Transcript
josh MacDonald: Hi, I'm Josh McDonald.
Miranda Materi: And I'm Miranda Matieri and we are Hand Therapy Academy.
josh MacDonald: Today we're going to get a little bit outside of my comfort zone and we're going to talk about edema versus lymphedema. And I am comfortable with the concepts of edema, but when it comes to lymphedema, I feel like it's something for me that has always been this like cloud issue over here that I just didn't really like have much experience or exposure to and I haven't really needed to investigate it all that much because my caseload so I'm not super familiar with it but Miranda is going to help enlighten us a little bit
Miranda Materi: Well, I first want to start by saying I'm not an expert in lymphedema. And i I do feel like if you have a patient that needs you know ongoing treatment, that I would definitely refer out to a lymphedema therapist, especially just because they have access to all the pumps and all the dressings and things like that. But I first will start by explaining what the difference is between edema and lymphedema and how as therapists, we could potentially recognize it.
Miranda Materi: Like Josh was saying, he's not as familiar with lymphedema because we honestly don't see it a lot in our clinics. Most of the stuff we see is after an injury, you know, the edema occurs after an injury.
Miranda Materi: And you can have acute edema and subacute edema. So it doesn't mean that it's going to go away quickly. You can still have it staying around for a while, but it's not really considered chronic versus lymphedema is a chronic condition. And it's a condition that the patient will always have. And the treatment is slightly different. So if someone is not improving with your typical edema techniques so elevation um the edema mobilization techniques wearing those compression gloves things like that and they seem to still have the swelling and some of those um you can still have pitting with lymphedema but it kind it's a little bit different it it feels different it's like i want to say more of like a gritty and a hardened like skin um
Miranda Materi: So if you still have a patient that's having some of those symptoms and you might want to look further, but they'd have to have some sort of insult to their lymphatic system, you know, whether it be a lymph node or something with the lymphatic flow versus an edema problem is from the acute trauma.
Miranda Materi: So kind of distinguishing them that way.
josh MacDonald: Yeah.
Miranda Materi: And someone with lymphedema probably won't respond well to your edema management techniques.
josh MacDonald: Yeah. And I've, I've heard it described in the the cycle of the fluid that gets deposited and and the reuptake that happens the lymphatic system, that lymphedema is more a problem with the vessels that do reuptake and edema that we see is the body depositing more than than can be reuptake up took. They can be, they can undergo reuptake, but it's it's more than it can undergo because it needs that fluid for the healing for joint stabilization. So the acute is too much deposited.
josh MacDonald: Whereas lymphedema is the reuptake system is insufficient from a chronic perspective.
Miranda Materi: Yeah, I think that's a great way to explain it. Nicely done.
josh MacDonald: Yeah, that's my contribution.
Miranda Materi: li what that great And I think the treatment is totally different, right? When we're doing edema management, we're putting more pressure, um, or when we're mobilizing the edema and doing that manual edema mobilization, we're putting more pressure in those areas. And with lymphedema, you don't do that because you can damage the lymph system, right? So with lymphatics, you're doing this really light pressure, um, and you're opening up all the lymphatic channels before you even start the mobilization. So I think knowing those things, it's helpful. And if you're having a patient, um maybe that isn't quite responding as well to some of your manual edema stuff, doing some of those lymph or that MLD, you know, the manual lymph drainage techniques can be helpful, like still simulating, you know, their um lymphatics and their armpit and their elbow and then through their fingers and then doing the drainage. You know, sometimes I'll just do that with a patient if they're continuing to have the swelling that won't go away. And I'm like, these you know, these techniques can still be helpful even when the person doesn't have lymphedema.
josh MacDonald: Yeah, yeah. And I think like when I was a ah newer therapist learning some of this stuff, I struggled because I had someone who was lymphedema trained therapist. and And she was trying to go through some stuff of how to work with this. And it was this.
josh MacDonald: insurmountable amount of information on how I was supposed to spend, you know, what seemed like 45 minutes of a session working edema reuptake from axillary space or proximal to that all the way down to the hand. I thought, I got do range of motion. I have to do some extras. We have all this other stuff to do. And it was this trying to balance what is really needed locally at that site after an acute injury.
josh MacDonald: And if it's just needed locally because the rest of the reuptake system is intact, then that's all you need to do. But if that is insufficient, then maybe all the other stuff won't matter until I address the edema that is blocking everything else.
