Hand Swelling and Hand Edema
Hand Manual Edema Mobilization: overview of a new concept in hand edema reduction
Sandra M. Artzberger MS OTR CHT
Lecturer, Consultant, Hartford, WI. USA
Manual Edema Mobilization (MEM) is a technique to decrease sub- acute persistent and chronic hand edema post surgery, trauma or stroke. Clinically this edema presents as thick, spongy, slow to rebound when pitted, and eventually becomes hard and fibrotic. It is an edema due to an overload and/or compromise of the lymphatic system. Therapists often become frustrated treating this type of edema because it “returns” even after using their best efforts with traditional edema reduction methods. A hand therapist can easily reduce or prevent this type of edema if he/she is aware of the anatomy of the lymphatic system, can distinguish types of edema, and knows how to specifically activate the lymphatic system.
Artzberger wrote an in depth chapter in the 2002 edition of Rehabilitation of the Hand and Upper Extremity 5th edition. Susan Howard OTR CHT wrote an extensive case study using MEM and published it in the Journal of Hand Therapy1. Manual Edema Mobilization is based on the principles of Manual Lymphatic Drainage (MLD) first described by Emil Vodder in 1934 and further developed and researched by Foldi, Casely-Smith, Le Duc and others20,4,5,6,16,24,25,27. These programs usually involve a centrifugal massage beginning proximally and proceeding distally, exercise, short stretch bandaging, and a skin care program4,24,25,5,6,16,26. The patients primarily treated with these techniques are those with lymphedema post removal of cancerous nodes and/or radiation treatment, primary lymphedema (congenital), or lymphedema due to filiaris (larve infestation that destroys the lymph system). After being trained in two of the European MLD techniques, Artzberger began treating traditional lymphedema patients and sub acute post surgical hand edema patients. It became evident, that extensive and timely trunk and head neck drainage was not necessary for reducing arm /hand edema when the nodes and the lymph system were intact but just overwhelmed as seen with “persistent” post surgical subacute hand edema. Manual Edema Mobilization then evolved as a modification of lymphatic drainage techniques. It was designed with specific protocols for sub-acute post trauma, post surgery and stroke hand edema
DEFINITION OF MANUAL EDEMA MOBILIZATION
MEM is a method of gentle stimulation of the lymphatic system to facilitate the flow of excessive tissue fluid, plasma proteins, and other large molecular substances from an edematous area7,8,9. It is a light proximal to distal then distal to proximal massage of the skin done in segments which include: specific pre and post exercises, exercise as part of the massage program, massaging the lymph node(s) proximal to the edema, and following the direction of the lymphatic pathways7,8,9. Application is to persons having persistent high protein edema with intact but overwhelmed nodes and lymphatic system. It is not designed for a person with lymphadenectomy or primary lymphedema.
1. Treatment Concepts 7,8,9
• Light massage, 20 mmHg pressure or less to prevent collapsing of lymphatic pathways
• Incorporates, where protocol allows, pre and post exercises in a specific sequence
• Massage, done in segments, is proximal to distal then distal to proximal, always directing lymph towards the trunk
• Massage follows the flow of lymphatic pathways
• Massage re-routs around incision scar areas
• A type of massage and exercise which doesn’t cause further inflammation of tissue
• Includes a patient home self massage program specific to the hand pathology that is very necessary for success of the program
• Has adaptations to various diagnoses and stage of high plasma protein edema
• Has guidelines for incorporating traditional edema control, soft tissue mobilization, and strengthening exercises without causing an increase in edema
• Follows specific precautions
• Incorporates, when necessary, low stretch compression bandaging 2. Contraindications to doing MEM on a patient 7,8,9
• if infection is present-there is the potential to spread the infection
• over areas of inflammation-potential to increase the inflammation and pain
• if there is a blood clot, hematoma in the area-potential to move the clot
• if there is active cancer-potential to spread the cancer but this theory is controversial. Never do MEM if the cancer is not being medically treated. Always seek a physician’s advice.
