* I would like to express my gratitude to the following people who contributed their time and material for this chapter: Janine Hareau, PhD, PT, OT, from Clinica de Rehabilitacion de la Mano Montevideo Uruguay for data and photos of M.G.; Joni Westenberger, OTR, from Occupational Therapy and Hand Clinic, West Bend, Wisconsin, for providing the L.S. case study data; Judy Colditz, OTR, CHT, FAOTA, of Raleigh, North Carolina, for drawing Fig. 53-4 ; to Alice Pollack, teacher and artist, from Colgate, Wisconsin, for all of the MEM sketches; and finally to Cynthia Cooper, MFA, MA, OTR, CHT, and Wendy Camp, OTR, CHT, for their insights and inspirations. A separate special thanks to Anne Callahan and the other editors of this text who are willing to risk bringing new concepts to the hand therapy community and for their challenging questions that mentored me through the development of this chapter and its subsequent effect on MEM. Thanks.
Manual edema mobilization (MEM) is not indicated for all hand patients but can be highly effective in cases of recalcitrant subacute or chronic edema. “Oedema is glue,” a phrase popularized by Watson-Jones in 1941, sums up the importance of reducing edema in swollen hands. Many edema treatment techniques were developed with the rationale that they “stimulated the venous and lymphatic systems.” This rationale gave the impression that one technique would affect each system with equal effectiveness. Clinically, however, some edemas seemed to reduce with little effort, whereas others progressed into a gellike and fibrotic state regardless of the intensity of therapy. The purpose of this chapter is to present the physiologic rationale and clinical application of MEM, developed by Artzberger in 1995. MEM is used to prevent or reduce subacute or chronic high-protein edema as seen in postsurgical, trauma, or post–cerebrovascular accident (CVA) hand edema.Review of the Literature
Information specifically about the role of the lymphatic system for reducing edema, or methods to activate lymph uptake from the interstitium, has not been readily addressed in American hand therapy literature. A Medline and CINAHL search going back 20 years using the search terms hand edema and hand edema rehabilitation listed 32 articles and only 2 specifically discussed lymphatic function and edema reduction.
Burkhardt and Joachim published a one-paragraph description of manual lymph drainage. Faghri acknowledged the role of lymphatics for drainage of protein-rich fluid from the tissues in his research using neuromuscular stimulation on the edematous hands of CVA patients. Numerous animal research studies addressing the effects of electrical stimulation for edema reduction, edema prevention, and lymphatic stimulation for protein uptake have been conducted.
In Europe, the significance of the lymphatics for reducing edema became widely known from the work begun in the 1930s by Emil Vodder, a massage therapist, who called his therapy manual lymphatic drainage (MLD). Initially, the therapy was directed at reducing recurrent nose and throat infections and later involved other conditions. Following Vodder’s successes, others began researching lymphatic function, mapping lymphatic pathways, and in recent decades, using the electron microscope to study the lymphatic system. Some of these physicians and researchers developed treatment techniques (e.g., compression bandaging, remedial exercise programs) that continue to be the standard for reducing lymphedema. Manual lymphedema treatment (MLT) is a generic term used to describe massage principles common to all schools of lymphatic drainage. The most common application of MLT techniques is for secondary lymphedema that can occur after breast or prostate cancer treatment (i.e., lymphadenectomy and/or lymph node radiation), in filariasis (filarial worm infestation damaging the lymphatic vessels and/or nodes), and in primary lymphedema (congenital, unknown cause).
In the mid-1990s, the use of MLT (drainage) techniques for secondary and primary lymphedema started to become known and gain popularity in the United States through reported outcomes. Experts such as the Casley-Smiths from Australia report that this lymph drainage technique works for “other edemas,” referring to inflammation and sports injuries. However, little information is given regarding specific application or methods to reduce these “other edemas.” These “other edemas” have an etiology different than the types of lymphedema described earlier, but the element common to all is an increase in plasma proteins in the interstitium and decreased lymph transport capacity. A high-protein edema has a concentration of plasma proteins greater than 1 g/dl in the tissue fluid. If excess plasma proteins remain in tissue for a prolonged period, they cause chronic inflammation, with the eventual fibrosis of tissue. For high-plasma protein edemas, a program of MEM or MLT is necessary to move excess proteins out of the interstitium to break the scenario of chronic inflammation leading to fibrosis. Only lymphatic drainage along with macrophage phagocytic activity removes the excess proteins. Table 53-1 describes common types of high-protein edemas, complex edemas, and low-protein edemas commonly seen by therapists. From reading the table, it becomes evident that as soon as there is some type of compromise of the lymphatic system and excess proteins remain in the interstitium, the gellike edema begins, which can lead to fibrosis.
