All edema is not the same.
Stimulation of the lymphatic system is necessary to decrease subacute and chronic edema.
The proteins associated with subacute and chronic edema need to disperse through the lymphatic system, as they are too large to permeate the venous system.
The initial lymphatic system is superficial, fine, and fragile, therefore firm compression may collapse the system.
Diaphragmatic breathing, light massage, and exercises help to stimulate the lymphatic system.
Manual edema mobilization (MEM) is a lymphatic stimulation technique used for recalcitrant subacute or chronic limb/hand edema in the orthopedic population. The phrase popularized by Watson-Jones in 1941, “Oedema is glue,” summarizes the importance of reducing edema in swollen hands because persistent edema can contribute to fibrosis, stiffness, and limited range of motion (ROM). Historically, many edema treatment techniques were developed with the rationale that the technique “stimulated the venous and lymphatic systems,” giving the impression that one technique would affect both systems equally. However, current literature now describes differences between how the venous and lymphatic systems remove excess fluid, thereby lending credence to the fact that not all edema reduction techniques work for all types of edema. Clinically, therapists have seen that some edemas reduce with little effort, whereas others progress into a gel-like and fibrotic state regardless of intense therapy. This phenomenon can be puzzling and frustrating for therapists. However, an understanding of the different types of edema and an understanding of the differences between the venous system and lymphatic system with regard to edema reduction can help therapists understand why some common edema treatment techniques may not work on all types of edema ( Table 65-1 ). The purpose of this chapter is to describe the MEM technique, which is an edema reduction technique used to stimulate the lymphatic system to decrease subacute and chronic edema in the orthopedic population.
|Type||Etiology||Clinical Description and Stages|
|Inflammatory edema (high-plasma protein edema)||Trauma to tissue as a result of injury, infection, or surgical procedure. The result is high capillary permeability, imbalance in Starling’s equilibrium, and an overload of the intact lymph nodes and lymph system because of excess plasma proteins flowing into the interstitium. There is also temporary obstruction and/or damage to the surrounding lymphatics that decreases protein uptake.|
|Lymphedema (high-plasma protein edema)||Often associated with lymphadenectomy and/or lymph node radiation, primary lymphedema, or filariasis. Foldi et al. , described it as a “low output failure of the lymph vascular system.”||Classified by grades. Grade I: pitting that reduces with elevation; no fibrosis. Grade II: does not reduce with elevation, fibrosis; ranges from moderate to severe with elephantiasis as the extreme of this grade. Magnetic resonance imaging and isotopic lymphoscintigraphy show that lymphedema occupies the epifascial compartment. Thus, fibrosis of a joint rarely occurs.|
|Stroke edema (complex edema)||Initially a simple low-protein edema from accumulation of fluid in the tissue as a result of the loss of muscle pump, dependency positioning, etc. If edema is not reduced, increased tissue hydrostatic pressure compromises lymph flow capacity, and then edema can become gel-like and indurated.||A simple pitting edema that is perpetuated by the loss of motor function (muscle pump) and eventually can become gel-like and then fibrotic.|
|Edema from kidney or liver disease (decreased plasma proteins)||Caused by decreased plasma proteins in the interstitium (i.e., loss of proteins through the urine as in nephrotic syndrome) or failure to produce plasma proteins (as in liver disease).||This is a pitting edema. MLT or MEM is not appropriate treatment.|
|Edema resulting from cardiac conditions||Heart failure, etc.||Often seen as bilateral pitting edema around the ankles/feet. However, other conditions can also produce this bilateral swelling. MLT or MEM is not appropriate treatment.|
Review of the Literature
MEM was first described in the late 1990s as a method of decreasing subacute and chronic edema in orthopedic patients through stimulation of the lymphatic system. , Using lymphatic treatment techniques for orthopedic patients to decrease subacute and chronic edema in people with healthy but overloaded lymphatic systems is relatively new. However, although the concept of MEM is relatively new, the history of MEM from a physiologic perspective is closely linked with historical revelations regarding the lymphatic system.