• patient has congestive heart failure or severe cardiac problems-potential to over-load cardiac system
• in the inflammation stage of acute wound healingpotential to disrupt “clean up” process and invasion of fibroblasts
• if renal failure or severe kidney disease problems existpotential to overload the system
• if patient has primary lymphedema or post mastectomy lymphedema
LYMPHATIC SYSTEM ANATOMY OVERVIEW AND MEM TREATMENT RATIONALE BASED ON RESEARCH
Both the lymphatic and venous systems remove excess fluid from the interstitium which if not removed results in swelling12. However, fluid and small molecules filter into the venous system via osmosis12,13. Fluid and large molecules such as fat cells, hormone cells, large plasma proteins, and tissue waste products have to be absorbed by the lymphatic system13,20,21,22,15. When absorbed by the lymphatic system these large molecules are collectively called lymph15. This absorption is not a passive filtration process but the endothelia cells lining the lymphatic capillaries have to be stimulated to open and close to absorb these large molecules13,15. The lymphatic capillary located in the dermis layer of tissue is a finger shaped, single cell structure lined with one layer of endothelia cells having a connector filament to surrounding connective tissue15. When there are changes in interstitial pressure (due to light pressure, massage, movement or pulling on the connector filament by movement of the connective tissue) the overlapping flaps of the endothelial cells open admitting the large molecules and fluid not permeable to the venous system15,16,13. Research by Miller and Seale (1981) showed these single cell lymphatic capillaries begin to collapse at 60mmHg and are totally collapsed at 75mmHg17. Eliska and Eliskova found that a friction massage done at 70 to 100mm Hg of force for 3 to 5 minutes on edematous tissue caused damage to the initial and collector lymphatics18. Thus in order to create an uptake of lymph, the therapist must use a very light massaging pressure in order not to collapse or damage the lymphatic capillaries. Clinically this is described as no more than the weight of the hand or no heavier than you would stroke an infants head. Initial uptake to reduce swelling begins at this superficial dermis level.
From the initial lymphatic capillaries the lymph is propelled to the three-celled valved collector lymphatic. As a bolus of lymph enters a chambered segment of the collector lymphatic, called a lymphangion, it is propelled proximally into the next segment due to a stretch reflex from the smooth muscle middle layer or middle cell 4,19. At rest, lymphangions pump lymph proximally at a rate of 6 to 10 times per minute 19. However, with exercise their pumping increases up to 10 to 30 times this amount 19,14. Thus, MEM involves active muscle contraction or passive stretching exercises after each segment massaged.
Figure 1. Interstitial space showing arteriole, venule, initial lymphatic, cross section of initial lymphatic, the three cell collector lymphatic with lymphangion section. Published in the Israel Journal of OT May 2002, printed with permission.
The collector lymphatics merge into the lymph nodes via afferent pathways. The nodes are extremely important for destroying bacteria and immunological purposes. However, according to articles sited by the Casley-Smiths, the nodes can give 100 times the resistance to the flow of lymph towards the deep thoracic duct where lymph eventually dumps into on its way back to the venous system (the left or right subclavian vein) and the heart 16. Thus MEM, like all lymph drainage techniques, involves massaging of noninfected nodes that softens them and creates a negative pressure drawing lymph proximally.
The lymph that doesn’t anastomose into the venous system as it leaves the nodes via efferent pathways, continues into large lymphatic trunks and eventually ends draining into the largest trunk called the thoracic duct. This vessel extends from L2 to T4 draining the entire lower extremities and left side of the body and enters into the left subclavian vein15,19. The right upper half of the body and right side of the head drains into the right lymphtic duct and into the right sub clavian vein15,19. It has been theorized that changes in thoracic pressure in the abdominal area moves lymph proximally in the thoracic duct13,20. This in turn creates a negative pressure that draws lymph into the lower abdominal area from surrounding tissue. Therefore, all MEM begins with diaphragmatic breathing, and active or passive trunk exercises or stretching, if not contraindicated by the diagnosis protocol. The actual soft tissue massage component of MEM also begins at the trunk at the uninvolved axilla area, see Figure 2. This draws the lymph from overwhelmed nodes and congested tissue to the uninvolved nodes. Rationale is based on research by Pecking and associates that showed in postmastectomy lymphedema patients, MLD to the contralateral quadrant exclusively increased uptake of lymph from the involved hand 22,7. Their same research showed that the uptake ranged from 12% to 38%22,7.
