrument Assisted Mobilization

Graston Technique(VIDEO)

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Trigger points

Soft tissue restrictions that prevent muscles from working normally

Can treat with LLLT and massageOpen the venous and lymphatic system

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SCAR

Mobilize around the scarBegin to stimulate or clear and flow proximal to scar or blocking area

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Manual Edema – Myofascial approach

Used in conjunction with other treatmentsMassage, passive stretchElongate and release the tightness or restrictionsGoal is to gain symmetrical balance of the restricted asymmetrical stress

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Edema Mobilization

Case by case Rationale to choosing technique/modalityWhat exercises will compliment edema mobilization and continue to rehabWhat should you avoid or put on holdWhat will be a good adjunct to treating edema

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Manual edema mob and Manual Lymph drainage

The term of manual lymph drainage was produced by Dr. Vodder in 1932MEM is taught by Sandra Artzberger and founded from Australian backgroundsThe Vodder technique is using the lymphatic pathways to reroute blocked fluid while the MEM is used to stimulate lymphatic flow but recommends certification for lymph drainage to treat patients with lymph node removal

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Manual Edema Mobilizationor Mobilizing EDEMAStimulate the venous and lymphatic system to absorb excessive fluidPrinciples of Manual lymphedema treatmentCompression bandagesExercise

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Artzberger

Sandy Artzberger developed specific MEM methods in the mid 1990sSandy offers continuing education courses to help prefect your methods

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Contraindications of MEM or Edema Mobilization

Cardiac or pulmonary status

CHF, if in doubt consult physicianInfectionAreas of inflammation

MEM proximal to area of inflammationActive cancerRenal failurePrimary Lymphedema or post mastectomy lymphedema

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Principles of MEM

Light pressure (14-25 mmHg)Pre-exercise & post exercise (PRN)Segments (proximal to distal: distal to proximal)

Lymphatic pathwaysSelf massageLow stretch compression bandaging Compression techniques

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Rationale

Stimulate collectors to open/close Initial lymphatics have no pumping mechanism needs stimulatedProximal muscle stimulation increases transportExercise to help stimulate the lymphatic system and increase transport by 10X

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Rationale

Massage nodes (elbow, neck) to help with uptake

Nodes can get “kinked” or are like a “bottle neck”Stimulate to increase effectiveness of nodes

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Method

Start proximalStimulate the neck and upper armElbowHand

First dorsal interosseous spaceDorsum of handPalm: lateral/distal Digits (lateral flow and clear to dorsum of hand)

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Method

Perpendicular stretch

StrokeLight stroke

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Home Massage

Important component to treatmentHave the patient demonstrateThis is self massage they can do independentlyNO CREAM

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Persistent edema

retrograde massage try the MEM or myofascial therapy. This should helpYou will want to stop heat modalities and modify

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Compression Therapy

Works with exercise to facilitate movement of excess fluid from extremity40mmHg is recommended for persistent edema if the patient is able to exercise or if L.E. walkWrapping (vicki darlington)

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Thank you and now we are going to end our talk with Vicki Darlington.

Vicki Darlington, OTR/L,CHT,CLT. has been an occupational therapist for 25 years, & has worked in St. Petersburg,Flher entire career. She graduated the SUNY at Buffalo, NY. She is the Director of The OT/Hand Therapy department @ The Rehabilitation Institute of Edward White Hospital, St. Pete Fl for the past 8 years.

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An Introduction to the Assessment and Managementby Vicki Darlington

of Lymphedema in the Upper Extremity

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Introduction

The lymphatic system is mentioned while studying human anatomy but I don’t recall ever discussing it in OT school.

This course will be a very brief overview. It is presented with the hope that you will be interested enough to pursue certification.

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Treatment of Lymphedema

Certification as a lymphedema therapist is a 2 ½ week course. These techniques can guide you to facilitate lymph flow in a swollen upper extremity.However, I highly recommend becoming certified before working with lymphedemapatients on a regular basis.

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Definition of Lymphedema

The swelling of a body part ,usually an extremity that is caused by an abnormal accumulation of protein rich fluid and water due to a low volume mechanical insufficiency of the lymphatic system, (The transport capacity (TC) of the LS falls below the lymphatic Load (LL). (fig. 1)

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Lymphatic System

Clears interstitial spaces of excess fluids,cellular debris,protein molecules and (long chain fatty acids –only in the intestines).

These are substances that are not reabsorbed by the venous end of the blood capillaries from the tissues.

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Anatomy of Lymphatic System

The lymphatic system is a one ended system, starting as dead-end vessels in the connective tissues and ends in the venous system. It is an accessory route by which lymph fluid can flow from the tissue spaces into the bloodstream.