| 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 as a result of an excess of plasma proteins flowing into the interstitium. There is also a temporary obstruction and/or damage to the surrounding lymphatics that decreases protein uptake. | Inflammatory edema usually spontaneously decreases within 2 days to 2 weeks. It responds to elevation because this decreases arterial hydrostatic pressure and thus reduces the flowing of fluid into the interstitium. If edema lingers beyond 2 weeks, it is considered subacute. Now there is a decreased lymphatic transport out of the involved area as a result of damage or destruction of the lymphatics resulting from incisional scar, compression from a cast, tissue loss, etc. Fibroblasts are activated by the proteins trapped in the interstitium and produce collagenous tissue. Thus, in the subacute phase, edema progresses from a soft spongy state to a dense gellike state. Edema lasting 3 months and longer is considered chronic and often leads to a fibrotic state. |
| Lymphedema (high-plasma protein edema) |
|
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| Stroke edema (complex edema) | Initially a simple low-protein edema from accumulation of fluid in the tissue as a result of 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 gellike and indurated. | A simple pitting edema that is perpetuated by loss of motor function (muscle pump) and eventually can become gellike and then fibrotic. |
| Venous edema (legs) (complex edema) | Excess low-protein fluid in tissue as a result of valve dysfunction or incompetence resulting in venous stasis. In severe cases, tissue hydrostatic pressure increases significantly, causing a leakage of plasma proteins, red blood cells, etc., into the interstitium. Tissue becomes indurated, “leathery,” and discolored by hemosiderin (an iron-rich pigment that is a byproduct of red cell breakdown). | At first, this is a simple pitting edema of excess fluid in the tissue that will decrease with elevation, compression hose, and retrograde massage because these push low-protein fluid from the periphery into the deep venous system. As venous valve incompetence progresses, tissue becomes hard. Previous treatment has minimal effect because the lymphatic system is compromised from the increased tissue hydrostatic pressure, resulting in eventual leakage of plasma proteins and red blood cells into the tissue. |
| 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). |
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| 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. |
The Lymphatic System
Anatomy of the Lymphatic System
A knowledge of the anatomy of the lymphatic system and its function is essential to develop effective edema reduction treatment programs. This understanding begins at the arterial, venous, and lymphatic capillary level. Arteriole hydrostatic pressure of 35 mm Hg is sufficient to cause the escape into the interstitium of electrolytes, nutrients, a few plasma proteins, and other elements needed for continued tissue cell metabolism. Ninety percent of the plasma and protein substances not needed by the cells leave the interstitium via the venous system; the remaining 10% leave via the lymphatic system. When fluid and large molecules enter the lymphatic system, it is called lymph. Lymph contains large molecules not permeable to the venous system, such as fat cells, hormones, tissue waste products, bacteria, and excess plasma proteins. The lymphatic tissue drainage system consists of three levels of structures. Lymph capillaries, called the initial lymphatics and precollectors, make up the first level. These 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. 53-1 ). The flaplike junctions formed by the overlapping endothelial cells open when the local interstitial pressure changes. 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 into the deeper collector lymphatics that 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 collectors are valves that prevent the backflow of lymph. These collector segments with a distal and a proximal valve and a space between the valves are called lymphangions. 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. 53-2 ). At rest, lymphangions pump 6 to 10 times per minute. However, with muscle contraction from exercise, lymphangions can pump 10 times that amount.
Collector lymphatics propel lymph to the nodes. The nodes consist of a complex of sinuses that perform immunologic functions. After leaving nodes, lymph either enters the venous system through lymph-venous anastomoses or continues to move into deeper lymphatic trunks and eventually returns to the heart.