This theory refers to the dynamic flow of fluid out of the arterial, into the interstitium, and into the venous and lymphatic systems12. It is a complex system of inter vascular, extra vascular, and tissue pressures that control this fluid movement that is always trying to seek equilibrium. Plasma proteins both intra vascular and interstitial create an osmotic pressure that influences the balance of flow12. Plasma proteins are hydrophilic and attract the water molecule14 either pulling it into the interstitial space or out of it13. Thus, if there are too few of plasma proteins swelling results because not enough fluid is being removed from the interstitium12,13,14. Examples of this would be kidney failure such as nephrotic syndrome, malnutrition, or severe liver disease14. Trauma or surgery causes damage to venules, arterioles and lymphatic capillaries and thus excess amounts of plasma proteins enter the interstitium and cannot be adequately carried away due to damage of the lymphatic system. The result is edema. Research by Casley –Smith and Gaffney (1981) showed that when excess plasma proteins remain in the interstitium for 64 days (induced lymphedema in an animal model) chronic inflammation leading to fibrosis resulted23. Thus the goal for therapists is to activate the lymphatic system and reduce the excess plasma proteins.
TYPES OF EDEMA AND THEIR TREATMENT
High Protein Edemas:
Acute Inflammatory Edema is seen immediately following surgery or trauma to tissue. This type of edema usually dissipates within 2 days to 2 weeks following surgery or trauma7. The goal of treatment is to decrease the flow of fluid into the interstitium by decreasing arteriole hydrostatic pressure29. This is done by use of a post surgical bulky dressing applied by the physician, elevation, icing if appropriate, and gentle proximal motion. Sub acute inflammatory edema is “persistent” edema that has not reduced with traditional techniques and is becoming thick, spongy, and slow to rebound from being indented8. Often this is seen post crush injury because of: (1) extensive damage to the entire microvascular system that blocks or slows plasma proteins from moving out of the area; (2) scar barriers interrupting the normal lymphathic pathways; (3) proximal congestion of lymph in the shoulder due to immobilization. This is a lymphatically compromised and congestion situation requiring stimulation of the surrounding intact lymphatic system to reduce the swelling. MEM can: (1) activate the surrounding intact lymphatic system; (2) re-route lymph flow blocked by scar barriers; (3) soften hard (indurated) tissue facilitating lymph flow from the area. After the edema has significantly begun reducing, tissue has minimal inflammation, then traditional techniques to increase ROM and strength can be begun. Chronic inflammatory high protein edema is lymphatic overloaded edema that has lasted 3 months or longer7,8. This edema will decrease with MEM. However, various tissue softening devices such as elastomer pads, chip bags (small pieces of foam of various densities in a stockinette bag), and low stretch non elastic bandaging will have to be used to soften tissue and prevent refill. Lymphedema is also a high protein edema described, in part, by the Casley-Smiths as “ a high protein edema due to a permanent blockage of the lymphatics”24. Hand trauma cases that have circumferential scarring or grafting with distal chronic edema would be considered lymphedema. Some lymphatic capillaries do grow back across scar tissue30.It can also be theorized that the larger venous vessels must absorb some lymph products otherwise tissue would necrose from lack of removal of lymph with its waste products. The term lymphedema is most often associated with primary (congenital), secondary (post cancer node removal and/or radiation) or filariasis edema. The treatment for the proceeding lymphedema is various lymphatic drainage programs that involve extensive rerouting of lymph to various non-involved areas.
Low Protein and Cardiac Edema
Malnutrition, severe liver disease and kidney disease such as nephrotic syndrome are examples of pathologies where there are too few proteins in the interstitium to attach to the water molecule and draw it out of the interstitium 13,14. The result is swelling. This is not a lymphatic overloaded edema and MEM is not appropriate. MEM massage would move the edema to another area and potentially overload the involved systems. Edema from cardiac failure is also not a lymphatic overloaded edema. MEM must not be done to reduce edema on these patients because it could send too much fluid back to the heart and over-load the already compromised heart.
Stroke edema is considered a “complex edema.” Initially in the flaccid state the edema is a low protein dependency fluid edema. Months later, the edema compromises the lymphatic function and it becomes thick and spongy. Initially elevation, light retrograde massage, and elastic gloves are effective treatment. MEM can be used when the edema becomes thick and spongy because this indicates the lymphatic system has become overwhelmed. However, great caution and slow progression of treatment has to be taken because this type of edema quickly reduces and can overwhelm cardiac function.