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Before reaching the venous circulation,lymph fluid travels through successive lymph nodes,thereby filtering impurities from the lymph fluid.The cardiovascular system is closely associated with the lymphatic system.

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How do both systems compare?Both have superficial and deep organ systems.Similar vessel structureCommon pathways to the heartProtect the body from infection and disease.

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The main differences between the two systems:

The LS is not a closed circulatory system. When speaking of the movement of lymph fluid it is called lymph transport , not circulation.There is no central pump to the lymphatic system.The lymph transport is interrupted by lymph nodes.

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Anatomy of the LS

The LS is divided into superficial and deep layers and is separated by fascia.The superficial (suprafascial) layer is responsible for drainage of the skinand subcutaneous tissue.The deep LS drains the lymph from muscle tissue,tendon sheaths,nervous tissues,periosteum and joint structures.

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Anatomy of the LS

The transport vessels of the superficial system are embedded in the subcutaneous fatty tissue.Deep transport vessels generally accompany blood vessels and are grouped together with them in the same membrane. Perforating vessels connect the deep with the superficial,

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Components of the LS

The LS consists of lymph vessels,which absorb and transport lymph fluid, and lymphatic tissue.Once the interstitial fluid enters the LS, it is called lymph.Lymph fluid is composed of protein water,cell debris, lymphocytes,a few erythrocytes (absorbed fatty acids –only in intestinal lymph called chylus).

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Lymphatic vessels are found in all areas with a blood supply with the exception of the CNS,nail tissue, cornea or hair.Lymphatic vessels are categorized as lymph capillaries, precollectors, lymph collectors and lymphatic trunks.

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The main purpose of lymph capillaries is lymph formation or the absorption of the lymph fluid into the LS.The main purpose of the pre-collectors are to transport lymph fluid from the capillaries to the lymph collectors.

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Lymph collectors are responsible for draining lymphatic fluid from certain body areas, called tributary or drainage areas. Each lymph collector has a section between a distal and proximal valve, which is made up of smooth muscle and is called the lymph angion.

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The valves allow the fluid to travel in the proximal direction only . The lymph angions allow the lymph fluid to travel by contracting. The frequency of contraction is determined by autonomous regulation of the SNS.

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This leads to Lymphangiomotoricity the safety factor of the LS.This is the ability to react to an increase in lymph formation by an increase in contraction frequency.This ability is used to our advantage in manual lymph drainage,diaphramaticbreathing and mm pumping (exercises).

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Most drainage areas of the superficial LS are subdivided into lymphatic territories.Lymphatic territories consist of several collectors which transport fluid into the same group of regional lymph nodes.

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Lymphatic territories are separated by lymphatic watersheds.Collectors on the extremities parallel the watersheds.Collectors on the trunk tend to originate at the watersheds.

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Figure 2

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Lymph collectors transport the lymph fluid from superficial, deep and organ systems to the lymphatic trunks, which then forward the lymph to the venous angles.(see figure 117)

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Lymph tissues are a framework of dense nodules within connective tissue or as aggregations of lymphoid cells enclosed in a capsule which are lymph nodes,spleen and thymus.

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Lymph nodes have 3 main functions.Protective function- filtering harmful material(cancer cells,pathogens,dust and dirt).Immune function-produce antibodies(lymphocytes which are white blood cells that attack foreign invaders).

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Thickening of lymph fluid-thereby reducing the amount of lymph returning via the thoracic duct into the venous system.A set number of lymph nodes is present at birth. They do not regenerate or vanish.

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Lymphatic Watersheds

Represent linear areas on the skin that separate territories from each other and contain relatively few lymph collectors. (see fig. 4)1. Sagittal Watershed- divides the lymphatic drainage of the head, neck, trunk and external genitalia into equal halves.

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Upper Horizontal Watershed- separates the neck and shoulder territory from the territories of the arm and thorax. It runs from the jugular notch (manbrium) running laterally to the acromion, and continues posterior to the vertebral levels between C7 and T2.

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Transverse Watershed-starts at the umbilicus and follows the caudal limitation of the rib cage to the vertebral column. This watershed separates the upper from the lower territories on the trunk.

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Congested lymph fluid causes the lymphatics in the affected area to dialate. The greater resistance in these dialatedcollectors and precollectors forces the lymph back into the lymph capillaries and across the watershed.

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Inter-territorial Anastamoses

This abnormal dialation may eventually result in valvular insufficiency which leads to a retrograde flow of lymph from the congested territory to an adjacent territory free of edema.These pathways are known as Interterritorial Anastamoses.(see Lymphetic pathways)

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AAA(Anterior Axillo-Axillary)-Thisconnection is found between the right and left upper quadrants.collectors here create a connection between the contrlateralaxillary lymph node groups on the anterior side of the trunk.(see Lymphatic pathways)

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AI(Axillo-Inguinal)- the collectors of the ipsilateral upper and lower quadrants connect the axillary and inguinal lymph node groups on the same side.PAA(Posterior Axillo-Axillary)-Theconnection between the contrlateralaxillary lymph nodes on the posterior side of the upper quadrants.