Anatomically, the trunk is divided into four lymphatic quadrants, or lymphotomes (drainage territories) ( Fig. 53-3 ). 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 (see Fig. 53-3 ). Between the lymphotomes are watershed areas (i.e., dividing areas) where normal drainage is away from the watershed moving toward the nodes (see Fig. 53-3 ). 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 Foldi and 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.
Clinical Application of Lymphatic Anatomy and Physiology
Success of edema reduction programs and related problem solving depends on clinically applying lymphatic anatomic information. For instance, movement of the large molecules not permeable to the venous system out of the interstitium depends on stimulating the flaplike endothelial cell junctions of the initial lymphatics to open and close. Heavy massage or compression will not stimulate, but instead collapse, the initial lymphatics and prevent absorption of lymph. Eliska and Eliskova found that a 10-minute friction massage to the dorsum of feet done with 70 to 100 mm Hg of force caused temporary damage to the endothelial lining of the initial and collector lymphatics. For patients with edema, this damage occurred within 3 to 5 minutes. Miller and Seale found that external pressure facilitates lymph clearance. They also found that a pressure of 60 mm Hg initiated lymphatic closure, with complete closure at 75 mm Hg. With complete closure of the initial lymphatics, there is no uptake of lymph from the interstitium. Thus the clinical treatment approach should be light-compression massage to stimulate, not hinder, absorption at the dermis level. Heavy compression or squeezing collapses the lymphatics, causing the fluid component of lymph to be pushed into the venous system. However, plasma proteins, tissue waste products, fat cells, and so forth, remain in the interstitium. The digit or limb temporarily looks smaller, but the swelling returns. Plasma proteins that remain in the interstitium increase colloid osmotic pressure, attracting more fluid out of the capillaries and into the interstitium, thus refilling occurs.
Light compression of initial lymphatics for absorption of protein can also be accomplished through a multilayered low-stretch bandaging system. Leduc et al. demonstrated that multilayered bandages consisting of stockinette, latex foam, and low-stretch bandages placed on the forearm, combined with exercise, had a positive effect of absorbing protein from the interstitium. It has also been shown that temperature affects movement of lymph. The flow of lymph within the vessel is best between 22° and 41° C and sharply slows down or stops before and after those temperatures. Thus bandaging can clinically affect the protein absorption, provide light compression, and provide a buildup of “neutral warmth” to mobilize lymph.
Lymph moves from the collector lymphatics through the lymph nodes. The Casley-Smiths state that congestion of lymph is often present around lymph nodes. They further state that lymph nodes give 100 times the resistance to the flow of fluid as the thoracic duct. Thus nodes can act as “bottlenecks” or “kinks in the hose” to the flow of lymph fluid as it is being filtered through them for immunologic purposes. In clinical treatment, it is seen that massaging the nodes proximal to the edematous site increases the rate of lymph movement out of the area and prevents lymph congestion in the node area. Thus, if the nodes proximal to the edematous area are first massaged (e.g., cubital elbow nodes when there is hand edema), tissue massage and active muscle contraction can more effectively move congested lymph out of an area. Enlarged nodes (e.g., potentially fighting infection) should never be massaged.
All lymph fluid eventually returns to the venous system and enters the heart as part of the venous system. As a result, therapists have to be careful not to quickly return a large volume of fluid back into the heart if there are any preexisting or uncontrolled cardiac or pulmonary problems. MEM classes teach how to safeguard against potential problems.
The division of the trunk into four lymphatic quadrants, or lymphotomes, is significant clinically. When edema is present, it often backs up into the entire quadrant. Pecking et al. showed that in a postmastectomy lymphedema patient, the speed of lymphatic transport increased in the involved hand immediately if the contralateral normal quadrant was treated with MLD. Pecking et al. also reported a 12% to 38% uptake from the involved limb when nodes were massaged in the contralateral axilla. Thus, when possible, MEM techniques begin in the contralateral quadrant. MEM done in the contralateral thoracic lymphotome can facilitate the flow of lymph across the few collateral lymph vessels lying deep and superficial in the watershed areas.
