Edema and Lymphedema

Edema

• Edema is a local or generalized condition where body tissues contain an excessive amount of tissue fluid.
• Etiology:
  • Increased permeability of capillary walls
  • Increased capillary pressure due to venous obstruction or heart failure
  • Lymphatic obstruction
  • Disturbances in renal functioning
  • Chemical substances such as bacterial toxins, venoms, caustic substances, histamine

Pathophysiology

• Two types: Lymphatic and Venous
• Lymphatic: Plasma proteins in the tissues stagnate and a mechanical insufficiency of lymph drainage
• Venous: Increased capillary pressure and venous obstruction

Types of Edema

• Localized:
  • Caused by venous or lymphatic obstruction
  • Increased vascular permeability
  • Limited to one area of the body
  • May be bilateral
  • May result from trauma, infection, or obstruction
• Generalized:
  • Systemic process occurring with chronic illnesses
  • Congestive heart failure
  • Kidney failure
  • Liver disease
  • Apparent in both lower extremities (LE), groin, and abdomen
  • May exhibit whole-body edema through retention of both sodium and water

Lymphatic System

• Removes excess proteins that have escaped from blood vessels, returning it to the blood
• Removes waste excreted from body tissue
• Fluid contains phagocytes and lymphocytes that trap and destroy invading cells

Lymphatic Considerations

• Without phagocytosis and lymphocytes, the individual is susceptible to infection
• The immune system is compromised
• Extreme vulnerability to disease

Characteristics of Lymphedema

• Pitting edema:
  • Due to accumulation of thick proteins in interstitial space
  • Returns to pre-pit within 30 seconds
• Turgor:
  • Tone of edematous tissue
  • Hard = more chronic
  • Hard turgor contributes to loss of ROM, loss of function, sensory impairment, and pain

Assessment

• Circumferential measurements:
  • Must be taken at designated landmarks
  • Marked and measured at 4-cm intervals
  • Taken at the same time of day
  • With the same tool
  • By the same person
  • Compare affected and unaffected sides
• Water displacement method:
  • Gold standard for measuring edema
  • Mainly used in research
  • Measures the amount of water displaced from a container when the limb or part of the limb is submerged
  • Provides information on the volume of the whole limb, including the hand or foot
• Range of motion and muscle testing:
  • Assess baseline function of involved limb
  • Note limitations due to pre-existing conditions or excessive weight or edema of body part
• Assess tissue quality:
  • Check for color, temperature, wounds, rashes, and texture changes
  • Palpate for sensitive areas, changed muscle bulk, tissue resistance, and temperature changes
• Neurologic assessment:
  • Assess sensation including hot/cold, sharp/dull, localization, light touch, and reflexes
• Look for:
  • Muscle wasting
  • Changes in hair growth
  • Patterns of skin
  • Skin texture
• Photograph:
  • Take a pre-treatment photograph of affected and unaffected body parts

Conditions that may Skew Circumferential Measurements

• Use of a diuretic
• 10-pound weight gain or loss
• Additional medical problems
• Change in treatment regimen

Physical Therapy Management of Lymphedema

• Manual lymphatic drainage:
  • Therapeutic technique used to reduce edema and symptoms
  • Accelerates lymphatic drainage
  • Consists of hand motions on the skin and subcutaneous tissue
  • Applied pressure is very soft
  • Applied motions are slow
  • Every maneuver is applied from distal to proximal
  • Stimulates internal contraction of lymphatic channels
  • Provides drainage of obstructed lymph fluid from local lymph nodes
• Compression therapy:
  • Pressure to the area on the lymph ducts, activates the muscles below lymph ducts
  • Creates a soft and natural pumping mechanism
  • Includes compression bandaging, compression dressing, static graduated compression tools, and pneumatic compression tools