Edema Management

Question 1

What is edema?

Answer 1

• A condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body
• A natural response following an acute injury as it is part of the inflammatory phase of wound healing

Question 2

What can edema cause?

Answer 2

• Swelling
• Pain
• Loss of motion and function
• Compression on nerves and blood vessels and tendons may result in stiffness. If edema is chronic it can result in fibrosis
• Increased scarring of the skin if there was a laceration injury/open wound

Question 3

What is fibrosis?

Answer 3

• The thickening of connective tissue, usually a result of injury. It is different than scar tissue. It is physical, mechanical change of the soft tissues that affect all tissues including: blood vessels, lymphatics, muscles, ligaments, tendon, and skin

Question 4

What are causes of edema?

Answer 4

• Trauma
• Infection
• Venous insufficiency
• Cancer
• Lymphatic dysfunction
• Arterial occlusion: cool pale, in this case in the LE
• Venous obstruction: blush with decrease in temperature. The extremity needs to be elevated
• Metabolic imbalance: salt intake, hypothyroidism, diabetes
• Poor circulation/immobility
• Pressure in an area or BP or too much compression in an area

Question 5

What is the physiology of edema?

Answer 5

• Body fluid regulation between interstitial fluid (IF) and blood plasma
• Arterial system brings oxygen and nutrients to the cells
• Venous system removes waste and carbon dioxide (CO2)
• Lymphatic system removes waste in the form of plasma proteins from interstitial fluid. It takes out the big molecules of trash in forms of plasma proteins

Question 6

What is the role of histamine?

Answer 6

• It is part of an immune response to foreign pathogens
• Found in nearby connective tissues
• There is vasodilation and a fall in BP
• Increases the permeability of capillaries to white blood cells and some proteins, to allow them to engage pathogens in the infected tissues - it essentially opens the gates
• Increased vascular permeability causes fluid to escape from capillaries into the tissues, which leads to the classic symptoms of an allergic reaction: a runny nose and watery eyes
• High amounts of histamine can increase edema
• Foods can increase histamine

Question 7

What are the key points of edema physiology?

Answer 7

• There is a constant fluid exchange between tissue and plasma across the capillary membrane
• Fluid enters and exits through gates along the capillary wall
• The molecules that make up this fluid vary in size
• For this reason fluid in the tissue can vary in consistency from thick to thin
• Protein molecules are large and have difficulty getting through the capillary gate

Question 8

What two forces determine whether water stays as part of the blood in a blood vessel or if water leaves to become part of the interstitial fluid?

Answer 8

• Hydrostatic pressure

- Osmotic pressure

Question 9

What is capillary hydrostatic pressure?

Answer 9

• The force that is exerted by a fluid against the capillary wall
• Helps in the movement of fluid between capillaries and the interstitial fluid. It is created by the pumping action of the heart
• The capillary wall is semipermeable and fluid will leak out at a rate depending on the pressure of flow
• When pressure inside is higher than outside, the BP forces fluid out of the capillaries
• ## The highest capillary hydrostatic pressure is observed at the arteriolar end of the capillary and the lowest pressure is observed at the venous end

Question 10

What is osmotic pressure?

Answer 10

• The minimum pressure applied to a solution to prevent the inward flow of water across a semipermeable membrane
• Also defined as the measure of the tendency of a solution to take in water by osmosis

Question 11

Is blood slightly more hypertonic or hypotonic compared to interstitial fluid?

Answer 11

• Hypertonic and tends to keep water inside the blood vessel

Question 12

Do osmotic pressure and hydrostatic pressure work together or against one another?

Answer 12

• They work against one another
• Blood pressure is forcing water out and osmotic pressure forces are trying to keep blood in
• The two forces do not cancel one another out. Hydrostatic pressure wins because it is slightly stronger than osmotic pressure

Question 13

What is the capillary hydrostatic pressure at the arterial end and the venous end?

Answer 13

• Arterial end: 35 mm Hg

- Venous end: 15 mm Hg

Question 14

How is the capillary filtration rate calculated?

Answer 14

• Capillary hydrostatic pressure minus osmotic pressure

- The rate depends on which end of the capillary and the BP

Question 15

What happens if capillary hydrostatic pressure is greater than osmotic pressure?

Answer 15

• Fluid leaves the capillary

Question 16

What happens if capillary hydrostatic pressure is less than osmotic pressure?

Answer 16

• Fluid enters the capillary

Question 17

Why is physiology important to therapy?

Answer 17

• Because therapists use pressure to push fluid into the capillaries

Question 18

What should a therapist remember when using pressure garments and performing various edema massage?

Answer 18

• Therapists must know the amount of pressure to provide
• For the purpose of reducing edema, garments should apply between 25 and 35 mm Hg of pressure but no more than 35 mm Hg in the UE and 30 to 40 mm Hg in the LE. Otherwise, the system will shut down and swelling will increase
• Compression garments for burns should be less (17-24 mm Hg)
• Damage to the lymphatic system occurs at 70 mm Hg

Question 19

What are the different types of edema?

Answer 19

• Normal acute edema
• Pitted edema
• Brawny edema
• Lymphadema

Question 20

What is normal acute edema?

Answer 20

• Response to injury
• Expected as part of the inflammatory stage of wound healing
• Necessary to clean up the area of trauma

Question 21

What is the viscosity of normal acute edema?