The final feature of the lymphatics to be addressed is effect of exercise on lymph uptake. Weissleder and Schuchhardt state that lymphatic uptake is increased by up to 10 times with exercise because muscle contraction increases the rate of lymphangion contraction. Exercise also increases the pumping speed of the thoracic duct. Thus exercise facilitates the movement of lymph fluid. It has been theorized that stretching and range-of-motion (ROM) exercises started proximally will have the effect of moving the most central lymph further in the direction of the heart and kidneys, and more peripheral fluid will move centrally. Vodder believed that changes in the intrathoracic pressure that occur during exercise and diaphragmatic breathing will stimulate lymph to flow more proximally in the thoracic duct. For these reasons, MEM includes a program that begins with diaphragmatic breathing, followed by exercises that begin at the trunk and proceed distally to the digits. In some cases, I have seen that this intervention alone will move lymph out of an area, for example, out of an edematous upper arm.
Table 53-2 summarizes some of the unique features of the lymphatic system with clinical application.
| 7 Whys | Rationale | Clinical Application |
|---|---|---|
| Why keep pressures light? | Initial and precollector lymphatics have to be stimulated to open and close to uptake lymph ; it is not a passive filtration/osmosis system. | Keep compression light to avoid collapse of the dermis layer lymphatics. |
| Why are stimuli needed to facilitate lymphatic pumping? | Initial lymphatics have no pumping mechanism of their own and have to be stimulated to open and close to uptake the large molecules and fluid from the interstitium. Collector lymphatics are capable of pumping. | Initial lymphatic uptake and flow are increased by mild stimulation, such as massage, light compression, and muscle contraction. Collector lymphatic rate of pumping is increased by surrounding muscle contraction. |
| Why start proximal? | Research by Pecking et al. showed that in a postmastectomy lymphedema case, the speed of lymphatic transport from the involved hand increased immediately if the contralateral normal quadrant was treated by MLD. They also reported a 12% to 38% uptake in the involved limb when the contralateral axillary nodes were massaged. | Start light manipulation (massage) very proximal to the edema. Start stimulation in the noninvolved contralateral quadrant. |
| Why proximal exercise? | Exercise and diaphragmatic breathing cause changes in the intrathoracic pressure, which draws lymph centrally. | Create a proximal suctioning effect by beginning exercises at the trunk. |
| Why massage nodes? | Lymph fluid passes through lymph nodes that can give 100 times the resistance to the flow of fluid as the thoracic duct. Nodes can become a “bottle neck” or “kink in the hose” to flow of lymph. | Use heavier manipulation (massage) pressure at the nodes. |
| Why exercise? | Exercise can increase lymph transport 10 times. | Consider a total body exercise program. |
| Why low-stretch multilayer bandages? | Leduc et al. found that the combination of multilayered bandages on the forearm and exercise increased protein absorption. Optimal temperatures to facilitate lymph movement are between 22° and 41° C. | When induration is present, consider using low-stretch bandages to increase protein absorption during exercise and for the buildup of “neutral warmth” and light compression with prolonged use for increasing lymph mobility. |
Definition and Principles of Manual Edema Mobilization
Casley-Smith and Gaffney found that when they injected excess native proteins into rat tissue, it caused chronic inflammation within 64 days. The Casley-Smiths also state, “If edema lasts several weeks, this promotes chronic inflammation with its aftermath of excess fibroblasts and collagen deposition in the tissue.” Thus the goal of therapy should be to reduce the excess plasma proteins in the interstitium. This will potentially reduce or eliminate chronic inflammation and eventual fibrosis of tissue.
MEM is a method of edema reduction based on methods to activate the lymphatic system ( Box 53-1 ). These methods include the principles of MLT massage, medical compression bandaging, exercise, and external compression adapted to meet the specific needs of subacute and chronic postsurgical and poststroke upper extremity edema. The goals are to stimulate the initial lymphatics to absorb excessive fluid and large molecules from the interstitium and to move this lymph centrally. See Fig. 53-4 for direction of lymph flow in the arm.
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Light massage, ranging from 20 to 30 mm Hg pressure, is used to prevent collapse of the lymphatic pathways or arterial capillary reflux.
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Where protocol allows, preexercises and postexercises are performed in a specific sequence, starting proximal to the edematous area or in the contralateral quadrant, if possible.