Miranda Materi: Yeah, exactly. And I think if you have a patient that's still chronic, sending them to a lymphatic trained therapist is really helpful. And, you know, they're going in and they're even opening up, you know, where, or I had a friend that worked in it and she'll, it would like go into the groin and open up the lymphatics and the groin to get some of the upper extremity stuff to drain, you know, and that's not something that we do or have even are set up to do in a hand therapy clinic.
josh MacDonald: Yeah.
josh MacDonald: Yeah, yeah. And you're right. There's both equipment that we don't have And knowledge base. If someone said, Josh, here's a cart full of the equipment to do that, I would still be at a loss. And it's just not an area that I have specialized in, in any capacity. So I think it's also important to know when this might be outside my scope and say like, I can't be master of everything. I just can't. And so I'm good at some areas and I can do some things effectively and in the next tier down. But there's some things like I might, I'm i'm not going to treat someone who has cervical injuries.
josh MacDonald: That's not to say an OT can't and a hand therapist can't. That's just not something I've done. And lymphedema is in that same category for me.
Miranda Materi: Yeah. Yeah. i definitely agree with that. Knowing what you don't know is very important. I do think there's things as hand therapists, we should know, right? Like if you have a patient that broke her wrist and she had, you know, um, a mastectomy and maybe some lymph nodes dissected, we need to be aware of that because we're going to follow those precautions, um, and I think as new grads and maybe as even some hand therapists, if you haven't seen that before, what are those precautions, you know, and what do you need to look for?
Miranda Materi: So I, and then asking the patient, do you know those precautions? Sometimes they don't even know. Like I've had breast cancer people there.
josh MacDonald: Yeah. Yeah.
Miranda Materi: They're like, why I remember those, but not really, but you know, they have lifting restrictions and things you're really not supposed to, or they don't really want you to do.
josh MacDonald: And I think too, a lot of our treatments for the localized edema can be part of the lymphedema and vice versa. Like with these things can cross over. So if I'm working on someone's edema in their hand after just raised fracture, I'll do local edema, uh, fluid reuptake and retrograde massage.
josh MacDonald: But then I'm also going to do large motor chain movements and I'm going to do whether it's wall slides or apple picking or, um, even just large, um, Like ah gross motor movements of the upper extremity just to open up some of that thoracic cavity and that axillary space just to get things moving and pumping because an injured patient is going to be more closed in, open up big and that can still be a productive thing.
Miranda Materi: Yeah, and then that opens up the lymphatics and helps with the reuptake, like you said. And I think one thing that as therapists, we know like, okay, we've been treating their edema. Is it getting better? Yes. Okay, we're on the right track. No.
Miranda Materi: Okay, what should we do differently? And do we need to refer out? So I think sometimes we try to overcomplicate things, but it's actually pretty easy, right? Are our interventions working and are they getting better?
josh MacDonald: Yeah, yeah. That definitely applies to a lot of things like wound care. We know we shouldn't be doing the same thing for more than two weeks with range of motion. You know, if it's not improving, I should be looking at something else because this isn't something that should take eight weeks to gain 10 degrees in a range of motion. Same thing with fluid.
josh MacDonald: If that circumferential measurement or however you're gauging it isn't improving, either you need to try something different or or seek some help.
Miranda Materi: Yeah, and that's why taking those measurements and and doing those re-evals is very important and maybe not even doing them just once a month like insurance wants us to making sure you're taking measurements, you know, once a week at least for whatever you're trying to quantify.
josh MacDonald: Yeah. Yeah.
josh MacDonald: Yeah. And, and I think ah I, some of my patients, I hesitate to take measurements too often. I like to know the changes, but then I know patients will get very caught up in that. I'll have patients who want to test, for example, their grip strength every time they come in and it's not going to change every time. Just like your circumference may go up one day because I don't know, you slept poorly or you had more salty foods the night before, or something like that, it may fluctuate. So yes, we need to take measurements on the regular. But I'm sometimes doing that and like not like not telling them but downplaying the importance of the weekly ones. And instead playing like let's we want to watch the the changes across a larger spectrum, not necessarily the good days, bad days that as they ping across a week.
Miranda Materi: Yeah, that's true. Yeah, you might be chasing some bad days in there.
josh MacDonald: Yeah. Yeah. Okay. So hopefully this has been helpful for you to kind of both differentiate tweet between the two different types of edema we may see, the more common types. Maybe it's just an idea to get you kind of rolling on maybe what to do with some patients of yours. But if you have any questions or comments, please reach out to us at info at handtherapyacademy.com.