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AII ( Anterior Inter-inguinal )-is located over the mon pubis area and connects the contralateral inguinal lymph nodes on the anterior lower body quadrants.PII ( Inter-inguinal) – collectors forming this anastamosis are found on the sacramand connect the contralateral inguinal lymph nodes groups on the lower body quadrants. (Lympathetic pathways)

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Lymphatic Drainage of the UE

Lymph vessels of the UE are divided into deep and superficial layer. Connections are found between the two layers in both directions. The regional lymph nodes for both layers are the axillary lymph nodes.

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Collectors of the hand-A pair of collectors run on the sides of each digit and incline backwards to the dorsum of the hand.(Fig. 5&6)From the palm, collectors transverse in different directions. Collectors belonging to the mesothenar territory drain the central palmar plexus.

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It runs on the volar side between the thenar and hypo-thenar eminence upward to form the medial forearm territory.The radial hand territory drains the radial border of the palm,the web space between the index and thumb, and the thenar eminence.

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Ulnar hand territory-drains the ulnar border of the palm,the hand and the hypothenar eminence.All of these collectors pass around to join the collectors on the dorsum of the hand and go to the dorsum of the wrist.The lymph vessels then join the collectors of the forearm.

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Collectors of the forearm- the collectors in this area are separated into the radial, ulnar and and median territories.They converge accompanying the cephalic and basilic veins and converge together in the antecubitalarea.

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There are antecubital lymph nodes.Collectors from the forearm continue to travel to the axillary lymph node group along the medial upper arm territory.- it is located between the biceps and the triceps on the medial upper arm muscles.

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Lateral upper arm territory- is responsible for drainage of the skin on the dorsolateralupper arm and shoulder. Its collectors drain partly into the axillary and supraclavicular lymph nodes.

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Manual Lymph Drainage

In order to drain an edematous upper extremity, the watersheds and anastamoses become important areas to work. The movements are very light, only to skin stretch.Due to our time contraints ,every massage technique can not be covered.

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Manual techniques that are designed to increase the flow of lymph and the interstitial fluid.The basic hand positions of MLD are adapted to the anatomy and physiology of the LS.Trunk work precedes arm lymph drainage in order to facilitate lymphangiomotoricity that was discussed previously.

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There are many different strokes. The strokes used only apply light pressure.

The sequence of strokes consist of a working and resting phase.

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Due to the high viscosity of the lymph fluid, the working phase lasts at least 1 second. To adequately stimulate the lymph collectors to contract, the strokes should be repeated 5-7 times in one area.

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Direction of strokes depends on the direction of lymph flow. If an area is congested due to surgery ,trauma or radiation , it will be necessary to redirect the flow of lymph towards areas of sufficient lymphatic pathways.

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Principals of treatment: the areas that are closest to the venous angle are stimulated first, which allows the drainage of more peripheral areas.In the UE , treatment begins proximally and continues to the distal region. Regional lymph nodes are treated first.

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Basic Strokes

1. Stationary Circles- are used mainly at lymph node groups, therefore the axillary and antecubital lymph nodes.

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Basic Strokes

Pump- Circle shaped stretching of the skin with the entire palm. Used in the extremities. Can be stationary or dynamic.

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Basic Strokes

For our limited time here today we will only cover stationary circles and pumps on the UE and associated watersheds, and anastamoses. There are several strokes yet, will not be covered today.Before starting lab, there are contraindications to MLD and compression bandaging that must be mentioned.

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Contraindications to MLD

Acute infections (Cellulitus)Cardiac or pulmonary edemaAcute BronchitisAcute DVTAnticoagulantsHemopheliaDeep variscosities

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Contraindications to MLD

Consider patients present cardio-pulmonary status. If the limb is 80-mlgreater in volume from the other extremity: Could moving this much fluid into the heart and lungs compromise the patient’s cardiac status?

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Contraindications to Compression Bandaging

Acute infectionsCardiac edemaArterial diseasesRSD/CRPSRaynaud’s DiseaseSpasticity

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Basic Strokes

Stationary Circles-Applied mainly at the lymph node groups.Circle shaped stretching of the skin with the palmar surface of the fingers or the entire hand.Working phase-the pressure increases for about a ¼ of a circle using radial or ulnar deviation of the wrist. (stationary circles)

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MLD Techniques for LUE1. Massage open pathway from L armpit to R armpit across top of chest- 5 times.2.Massage lymph nodes in R armpit using circular upward motion-5 times.

