Fundamentals of Edema management and nerve desensitization/ re-education

Edema vs Swelling

- Common condition after UE injury or surgery
- Swelling- enlargement of the tissue
o Tumor, excessive fluid, infection, inflammation
- Edema- excessive amount of fluid in the interstitial space
o Edema is not seen by the naked eye until interstitial fluid has increased over 30%

Edema

- Acute (0-4 days)
- Mild
- Brawny (non-pitting)- cannot be indented easily
- Pitting- leaves a pit or indentation
- Lymphedema-caused by removal or damage to lymph nodes

Damage from edema

- Swelling can lead to fibrin deposited into the spaces surrounding the joints, tendons and ligaments resulting in decreased mobility, flattening of hand arches, tissue atrophy and further disuse.
- Gliding of tendons and tissues is eliminated resulting in a stiff and painful hand.
- Scar adhesions form and limit tissue mobility
- Edema untreated can lead to permanent loss of function

Edema risk factors

o Medications
o Sitting/Standing too long
o Obesity
o Pregnancy
Low Protein

Edema treatment

o Elevation (mild)
o Diuretics (severe)
o Compression (chronic)

Circumferential edema measurement

- Flexible tape to measure around the hand/ limb in a circular patter at specific anatomical landmarks.

Edema Management opportunities

- Elevation
- AROM
- Manual edema mobilization
- Compression
- KT tape

Elevation

- Elevation- Gravity assists with fluid drainage
- Elevate hand above the heart
o Elbow higher than shoulder
o Wrist higher than elbow
o Hand higher than wrist
o Extended elbow
o Support pathway of drainage

AROM

o Be mindful of any medical contradictions.
o Patient should use the hand for ADLs within limitations
o Ok for light ADLs when had is in a dressing

Manual edema mobilization (MEM)

- MEM-Manual Edema Mobilization

- Light proximal to distal than distal to proximal mobilization of the skin

- Massage over lymph notes proximal to edema

- Contraindications:

- Blood clots, CHF, renal failure, CA **

- MEM based upon lymphatic drainage system

-** Goal: Stimulate the initial lymphatics to absorb excess fluid

Techniques

- Provide light, stroking massage of the involved area, very light pressure
- Incorporate exercise before and after massage in specific sequence
- Massage is done in segments, proximal to distal
- Massage reroutes around incision areas
- MAM should not cause additional inflammation
- MEM HEP
- Incorporate low stretch bandaging for warmth to soften hardened tissues

Compression

- External compression
- Reinforces tissue hydrostatic pressure and facilities venous and lymph flow
- Contraindications = severe arterial insufficiency, DVT, heart failure, HTN, active TB

Types of compression

- Stokinette
- string wrapping
- coban
- KT tape

Stokinette

o Elastic Tubular Stockinette
o Gentle compression
o Cut to size
o Combination with edema glove
o Monitor the skin for marks (too tight)

String wrapping

o Outdated
o Distal to proximal compression to move edema

Coban

o Short Stretch- 20% of the original length

KT tape

o Increase lymphatic & vascular flow leading to reduced edema and diminishing pain
o Lymphatic and venous circulation
§ raising the epidermis
§ Creating space for drainage
§ Applying the tape in the direction of lymphatic flow
o ***Contraindications
§ Allergy, open wounds, DVT, infection, CA

Contrast bath

o Contrast Bath video: https://youtu.be/lyf3g_byG1o
o Creates a "pumping effect" for edema reduction
o ** Edema reduction- end in cold water
o ** Pain- end in warm water
o Contraindication:
o Open wounds, poorly controlled epilepsy, HTN, and DMII

Intermittent pneumatic compression (SCD)

o Pump that consists of multiple pressure compartments that encompass the entire limb
o SCD-Sequential Compression Device
o Working distal to proximal
o Moves the edema to lymph drainage areas
o **Contraindications
§ CHF, DVT, PE, infection, CA, non-healed fx

E-stim

o Muscle contractions to assist with lymphatic drainage
o Current high enough to elicit muscle contraction- encourage pt. to use muscles during contraction
o Tx: 20 min- 5 min on/off cycle
o Contraindications: pregnancy, pacemaker, active TB, thrombosis, active hemorrhage

Cryptherapy

o Acute edema
o Ice packs, gel wraps, cold water baths
o Promotes vasoconstriction & reduces local blood flow
o Decreases prostaglandin synthesis & histamines reducing pain & swelling
o Contraindications: DVT, thrombophlebitis, impaired sensation, nerve regeneration, impaired circulation, chronic wounds.

Edema glove

o Gentle compression of nylon or spandex
o 15-25 mm Hg pressure stimulate superficial lymphatic system
o Custom & off the shelf available

Nerve injuries

- Following nerve repair, the hand is placed in a position that minimizes tension to the nerve.

- Orthosis can be used to substitute for weakened musculature

- Sensory Re-education/ Desensitization Program

- Tendon Transfers- If a motor nerve has not reinnervated its muscle after one year- surgeon may consider a tendon transfer to restore a needed motion

- Flexor/ Extensor Injuries

Desensitization/Re-education

- Hyperalgesia: or hypersensitivity occurs following hand trauma
- The patient will experience exaggerated, painful response to nonpainful stimuli
- Desensitization techniques are used to diminish of symptoms of hypersensitivity to gradually increase tolerance of for touch
- Sensory re-training or sensory re-education is a cognitive behavior therapy technique that helps the patient with nerve injury to a meaningfully interpret the altered profile or neural impulses
- Repetitive neural input from sensory re-training exercises uses neuroplasticity to retrain the brain
- Nerve grows approx. 1 mm per day resulting in a new sensibility that you need to interpret
- The brain has a detailed map of the body where touch is registered and interpreted
- Need to re-train the brain

Treatment goal **

- To help the patient achieve maximal level of function by increasing tolerance to touch in the hypersensitive area

Precautions

o Diffuse/ widespread pain
o Open wounds
o Deep pain- not remediated with desensitization

Desensitization program

- Treatment done 3-4x/day (short bursts)
- Treatment time: 5-10 min (stop when stimulus become noxious)
- Start/demo on univolved side
- Stimulus should feel comfortable before advancing to more irritating stimulus

Complications that cause hypersensitivity

- Nerve regeneration without intact endoneural tube
- Scar formation and adhesions that limit tissue mobility
- Neuroma formation
- Adherence of nerve to its bed
- Constriction of blood flow
- ** patient should be rechecked 2-3x/wk for treatment, assessment and HEP reviews