OVERVIEW OF THE MEM MASSAGE TECHNIQUE
A Manual Edema Mobilization program consists of using: one of two types of MEM lymphatic massage approaches; exercise; a self management program; tissue softening devices; possibly low stretch bandages; and incorporation of traditional treatment techniques that will not cause tissue re-inflammation. Two techniques that complement MEM include myofascial release and use of Kinesio taping methods because they stimulate the lymphatic system. One of the massage techniques is called Pump Point Massage, a term coined by Artzberger and unique to the MEM program. It is a technique where the therapist simultaneously massages two sets of nodes or a set of nodes and lymphatic bundles in the extremity. Clinically, it has been theorized that this motion creates a negative tissue pressure and suctions the congested lymph to the nearest set of proximal nodes. For mild to moderate edema, it has been observed, initially using extremity Pump Points along with MEM massage across the upper trunk, edema will quickly reduce, eliminating the need for the full MEM massage program. Further research is needed regarding use of Pump Point Massage. The second MEM massage technique is use of the full MEM massage program that is MEM across the upper trunk, Pump Points and MEM massage to the entire involved extremity. This is used with an extensive and chronic edema situation. “Chip bags” and other devices are needed to soften the lymph to facilitate it to flow.
Another component of MEM is re-routing congested lymph around scar blockage areas. This too is a suctioning technique where light compression MEM massage proximal to the scar creates a negative pressure and draws the congested lymph around the damaged area of the lymphatic system to an intact area. Below are photos of the MEM massage techniques. The techniques are usually done on a bare arm/hand and in the upper trunk over thin clothing. MEM massage strokes are “U” shaped with the end of the “U” pointing towards the uninvolved or more proximal area. Figure 2 shows horizontal MEM “U”s beginning at the uninvolved axilla area and proceeding simultaneously anteriorly and posteriorly to the involved side. Figure 3 shows Pump Point stimulation. Here the anterior deltoid and pectoralis major/minor area are being simultaneously massaged in a “U” along with the posterior deltoid and teres major/minor area. Figure 4 is of scar re-routing. “X” is proximal to the edema on the dorsum of the hand. “V” is on the volar surface of the wrist where there are a bundle of lymphatics. Simultaneously lightly massaging these two areas draws the edema proximally to “V.” More extensive sketches can be found in Rehabilitation of the Hand, 5th Edition, Vol. 1, 2002.
CASE EXAMPLE ILLUSTRATING THE USE OF MEM ON A FOREARM CRUSH INJURY
Mr. KC is a 48 year old owner of a well drilling company who also actively works at the trade. On April 24th 2001 a 400 pound drill rod fell on top of his right forearm resulting in a mid forearm fracture to both the radius and ulna. This was surgically repaired on the same day with internal fixation by plate and screws to both the radius and ulna. Following surgery, the surgeon placed the arm in a plaster splint for immobilization and the patient wore a sling. This treatment continued for three and a half weeks.
On 5/22/01 Mr. KC began hand therapy aimed at reducing pain which was most significant at the dorsum of the right wrist, increasing extremity range of motion (ROM), reducing edema, and increasing functional usage. Evaluation of the right hand and forearm revealed that the skin was taut and shiny, had uniform swelling in the forearm and hand, plus “modeled” redness and slight warmth of tissue. Volumetric displacement on the right hand/forearm was 795 ml compared to 665 ml on the left, a 130 ml difference. The patient described pain as “hurting all the time.” He rated the pain as a 4 at rest and a 6 with activity on a scale of 1-10. The left hand was used to perform all functional tasks and sensation was intact. Active range of motion (ROM) was most limited at 0 degrees supination, 14 degrees of wrist extension, 4 degrees of radial deviation, and total active finger flexion was 50% of normal. After completing the evaluation on 5/22/01 the therapist did Manual Edema Mobilization (MEM) across the chest and pump points to the extremity. This took 20 minutes. The patient’s wife was then instructed how to do this to the patient 3 to 4 times a day. He was also instructed in tendon gliding exercises and light scar massage. To prevent edema re-fill, Mr. KC was issued a loose elastic hand glove and an elasticized stockinette for the forearm. Re-evaluation on 6/7/01 showed that his edema had decreased 56 ml to 739 ml, pain decreased to a 3 at rest and a 5 with activity, ROM improved and he had begun using the right hand for light ADL and work tasks. Between 5/22/01 and 6/21/01 the patient was seen for 5 treatment visits. At visits 3 through 5 the therapist spent minimal time doing MEM because the edema was reducing so well with the home MEM program.