Throughout the 17th and 18th centuries, scientists, anatomists, and physicians described the role of the lymphatic system as part of the circulation system within the body, with lymph flowing from tissues, through the lymphatics, and into the bloodstream. Additionally, during this time frame, the connection between the lymphatic system and edema was also appearing in the literature. Treatment techniques designed to capitalize on this link between the lymphatic system and edema started appearing in the literature during the 19th and 20th centuries, as several massage therapists and physicians designed different manual techniques to stimulate the lymphatic system for edema reduction purposes. , The most well-known lymphatic massage technique, known today as manual lymphatic drainage (MLD), was developed in the 1960s through a collaboration of different German health care specialists. Since then, variations of the MLD technique have been reported in the literature under terms such as decongestive lymphatic therapy, complex decongestive physiotherapy, and lymph drainage therapy. Recently, the term manual lymphatic treatment (MLT) has been increasingly used in scientific publications to describe principles common to all schools of lymphatic drainage, and, therefore, despite the numerous acronyms, all these aforementioned techniques are designed to stimulate the lymphatic system through the application of light compression bandages, light massage, exercises, and skin care.
Currently, there is one published quasiexperimental study on MEM. This study demonstrated statistically significant reductions in edema in four of the five subjects by using a single-subject design study when MEM was entered into the standard treatment protocol. Additionally, there is one published case study on MEM demonstrating how MEM can be incorporated into a treatment program for a patient with multiple traumas to the upper limb. Although MEM is starting to appear in the literature as an effective treatment option for specific patient populations, , there is still a need for continued research on the use of lymphatic therapies for orthopedic patients because such research may alter how therapists initially treat orthopedic edema.
Theoretical Foundation: Anatomic and Physiologic Support
MEM is built on the same theoretical foundation as manual lymphatic therapies. The anatomical and physiological support for manual lymphatic therapies is that stimulation of the lymphatic system is necessary to decrease high-protein edema. , Normally, plasma proteins, which are proteins found in the blood, are present in lower concentrations in the interstitial fluid compared with the microvessels. Typically, the concentration of these larger proteins in the interstitial spaces remains low because these proteins do not diffuse easily through the microvessels. , However, after an injury, the inflammatory response changes the permeability of the microvessels, allowing these plasma proteins to leak into the interstitial spaces. ,
These plasma proteins that leak into the interstitium are too large to permeate the venous system , and need to be disposed of through the lymphatic system , because a primary role of the lymphatic system is to dispose of matter that is too large for the venous system. However, after an injury, the lymphatic system may be damaged or overloaded, which can hinder its ability to dispose of these larger plasma proteins. , If these plasma proteins remain in the interstitium, the colloid osmotic pressure, which is “the pressure to diffuse exerted by proteins and macromolecules,” of the interstitial fluid increases. This increase in the interstitial colloid osmotic pressure subsequently draws more fluid into the interstitial spaces. Therefore, if these proteins remain in the interstitium, the edema will persist because of the pull of fluid into the interstitium. Prolonged stagnation of plasma proteins in the interstitium leads to chronic inflammation. As stated by Casley-Smith and Casley Smith, “If edema lasts several weeks, this promotes chronic inflammation with its aftermath of excess fibroblasts and collagen deposition in the tissue.”
The lymphatic tissue drainage system consists of three levels of structures. The lymph capillaries, called the initial lymphatics and precollectors, make up the first level. , These structures are finger-shaped, closed at one end, netlike vessels located in the interstitium that directly or indirectly drain every part of the body. The vessels consist of a single layer of overlapping endothelial cells that have connector filaments anchoring them to surrounding connective tissue , ( Fig. 65-1 ). The flaplike junctions formed by the overlapping endothelial cells open when the local interstitial pressure changes. When the junctions open, fluid flows in, changing the internal pressure of the lymphatic from low to high, thus closing the flaplike junctions. ,
Lymph then enters the deeper tube-shaped collector lymphatics. The collector lymphatics have walls consisting of three layers. The inner layer is called the intima or endothelium. The media or middle layer consists of smooth muscle and thin strands of collagen fibers that respond to the stretch reflex. The outer layer, called the adventitia, is formed by connective tissue. Every 6 to 20 mm within the tube-shaped collectors are valves that prevent the backflow of lymph. The space, or chamber, between the valves is called a lymphangion. As fluid enters a lymphangion, it fills the segment, stimulating a stretch reflex of the medial smooth muscle layer. The ensuing contraction causes the proximal valve to open and propel the lymph to the next proximal lymphangion , ( Fig. 65-2 ). At rest, lymphangions pump 6 to 10 times per minute. However, with muscle contraction from exercise, lymphangions can pump 10 times that amount. ,
The collector lymphatics propel lymph to the nodes. The nodes consist of a complex of sinuses that perform immunologic functions. After leaving the nodes, lymph either enters the venous system through lymph-venous anastomoses or continues to move into deeper lymphatic trunks and eventually returns to the blood circulatory system via the left and right subclavian veins.
