Edema Edema - result of altered physiologic function Local histamine release following injury Systemic disease heart failure

ure Obstruction of lymphatic vessels Lymphedema - chronic accumulation of fluid in interstitial tissue spaces Primary - congenital (hypoplasia or hyperplasia) Secondary tumours, trauma, parasitic infection Lymphatic System Blood = red and white blood cells Fluid pumped through arterial ends into interstitial spaces Excess clear, watery interstitial fluid is collected, filtered and returned to circulation by lymphatic system Returns 1 - 10% of fluid to circulation (2.4 litres/day) Lymphatic vessels have minor contractile capability 1-30 bpm (considered to be passive) Majority of lymphatic flow is stimulated by movement of skeletal muscle, diaphragm, peristalsis Lymph nodes filter the fluid Nodes contain lymphocytes (part of immune system) Specific drainage patterns or territories Drainage territories are separated by watersheds

Causes of Edema: 1. Increased permeability of capillaries Inflammation Tissue trauma Immune response Burns

2. Obstruction of lymphatic flow Infection Parasites Lymphatic disease Surgical removal Radiation treatment Scarring Congenitally reduced number of lymph vessels

3. Increased Capillary pressure Heart failure Thrombophiebitis Pregnancy Generalized allergic response Hot weather Sodium retention Orthostatic edema

4. Decreased plasma protein Liver and kidney diseases Starvation Extensive burns

Massage and the Lymphatic System 1. Swedish Massage Therapy: Improve lymphatic flow Reduce edema Ease pain secondary to edema Lower chance of scar tissue formation Remove metabolic wastes secondary to edema and inflammation Light Swedish techniques, stroking and kneading with elevation of limb 2. Manual Lymphatic Drainage (MLD): Researched and developed by Emil Vodder in the 1930s Technique: Hands soft and relaxed, no lubricant needed Each manipulation repeated 5 7 times Strokes are unidirectional and overlapping Pressure towards heart Rhythmic Start at proximal lymph nodes Treatment of a single limb may take up to 20 minutes Pressure 20-40mm Hg Capillaries take 5 seconds to refill after compression

Lymphedema is treated with complex decongestive physiotherapy, MLD, skin hygiene, bandaging and remedial exercises Research: Shows increase in urine output, and an increase in urine concentrations of histamine, corticosteroids and noradrenaline Shows that lymph vessels take 5 seconds to refill after compression

3. Other Lymphatic drainage techniques: Nodal pumping/nodal compressions o Arm axillary lymph nodes o Leg inguinal lymph nodes o Pressure is applied in wave-like motion from just distal to node in a proximal direction Stationary circles o Treat larger areas of the limb between edema and proximal nodes Local Technique o Performed on tissue immediately proximal to the edema o Use ulnar border of hands; web between thumb and index finger; broad surface of thumb Effects: Encourages lymph flow in superficial capillaries Reduces certain types of edema Decreases pain perception Decreases SNS firing Reduces formation of scar tissue Increases urine output (up to 1 litre per hour of massage)

Contraindications: Chronic heart failure Acute conditions d/t bacterial or viral infection Recent thrombosis Low-protein edema d/t kidney pathologies Malignancy Lymphatic obstruction by parasites

Health History Questions General health Cause of edema - infection? Recent surgery Peripheral nerve lesion Pregnancy History of edema Duration Injury Other health care practitioners Meds Bandages or stockings to reduce it Interfere with ADL Aggravates or relieves Assessment Observe extent of edema Palpate for infection, pitting AF ROM reduced PR ROM reduced Measure girth Test for pitted edema

Symptoms of Edema Due to trauma o Local or distal to injury site o Taut and firm o tissue is hot in acute Due to general systemic conditions o affects entire body o tissue puffy and congested Due to local lymphatic obstruction o whole limb distal to edema site o taut and firm (due to parasitic infection or thrombophlebitis) o puffy and congested (due to lymphectomy) Due to surgery o may take weeks, months or years before it occurs Pain or feeling of discomfort or fullness Decreased ROM May have hematoma Treatment Use for chronic lymphedema - general or local Use for local edema present with acute or subacute injury prior to using more specific, deeper massage techniques For chronic edema, use deep fascial techniques proximal to site of edema to release restrictions, then wait and use drainage techniques

Acute Initial treatment goal reduce edema before general work to related structures which will reduces pain and congestion. Begin on trunk or opposite limb, followed by drainage of affected limb followed by specific massage for the specific condition Elevate limb Apply cold hydrotherapy to edematous area Begin with nodal pumping at terminus (SC joint area) Pumping at proximal nodes of affected limb Use drainage techniques following the drainage pattern, stay proximal to edema Use stroking and effleurage proximally Onsite and distal work is CI Gentle PR ROM is beneficial for proximal and distal joints

Early Subacute Same as acute Drainage techniques right up to the border of the edema Midrange PR ROM to proximal and distaI joints

Late Subacute Same as subacute Use cold-warm contrast hydrotherapy Edema should be decreasing so less time is needed to treat Treat the edema site with drainage techniques, work through to the distal border Effleurage proximal, through edema and distally Mid-full PR ROM proximal and distally

Chronic Continue to elevate limb Hydrotherapy can vary from cold, cool, to warm, to contrast If edema is resut of trauma, use light connective tissue techniques to reduce scar tissue formation followed by petrissage on proximal hypertonic muscles. Then use drainage techniques as in late subacute. If edema is from pregnancy, peripheral nerve lesion, sitting, standing, use massage techniques first, then drainage techniques.

Lymphedema o o o o No deep techniques or frictions Treat neighbouring watersheds (contralateral) Hot hydrotherapy is a CI Heavy pressure techniques and frictions could cause lymphedema where lymph nodes have been removed o Tissue feels waterlogged, soft, spongy, and congested

Self-care Hydrotherapy Self-massage Diaphragmatic breathing Painfree AF ROM to distal and proximal joints Painfree isometrics Beurgers Exercise lower limb