Re-evaluation on 6/21/01 showed that the edema had reduced to 718 ml, a total of 77ml decrease. This was 53 ml greater than the left hand/forearm. The therapist discontinued performing MEM during the next treatment sessions because of his continuous decrease in edema. At the next evaluation, 7/5/01, edema in the right hand/forearm had completely resolved. Also, the patient had begun doing heavy work tasks with the right hand, improvements in ROM of the wrist enabled him to feed himself pain free. ROM was within functional limits except for supination and wrist extension that had improved to 50% of normal range. Pain on the dorsum of the wrist was rated as a 3 to 4 with activity only. Swelling following crush injuries can be very difficult to reduce and the loss of ROM devastating. This case example shows how intervention with the shortened version of MEM is extremely effective in quickly reducing edema and pain. Once the edema began to reduce the therapist could begin early intervention to prevent joint stiffness and get the desired ROM and functional usage. It must be noted that the therapist did not begin any passive ROM until the 5th treatment nor any strengthening until the 7th visit.
This enabled the inflammation of the tissue, warmth noted on initial visit, to resolve and not to cause re-inflammation and further edema by too quickly beginning resistive activity. Equally important was the patient’s compliance to the home MEM program. Frequent, throughout the day, light MEM massage is essential to removing the congested lymph from the area and eliminating re-congestion. Success in this case occurred because of the patient and therapist team approach.
Five published case examples have shown the effectiveness of MEM in reducing early and chronic stages of lymphatic overloaded edema1,7,8. Comparative research is needed to confirm these results and two such research studies are in progress. The essence of the MEM technique is that through changes in interstitial pressures the most proximal congested lymph is moved into uninvolved tissue for uptake by an intact lymphatic system. This enables the more distal edema to move proximal and out of the involved area. It is a technique that specifically activates the function of the lymphatic system without causing damage to it. MEM is a technique that is effective only with lymph congested edema. This challenges the therapist to determine the etiology of the edema. Therapists are further challenged to determine when to implement MEM. Should MEM only be implemented when there is visible edema is one question. The second consideration is should MEM begin, in the appropriate cases, before there is visible edema knowing that the lymphatics can take up to 10 to 20 times their normal capacity before they become overloaded and edema becomes visible13. Homeowners often face the same challenge, de-clog a slow draining sink or wait until it is fully clogged.
The greatest challenge to therapists is to re-examine the rationale and any biological support for traditional edema control techniques. For instance, why after retrograde massage or string wrapping does the edema often return and it sometimes is harder? Questions to explore to find the answer might include: (1) is the pressure sufficient when string wrapping or using retrograde massage to cause collapse and damage to the initial lymphatics preventing uptake of lymph; (2) do the techniques cause inflammation of tissue and thus more edema; (3) is the initial reduction achieved because the fluid component of the lymph is forced into the venous capillaries reducing the amount of swelling; (4) does edema return within a few hours, in this situation, because the large molecule lymph components can’t be compressed out of the interstitium and the hydrophilic plasma proteins re-attract the water molecule; (5) is there any biological research showing that strong distal compression forces lymph into the lymphatics and moves the lymph proximal. Therapists must analyze from a biological standpoint the “whys” or the “why nots” of treatment technique effectiveness.
Manual Edema Mobilization is a tool for treating an overloaded or congested lymphatic system post hand surgery, trauma or stroke hand edema in the sub acute and chronic stages. It accomplishes permanent edema reduction by specifically facilitating the lymph capillaries to up take lymph because the technique works in tandem with the biological structure and function of the lymphatic system. Comparative research is needed to further explain the validity of the method. Manual Edema Mobilization is just another tool in reducing edema and the disastrous effects edema can have on tissue, joints, and functional ability.
The author would like to thank Joni Westenburger OTR from the Occupational and Hand Therapy Clinic, West Bend Wisconsin for providing the KC case study data.
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