Answer 21

• Thin and can be mobilized
• Responds to elevation
• Responds to retrograde massage
• Responds to compression garments

Question 22

What is the viscosity of pitted edema?

Answer 22

• Thick and harder to mobilize
• Pitted edema can be displaced with pressure but leaves an indentation
• Pitted can advance to brawny
• Can be caused by diabetes

Question 23

What is the viscosity of brawny edema?

Answer 23

• Firm to touch, fluid does not move freely, hard

- There are more plasma proteins in pitted and brawny edema which makes the viscosity thicker

Question 24

What is lymphedema?

Answer 24

• A result of a compromised lymphatic system
• Can be either congenital/genetic or the result of cancer treatments or cancer in general
• Can also result from excision of lymph nodes, parasite infection, or hypothyroidism
• People with lymphedema are more susceptible to infections because the system is already under stress

Question 25

How is edema assessed?

Answer 25

• Varies in severity: mild, moderate, severe
• Quality: acute, chronic, pitted, brawny
• Conditions of why it is present: trauma, circulatory issue, dietary or metabolic concerns, etc.

Question 26

How can edema be measured?

Answer 26

• Tape measure: good for measuring small areas or if there is an open wound. Measurement should be taken in cm
• Volumeter: water displacement measurement that measures the amount of water displaced in milliliters

Question 27

What is the Allen’s Test?

Answer 27

• A vascular test
• Simultaneously compresses the radial and ulnar arteries at the wrist
• Open/close fist five times and then relax
• Release radial artery: if palm and all digits fill with blood then the radial artery is functioning
• Repeat 1 and 2
• Release ulnar artery: if hand flushes then ulnar artery is functioning
• Normal capillary refill is 2 seconds. Anything over 5 seconds should be further assessed

Question 28

What should a functional goal to reduce edema include?

Answer 28

• Occupational intention
• Improvement/increase in motion
• Decrease in pain
• Prevention of adhesions

Question 29

What are some edema management and interventions?

Answer 29

• Pressure: garments and bandaging or wraps
• Positioning: elevate
• ROM: movement stimulates lymphatic system and circulatory system
• Massage/mobilization: retrograde for vascular system vs lymphatic drainage for lymphatic system
• Patient education: diet and water intake

Question 30

What are treatment interventions for acute edema?

Answer 30

• Elevate, ice, rest, ROM of non-affected joints, heat with compression and elevation
• If after 7 days, do not use heat if there is inflammation. After inflammatory stage, edema is considered to be linked to a circulatory problem
• Heat must be at least 45 degrees Celsius in order to be able to move tissue

Question 31

What is an example of a deep and superficial modality?

Answer 31

• Deep: ultrasound

- Superficial: heat packs

Question 32

What are treatment interventions for chronic edema?

Answer 32

• Elevate
• Warmth after initial phase of healing with elevation and possible compression
• ROM: gentle and within toleration
• Pressure: not too much. Massage, garments, or pumps should NOT exceed 25 to 35 mm Hg

Question 33

What is retrograde massage?

Answer 33

• Still performed as a standard form of edema massage
• Used for edema that is not pitted or brawny. Best for acute edema
• Works on smaller molecules in the interstitial tissue
• Mechanism of mobility: venous system through elevation and massage from distal to proximal. Massage from fingertips to back of hand, to wrist to forearm, to elbow, etc
• Resembles a “milking action”
• AROM may be performed following and is highly recommended when possible
• Patient should be education on home program

Question 34

How do protein molecules in the interstitial tissue act and respond to massage?

Answer 34

• They bind to water
• Increased protein in tissue causes the edema to thicken
• Protein molecules are large and can’t fit through the capillary gates
• Retrograde massage relies on being able to push the fluid into the circulatory system. And is contraindicated when protein molecules are too large to fit through capillary wall

Question 35

What is the lymphatic system?

Answer 35

• A one-way system: lymph flows toward the heart
• Lymph vessels include:
• • Microscopic, permeable lymphatic capillaries
• Lymphatic collecting vessels
• Lymphatic trunks and ducts
• Located in the skin - shallow, lies superficial to vascular system
• Interconnected with vessels throughout the body
• The lymphatic gates are bigger and allow the passage of larger protein molecules

Question 36

What is manual edema mobilization?

Answer 36

• Comes from manual lymphedema techniques used with cancer patients
• Protein molecules in the plasma are too large to pass through the capillary gates
• Lymphatic gates and channels are large enough to accommodate the protein molecules
• Unlike retrograde massage, MEM/MLD starts proximal (to open the gates first - subclavicular region) to distal and is shallow and light vs deep and milking
• Sandy Artzberger introduced it to orthopedics
• There are about 4-5 different techniques. Vodder, Leduc, Artzberger
• You want to try to mobilize as much skin as possible

Question 37

What body system can MEM affect if done properly?

Answer 37

• It can affect the autonomic nervous system

- Has an analgesic/calming effect

Question 38

What are contraindications with MEM?

Answer 38

• Should not be done in area of infection
• Should not be done in presence of open wounds
• Should not be done if there is active, untreated cancer
• Should not do if pt has CHF because it can overtax the heart by pushing too much fluid to heart
• Should not be done with pts with renal failure or kidney disease
• Should not be done with pts with severe pulmonary problems
• Precaution: post-mastectomy lymphedema requires certification and techniques to compensate for the removed lymph nodes - therapist must know what lymph nodes were removed in order to know which route to take