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Massage is performed in segments, proximal to distal, then distal to proximal. The direction of the massage ends proximal, meaning toward the trunk.
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When possible, treatment includes exercises specific to muscles in the segment being massaged.
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Massage follows the flow of lymphatic pathways.
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Massage reroutes around scar areas.
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This provides a method of massage and type of exercise that does not cause further inflammation of the involved tissue.
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Treatment includes a patient home self-massage treatment program specific to the hand condition.
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Adaptations to various diagnoses and stages of high-plasma protein edema are available.
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Guidelines are available for incorporating traditional edema control, soft tissue mobilization, and strengthening exercises without causing an increase in edema.
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Specific precautions are followed.
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When necessary, low-stretch compression bandaging or other compression techniques are incorporated.
Contraindications for Manual Edema Mobilization
Precautions and contraindications are those universal to most massage programs and specific to the impact of moving large volumes of fluid through the system ( Box 53-2 ). A physician should always be consulted if the therapist is concerned about the patient’s present or past cardiac or pulmonary status. For instance, if there is an 80-ml volumetric difference between the two extremities, a therapist should inform the physician that there is the potential to move that much fluid through the heart and lungs. The physician should be asked whether this would compromise the patient’s cardiac status.
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If infection is present because there is the potential to spread the infection
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Over areas of inflammation because of the potential of increasing the inflammation and pain (Do MEM proximal to the inflammation to decrease congested fluid.)
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If there is a blood clot or hematoma in the area because there is the opportunity to activate (move) the clot
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If there is active cancer (A controversial theory notes the potential to spread cancer. Absolutely never do MEM if the cancer is not being medically treated. Always seek a physician’s advice.)
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If the patient has congestive heart failure, severe cardiac problems, or pulmonary problems because there is the potential to overload the cardiac and pulmonary systems
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In the inflammation stage of acute wound healing because theoretically there is the possibility to disrupt the “clean-up” process and the invasion of fibroblasts
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If renal failure or severe kidney disease problems exist (This is not a high-protein edema. There is the potential for overloading the renal system and/or moving the fluid elsewhere.)
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If the patient has primary lymphedema or postmastectomy lymphedema (To successfully treat this condition involves knowing how to reroute lymph to other parts of the body and how to perform specific treatment techniques that are beyond the scope of this chapter.)
Overview of Three Manual Edema Mobilization Treatment Concepts
The following is an overview of three MEM treatment concepts: “clear” and “flow” exercises, MEM drainage terms, and incorporation of traditional treatment techniques. It is not intended as treatment instruction. Only an MEM course can fully teach the concepts needed for safe application. The biologic and scientific rationale for many of these concepts is found in Table 53-2 .
Concept I: “Clear” and “Flow” Exercises
Every session starts with active or passive exercise beginning proximal to the edema, if not contraindicated for the specific diagnosis. Best results are obtained if the exercises begin at the trunk. These are called clear exercises; these exercises facilitate first the proximal fluid to move deeper into the trunk and the more distal fluid to move proximally. After the massage or drainage part of MEM treatment, the patient is asked to do “flow exercises.” Because of the sequence, these exercises facilitate distal fluid and lymph to move proximal by the muscle pump action. Critical to effective edema reduction is active muscle contraction (if not contraindicated by the diagnosis) following the lymphatic and node stimulation in the particular segment that was massaged before proceeding to the next segment.
Clear exercises start with diaphragmatic breathing, which causes a change in thoracic pressure. Next, the patient massages the axillary nodes of the uninvolved and then the involved extremity. Exercises begin at the trunk and progress distally to the digits. These exercises could consist of trunk twists and lateral bends, head and neck rotation, shoulder flexion/extension, shoulder horizontal abduction/adduction, back and forward shoulder rolls, pectoralis stretches, elbow flexion/extension and forearm supination/pronation, wrist flexion/extension and circumduction, and extrinsic and intrinsic finger motion.
Flow exercises are performed at the end of the massage and involve active muscle contraction or passive movement starting at the digits and ending at the trunk. This is a reversed sequence of the same exercises used for the clear exercises.
