In Figure 9-1, A, the lower limb is divided into four sections, beginning at the thigh and finishing at the foot. The longer the limb, the more sections may be used. Typically, in the lower limb, section 1 would be the upper thigh and section 4 would be the forefoot and toes. Likewise, the upper limb is divided into four sections (Figure 9-1, B). Section 1 would be the upper arm, and section 4 would be the fingers and hand. The limbs are divided in this way to stress the importance of beginning the massage in the proximal sections. The rationale for this approach is that because the tissues are already congested, a pathway needs to be cleared before working on the swollen areas themselves. In this way, the venous and lymphatic channels will be opened to receive the fluids from the swollen areas.

Effleurage to the lower limb is a good example of this idea. Normally the stroke begins distally at the foot and ankle and finishes proximally in the femoral triangle (see Chapter 4). If this technique were applied to a very swollen foot, there would be no space to receive fluids, because the swelling causes collapse of the local capillaries, veins, and lymphatic vessels. The depletive massage concept aims to open up these vessels in the more proximal tissues first, thereby producing open channels that allow the fluids to move. Once the circulation is flowing in a more normal manner, the conventional direction and methods for the various strokes can be used.

At the end of treatment, there is the important issue of how to prevent the return of swelling in the limb when it becomes dependent again. The basic issue is one of pressure in the circulatory system. Essentially, there is a greater pressure (including gravity) forcing fluids into the tissue spaces than there is driving it back into the circulation. Over time, this pressure produces a net accumulation of fluids into the tissues (edema). The pressure tending to drive fluids back into the circulation can be increased with the use of elasticized stockings or socks. Many different types of stockings are available, but they all work in the same basic way. The better ones feature some kind of graduated pressure from distal to proximal in the garment. It is important that such a garment is applied at the end of treatment while the limb is still in elevation. Of course, the patient is instructed to keep the limb elevated as much as possible during the day.

CHRONIC EDEMA

Chronic interstitial swelling in the limbs (edema) is a potentially serious condition if it is allowed to persist, especially in older patients. It is typically produced by trauma to the tissues (such as a fall), or it is the result of an underlying problem with the circulation. In either case, long-term congestion of the tissues can lead to stiffness and pain, which can result in deformity and loss of function. In the lower limb, this may mean an inability to walk, resulting in the patient spending most of the day in a chair or bed. If the patient is older, this can lead to a serious health decline caused by inactivity. Removing edema and increasing functional range of motion in joints and soft tissues is therefore a top priority, especially in the elderly patient with a swollen lower limb. An exception to this case might occur if the swelling in the lower limbs is the end result of severe congestive heart failure. Fluids are then offloaded into the tissues to relieve the load on the heart (less fluid to pump). In this case, vigorous attempts to treat the swelling might result in cardiac complications. Obviously, close cooperation with the patient’s medical team will be needed to manage the situation properly.

One of the reasons chronic edema is a potentially serious problem is that it tends to organize; it becomes thickened, thereby preventing normal movement and function. In addition, the stiffness is often painful, adding to the patient’s unwillingness to move the affected parts. This lack of movement results in even more stiffness. Much of the stiffness is produced by a fibrosis that occurs in the interstitial spaces. Under normal circumstances, the plasma proteins are unable to escape from the capillaries into the interstitial fluid (tissue fluid) because their molecular size is too large to pass through the vessels. However, one of the consequences of local trauma to the tissues is that the capillary walls open up and allow these large molecules to pass into the tissues. Many of the plasma proteins are concerned with the ability of the blood to clot, and this process is triggered in the tissue spaces. The end result of the clotting process is the formation of fibrin threads, eventually leading to scar tissue. Such interstitial scarring causes adhesion of the various layers of the tissues and prevents the free movements of one tissue on another. A classic sign of this process is the presence of pitting edema. In this case, an indentation (pit) is left behind in the skin and subcutaneous tissues when the thumb is pushed into a chronically swollen area.

The importance of the lymphatic system in the resolution of chronic edema cannot be overstated. Once the acute inflammatory stage has passed and the capillary walls have closed up, the plasma proteins and other large molecules cannot get back into the capillary network. The only place for them to go is into the lymphatic vessels. In many ways, the lymphatic vessels act as the drainage system for the tissues. Because the lymphatic vessels are thinly walled, without a well-defined valve structure, any massage stroke that involves alternate squeezing and relaxation of pressure will have a powerful effect in promoting flow in this system. However, the normal architecture of the lymphatic system has to be in place for this to work efficiently. Where the lymphatic network has been disrupted, such as may be the case with significant lymph node resection, the swelling may be more widespread and treatment more challeng-ing. This situation is considered at length in Chapter 12, which explores decongestive therapy for the treatment of lymphedema.

Localized, chronic edema can be mobilized using a variety of techniques, including massage. The basic sequence is listed in the tables that follow, and the specific focal massage techniques are italicized. Because the limb is elevated, the therapist may need to stand on a suitable platform, or the therapist may face the patient’s foot and reverse the usual positioning (i.e., by working from knee to hip and from foot to knee). In each case, the massage is always performed from distal to proximal structures (Tables 9-1 and 9-2).

Table 9-1 Focal Massage Sequence for Chronic Edema in the Foot and Ankle Region

PROCEDURE^*	REPETITIONS
Depletive stroking to the whole limb	3
Depletive effleurage to the thigh	3
Palmar kneading to the thigh	3
Wringing to the medial thigh	3
Picking up to the thigh	2
Depletive effleurage to the thigh	3
Finger pad kneading around the knee	3
Palmar kneading to the calf and leg muscles	4
Thumb pad kneading to the anterior tibial muscles	4
Picking up to the calf	4
Depletive effleurage to the thigh, calf, and leg	3
Finger pad kneading around the ankle region	4
Thumb pad kneading to the foot	4
Effleurage to the whole limb	3

Italics indicate specific focal massage techniques.

* Performed with the patient supine and the lower limb elevated.

Table 9-2 Focal Massage Sequence for Chronic Edema in the Forearm and Hand Region

PROCEDURE^*	REPETITIONS
Depletive stroking to the whole limb	3
Depletive effleurage to the upper arm	3
Palmar kneading to the biceps and triceps	3
Picking up to the biceps and triceps	3
Depletive effleurage to the upper arm	3
Finger pad kneading around the elbow region	3
Palmar kneading to the forearm muscles	3
Thumb pad kneading to the forearm muscles	3
Depletive effleurage to the upper arm and forearm	3
Thumb pad kneading to the wrist, hand, and fingers	4
Effleurage to the whole limb	4