Anatomically, the trunk is divided into four lymphatic quadrants, or lymphotomes (drainage territories). These consist of left and right upper quadrants, called thoracic lymphotomes, and left and right lower quadrants, called abdominal lymphotomes. The thoracic lymphotomes extend from the anterior midline to the vertebral column on both the left and right sides of the upper trunk. Lymph drains within the lymphotomes from superficial to deeper vessels that connect to nodes. Between the lymphotomes are watershed areas (i.e., dividing areas) where normal drainage is away from the watershed, moving toward the nodes. , There are only a few superficial and deep connecting lymph vessels across watershed areas, but there are superficial collateral vessels. These collateral connections across watersheds are very important because when there is lymph congestion, they provide alternative pathways to uncongested lymph vessels. The extremities also have lymphotomes. The upper extremity lymphotomes drain mainly into the axillary nodes. Detail of this information and more extensive drawings can be found in the work of Kubik.
Lymph from the right thoracic lymphotome, right upper extremity, and right side of the head drains into trunks that eventually empty into the right lymphatic duct. This duct empties into the right subclavian vein and into the superior vena cava of the heart. Both lower extremities, both abdominal lymphotomes, the left thoracic lymphotome, and the left side of the head drain into the thoracic duct, which is the largest lymphatic vessel in the body and extends from L2 to T4. , The thoracic duct empties into the venous system at the juncture of the left subclavian and jugular veins. As described by Chikly, “the lymphatic system is therefore a second pathway back to the heart, parallel to the blood venous system.”
The lymphatic system is described as “a ‘scavenger’ system that removes excess fluid, debris and other materials from the tissue spaces.” It is an alternate path for those substances that are too large to be disposed of through the venous system. There is a close link, therefore, between an adequately functioning lymphatic system and edema because “oedema can only occur if the lymphatic system has failed.”
Therefore, the overall theory of lymphatic therapies, including MEM, is to remove plasma proteins from edematous areas by stimulating the lymphatic system, which subsequently enables these proteins to leave the interstitial spaces and enter the lymphatic structures. By ridding the interstitial spaces of these hydrophilic proteins, subacute and chronic edema decreases.
Differences Between MLT and MEM
Despite physiologic similarities between MLT and MEM, there are differences worth noting. One difference between the MLT technique and the MEM technique is the patient population. MLT techniques were originally devised for individuals with lymphedema, which is a high plasma protein edema associated with a mechanical obstruction or insufficiency of the lymphatic system. MEM was designed for orthopedic patients with subacute and chronic edema in whom the lymphatic system is intact but temporarily overloaded.
Another difference between the MLT techniques and the MEM technique is the length of the treatment. Because MLT is used on people with a permanently insufficient lymphatic system, the treatment sessions are longer and more involved because large amounts of fluid may need to be rerouted throughout the body. Conversely, because the MEM technique is used on people with intact lymphatic systems, the treatment sessions are shorter and typically involve moving less fluid. Also, unique to MEM is the use of pump point stimulation, which helps to eliminate the extensive massage time spent on an involved extremity because of the simultaneous stimulation of areas in the body with concentrated lymphatic structures. When using MEM on someone with subacute edema that has been present for 3 to 4 weeks, it is not unusual to see the edema decrease after two 20-minute sessions, especially if the patient is compliant with the home MEM program. These shorter treatment sessions are conducive to the needs of today’s clinicians in the orthopedic setting.
Manual Edema Mobilization Concepts
The basic MEM technique consists of diaphragmatic breathing, light skin-traction massage, exercise, pump point stimulation, and a self-management program. Adjunctive methods such as chip bags, low-stretch bandaging, and Kinesio taping may also be used for patients with chronic edema, when lymph softening techniques are necessary. To effectively use the MEM treatment method, therapists need an understanding of the physiologic and anatomic rationale underlying the five basic treatment concepts as related to lymphatic stimulation ( Table 65-2 ).