To cause stretch and compression on the lymph nodes and to achieve good muscle pumping action, these exercises must be taken to full muscle excursion when protocol allows. Choosing appropriate exercises is based on what is allowable within the diagnosis protocol. A home program that incorporates clear and flow exercises is essential to success.
Concept II: MEM Massage, Drainage, and Term Description
U ‘s are a pattern of hand movement that involves placing the flat, but relaxed, hand lightly on the skin. The hand gently tractions the skin slightly distal and circles back up and around, ending in the direction of the lymph flow pattern. The movement is consistently a clockwise or counterclockwise motion in a U or teardrop configuration. A very light pressure of 20 mm Hg or less is used to move just the skin, thereby stimulating the initial lymphatics. Clinically, this is taught by having the therapist place the full weight of his or her hand on the patient’s arm and then lifting so that only half the hand weight rests on the arm. However, the therapist’s entire palm and digits must remain in contact with the patient’s skin. The MEM massage proceeds at this very light pressure tractioning and moving, not sliding, the skin.
Clearing ‘s are a pattern of skin tractioning done in segments starting proximal and moving to the designated distal part of the trunk or arm segment (i.e., the upper arm, forearm, or hand). A minimum of five U ‘s are done in three sections of each segment. The purpose is to create interstitial pressure changes, causing the initial lymphatics to uptake lymph. The direction of “flow” movement follows the lymphatic pathways toward the heart (i.e., flowing proximally, not distally). Active muscle contraction is done in each segment following “clearing” in that segment, if not contraindicated by diagnosis protocol. This increases the rate of lymphangion contraction.
Flowing ‘s consist 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 or slightly beyond them. This could be described as “waltzing” up the arm. This process of moving one U after another from distal to beyond the node is repeated five times. When the final repetition is completed, the flowing U motion is performed all the way to the contralateral upper quadrant. The purpose is to move the softened lymph out of the entire segment and facilitate its eventual return back into the venous system and the heart.
Stimulating ‘s consist of several light “in-place U ‘s” done to soften thickened or indurated tissue. At the lymph nodes, more pressure (i.e., 30 to 40 mm Hg) is used because of the resistance that nodes give to lymph flow.
Concept III: Incorporation of Traditional Treatment Techniques
Clinically, it has been seen that MEM decreases swelling and pain. Traditional treatment techniques are still essential to increase ROM, decrease stiffness if present, and increase strength and so on. It has also been observed that using selected traditional edema control techniques works more effectively and with a consistent edema reduction after initiation of MEM. However, if traditional treatment techniques are done too vigorously, causing even microscopic reinflammation of tissue, then swelling recurs. Thus therapists have to progressively grade advancement of treatment programs and assess whether the traditional technique they are using will collapse the lymphatics.
Case Examples
The results of using MEM can be seen in the following brief case examples. The first case example, Mrs. M.G., shows the results of exclusive initial use of MEM and low-stretch bandaging followed by ROM modalities once the edema reduction had begun. The second example, Mr. L.S., demonstrates edema reduction with the exclusive use of MEM after edema was not reduced with traditional techniques.
Case Example: Mrs. M.G.
M.G. is a 75-year-old woman who was referred to hand therapy 8 weeks after a (L) hand infection that had involved the thumb, thenar eminence, and first dorsal interosseous space ( Fig. 53-5 ). Infection was resolved after a series of antibiotics. The exact cause of the infection was never determined but was thought to be related to a (L) thumb nailbed infection. Evaluation revealed severe hand inflammation, severe left hand thenar eminence and dorsal swelling, “spongy pitting” dorsal hand and digit edema, shiny taut tissue on the dorsum of the hand and digits, a pain rating of an 8 on a scale of 1 to 10, active flexion ranging 0 to 20 degrees for each joint of each digit, full active extension to 0 of all digits, pain prohibiting passive flexion, no functional use of the hand, and sensory limitations ranging from decreased to loss of protective sensation throughout the entire hand. Hand pain prevented M.G. from sleeping throughout the night for 8 weeks. Left and right comparison girth measurements were taken at the elbow, palm, wrist, and proximal phalanx of each digit. These girth measurements were totaled up for each upper extremity from elbow to fingertips. The total girth measurement for the left was 102.5 cm, compared with 89 cm on the right, or a 13.5-cm girth difference.