3.Massage down L side of body from L armpit to L crease of thigh-5 times. 4. Massage lymph nodes in L groin area,along crease of thigh ( upward circular motions)-5 times

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MLD technique continued

5.Massage outer upper L arm from elbow to top of shoulder,stretchingupward-5 times.6.Massage inner upper L arm going across to outer arm in sets of 2-3,working

from elbow up to inside of armpit,pushing to outside of arm (each set 5 times.

Repeat #5 (2 times)7. Massage L forearm both top/bottom pushing upward,thenmassage top of hand & fingers-5 times

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MLD techniques for RUE

1. Massage open pathway from R armpit to L armpit across top of chest- 5 times.2.Massage lymph nodes in L armpit using circular upward motion-5 times.

3.Massage down R side of body from R armpit to R crease of thigh-5 times.4. Massage lymph nodes in R groin area,along crease of thigh ( upward circular motions)-5 times

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5.Massage outer upper R arm from elbow to top of shoulder,stretchingupward-5 times.6.Massage inner upper R arm going across to outer arm in sets of 2-3,working from elbow up to inside of armpit,pushing to

7. Massage R forearm both top/bottom pushing upward,then massage top of hand & fingers-5 times

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Basic Strokes-stationary circle

Resting phase-the hand is relaxed and maintains contact with the skin.Can use both hands or one. Can be done at the same time or with alternating hands.Think of a clock ,directing pressure towards 12 and perpendicular/directional stretch towards 3 o’clock.

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Basic strokes

PUMPApplied mainly at extremities. A circle shaped stretching using the entire palm.Working Phase- the hand is put in palmar flexion and ulnar deviation, the thumb is in opposition of the fingers.

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Basic strokes-Pump

During the transition into radial deviationand wrist extension, the pressure increases smoothly.Resting Phase- The hand relaxes and goes back into palmar flexion and ulnar deviation.(Fig.8)Can be done with one or both hands alternating.

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Direct Lymph Flow

Pumps across AAA to unaffected side.(5-7 times)SC’s to healthy lymph nodes(5-7 times)Dynamic SCs down affected side of body from arm pit to inguinal lymph nodes.Dynamic SCs to affected inguinal lymph nodes(5-7)

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Direct Lymph Flow

Pumps on outer upper arm (affected) from above elbow to top of shoulder in upward motion (5-7).Dynamic SCs inner upper arm starting at

elbow, going across towards outer arm in 2-3 sets ,going up to arm pit region (5-7)

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Direct Lymph Flow

Bilateral SCs using thumbs at antecubitalLNs.Pumps bottom then top of forearm (5-7)Bilateral thumb SCs to volar aspect of hand,mini scs with thumb & index to each digit,then to dorsal aspect of hand (5-7)

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Direct Lymph Flow

Repeat (5-7) times to axillary lymph nodes on affected side.

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Compression Bandaging

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Relevance in Hand Therapy

Techniques appropriate forInflammatory edema which results from

trauma,injury and/or surgical procedures in which edema lasts more than 2 weeks. This decreases the lymphatic transport out of the affected area due to casting,surgical incisions,scars or tissue loss.

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Protein is trapped in the tissue which activates fibroblastic activity. This activates production of collagenoustissues. This changes the spongy-like edema to turn to a thicker gellikeconsistency resulting in chronic fibrotictissues.

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PATIENTS AT RISK:• Nerve laceration/compression

causing muscle paralysis •Crush injury/Compartment Syndrome•Skin/Graft Tissue loss• CVA/Stroke patients with lack of

muscle pumping due to paralysis

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TIPS & TRICKS

Mark arm/ hand in 4 cm. increments with a dry erase marker to measure swelling at initial evaluation and at 3 treatment intervals.Use tendon glides, joint blocking , isometrics, while in compression bandaging for HEP.

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TIPS & TRICKS

If scarring and fibrosis (from radiation/removal of lymph nodes) blocks lymph flow, use watersheds (pathways) to re-rout lymph to functioning lymph nodes.Use handy inexpensive bandage winder to quickly rewind bandages.

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References

Lymphedema Management-”The Comprehensive Guide for Practitioners.”Joachim E. Zuther.C.I.,M.L.D./C.D.T.Thieme Medical Publishers, copyright 2005.

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References

Academy of Lymphatic StudiesCourse manual.

Phone: 1-800-863-5935WWW.ACOLS.COM

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References

Textbook of Dr. Vodder’s manual lymph drainage,Kasseroller,R: Heidelberg,1998,Haug.

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References

Special thanks to Crystal Hollingsworth,OTR/L,CLT for providing MLD handouts for patientsAnd detailed UE bandaging handout.

edema management spaces - liveconferences.com · pitting edema 18 pitting edema. 4 19 edema

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