|Anatomic Rationale||Physiologic Rationale|
|Premise 1: diaphragmatic breathing|
|Premise 2: light skin massage|
|Premise 3: exercise||Lymphangions are muscular units found in the collector lymphatics|
|Premise 4: pump point stimulation||Refer to Table 65-3||Fluid moves from an area of higher concentration to an area of lower concentration|
|Premise 5: low-stretch bandaging||See Premise 2.||Changes in interstitial pressure increase initial lymphatic protein absorption. Neutral warmth softens indurated tissue increasing lymph flow|
MEM Treatment Concept 1: Diaphragmatic Breathing
All MEM sessions begin with deep, diaphragmatic breathing. This “belly” breathing involves breathing in deeply through the nose, causing the abdomen to expand, and then slowly exhaling through “pursed” lips. Feeling or seeing the rise and fall of the abdomen can help the therapist ensure that the patient is correctly performing the technique. ,
Respiration changes tissue pressure, and thus lymphatic absorption is stimulated. The thoracic duct is the largest and one of the deepest lymphatic structures. It lies anterior to and parallel with the spine beginning at L2 and terminating into the left subclavian vein at approximately T4. Diaphragmatic breathing, also known as the pulmonary pump, changes pressure within the thoracic duct. , The thoracic duct functions on hydrodynamic principles. Therefore, the pressure differential created from diaphragmatic breathing helps propel the lymph centrally toward the subclavian veins. These pressure changes in the thoracic duct then create a vacuum (suction), pulling lymph from the peripheral structures centrally.
MEM Treatment Concept 2: Light Skin-Traction Massage
A light skin-traction massage is a massage so light that no blanching or indentation of the skin occurs yet it is firm enough to move the skin, thereby preventing the hand from sliding on the skin. The light skin-traction massage technique involves a rhythmical massage that forms U shapes on the skin, with the opening of each U in the direction of lymphatic flow proximally to an uninvolved or previously decongested area. The massage technique should remain light and should follow lymphatic pathways.
Clearing U Massage
Initially, the therapist performs the MEM massage technique (the U technique) in one segment of the body, starting proximally (or centrally) and moving distally down the segment. This proximal- (or central-) to-distal massage technique is referred to as the “clearing U s,” and its purpose is to clear the lymphatic system within that segment. The clearing U s technique consists of performing five consecutive U massages in the most proximal (or central) location within that segment, then performing another five U massages just distal to the previous five, and continuing in this manner down to the distal portion of that segment. For example, if edema is in the right hand, the clearing U s would start with five U s at the left shoulder region, then five at the left clavicle, five over the sternum, five over the right clavicle, five at the right shoulder region, and so on down the arm until the therapist reached the hand.
Immediately after performing the clearing U massage technique in each section (trunk, upper arm, elbow, forearm, hand), active and/or passive exercises that move the joints and muscles associated with the recently cleared body segment are performed. In the example given, active and/or passive shoulder flexion, shoulder abduction, elbow flexion/extension, wrist flexion/extension, and fisting exercises would be performed after the clearing U massage.
Once the clearing U massages have been performed throughout the entire segment and the active and/or passive exercises have been performed, that segment is then considered cleared. The purpose of clearing a segment is to open and clear out the lymphatic pathways to allow the flow of lymph into the central structures.
Flowing U Massage
After a segment has been cleared, the therapist changes the direction of the massage technique to promote the flow of lymph through the recently cleared segment. During the flow portion, the U massage is performed distally to proximally (or centrally) within the newly cleared segment. This distal-to-proximal (or -central) massage technique is referred to as “flowing U s,” and it consists of performing one U massage in a distal location within the cleared segment, then performing another U massage just proximal to the previous one, and continuing up to the most proximal portion of the segment. At this point, the sequence is repeated until five U massages have “flowed” up the cleared segment.
In the previous example, after the right arm had been cleared, the therapist would perform one U massage over the dorsum of the right hand, then over the right volar wrist, the right volar forearm, the right cubital tunnel, the right volar upper arm, the right shoulder, the right clavicle, the sternum, the left clavicle, and then finally the left axilla. This entire sequence would then be performed a total of five times to “flow” the lymph up the right arm over to the left axilla, so it drains centrally. Flowing U massage consists of sequential U s (one following another) starting in the distal part of the segment being treated and moving proximally past the nearest set of lymph nodes. The flowing can be described as “waltzing” up the arm. After the five flowing U s have been performed within a segment, active and/or passive exercises associated with the body area are performed.
Differences Between Clearing U Massage and Flowing U Massage
Although the clearing U massage and the flowing U massage are performed in the same segmental area, they differ from each other in two ways. First, the clearing U massage is performed in a proximal- (or central-) to-distal fashion, whereas the flowing U massage is performed in a distal-to-proximal (or -central) fashion. Second, the clearing U massage consists of performing five U massages in each location before moving distally, whereas the flowing U massage consists of performing only one U massage distally within a segment, and then moving sequentially up the segment until the proximal (or central) portion of that segment is reached. The flowing U massage sequence is then repeated a total of five times ( Figs. 65-3 through 65-5 ).