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Edema Management
1k Plays2 years ago
Miranda and Josh talk about various way to manage hand swelling.
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Transcript
Introduction to Hand Therapy Academy and Edema Management
00:00:06
Speaker
Hi, I'm Josh McDonald. And I'm Randa Materi, and we are Hand Therapy Academy.
Managing Edema in CRPS and Fractures
00:00:11
Speaker
Today, we're gonna talk about managing edema, whether it's from a patient with a dysteritis fracture, maybe CRPS, maybe some other injury. We're gonna talk about our ways that we like to manage edema, kind of how we, what patterns we fall into. So, Miranda, what would you say is your number one way to manage someone's edema?
Elevation Techniques for Edema
00:00:30
Speaker
Yeah, I think this is, there's lots of ways to manage it, but I think just from taking the CHT exam and I remember there was some sort of question about managing edema and what is the best way and that was elevation. So usually the first thing that I'm always talking to patients about is elevation and the correct way to elevate, right? Sometimes people think you just stick your hand, you know, you prop your hand up on the table and if your hand is above your elbow, then that's good elevation. When we know
00:00:56
Speaker
It's much better if you can get more fluid moving So if you could raise your arm up over your head and bring your hand Like you're picking a cherry or picking an apple and bringing an apple down to look at it then that's much better in terms of elevation or if you're gonna be sitting at a table to have your arm propped up and have it at kind of a slope making sure your Handed wrist is higher than your elbow and that it's kind of propped up at an angle so that edema can
00:01:22
Speaker
move out.
Exercises for Lymphatic Drainage
00:01:23
Speaker
So I would say elevation is my number one first thing to go to along with a few others. What about you? I like to do like movement, whether it's an exercise we give them like apple picking just to get some big lymphatic vessel movement. So we have them reach up. We go through a little bit more just reach up and down its reach up, grab that imaginary apple,
00:01:45
Speaker
come back down, turn and look at it, and put it in your pocket across your body. And that big cross movement kind of looks like a PNF movement a little bit, gets good active movement. And when they reach, I have them open up hands nice and big, get good digit abduction in there. That pumps those intrinsics a little bit. That can be a really effective way too. That exercise, sometimes I'm even teaching them that at-home self-adema management stuff. So getting those soft tissues moving as much as we can.
Breathing and Elevation for Edema
00:02:12
Speaker
Yeah, that's a big one, and that kind of brought me to thinking about also doing deep breathing, right? So we know that doing some really deep breathing can help manage the edema as well, which I think is sometimes we don't think about that. And a lot of times those patients who have edema have other things that go with it, the stress, the anxiety, the tension in their system, and that deep breathing can help relax all of that actual mechanical tension, and then some of the psychological too, and that can help the whole system function better for sure.
00:02:41
Speaker
Right. And then along with doing the exercises, like you explained, I think it's really great because then they keep their shoulder and their elbow loose as well at the same time. Right. So we know people that have hand and wrist problems often end up having some subsequent shoulder pain.
00:02:57
Speaker
Yeah, yeah. And then if we tell them, well, you have to elevate with that hand up in the air all the time, then they're gonna think they're being unsuccessful, their shoulders tight, they can't get it up. When I'm teaching patients elevation, same thing you said, I don't just teach them, you know, hand above elbow, and then it all pools down at the elbow. I teach them, like, if you put a drop of water on the back of your hand, would it run downhill to your shoulder? That doesn't mean it has to be way up in the air, like you're asking to go to the bathroom or something.
00:03:22
Speaker
It can just be like, at the armrest of your couch, put a couple pillows and let it be downhill towards your heart. Or if you're laying in bed, lay that arm on a couple of pillows and it doesn't have to be sticking up in the air, just so it's that drop of water runs downhill towards your shoulder, towards your heart. Yeah, that's some good ones. All right, what else? Do you do anything else?
Compression Gloves and Chip Bags
00:03:41
Speaker
Gloves, compression gloves. Yeah, we like compression gloves. That's something that we use frequently for those patients that have significant edema. When edema comes down to a certain point, I feel like the glove just doesn't apply the same amount of tension because it's on the high points of maybe MCPs dorsally across those knuckles. But if there's a lot of that interstitial tissue buildup, then we'll do gloves.
00:04:05
Speaker
if they aren't in a splint and they can accommodate a chip bag, we'll also do a chip bag where we kind of shove that in the dorsal side if it's a lot of dorsal edema in there. And that can be an effective way to kind of give that continuous soft tissue stimulation. Yeah. So you talked about chip bags and whenever I say, oh, we should make a chip bag for that patient, right?
Creating Low-Tech Chip Bags
00:04:23
Speaker
Or you're talking to students, they're like, what's a chip bag, right? So what is a chip bag?
00:04:28
Speaker
We are super low tech with our chip bags and a lot of that has to do with the fact that I don't have a sewing machine set up at my clinic. But we take a stockinette, two inch usually, cut it about 10 inches, fold one end over and tape it so it's closed, shove a bunch of little random cut off pieces of the memory foam. Shove, you know, I don't know, maybe like a medium sized handful of them inside there and then fold and close the other end. And then kind of spread it out so it's more like a square than a long rectangle.
00:04:56
Speaker
and put that under the glove along the back of the hand and all of that movement helps like I'm doing a little retrograde massage but it's just kind of pushing on all of that maybe pitting that they have in there and kind of keeping that fluid from coagulating and getting thick inside that hand.
00:05:13
Speaker
Yeah, and I think it's key with those when you're doing the memory foam or we use like the slow foam cubes in our clinic, we cut them up and it's good to have different densities. And then as that pressure is different in that area, then it helps kind of create these channels for the extra fluids and whatnot to go to. So I think
00:05:31
Speaker
Chip eggs, sometimes I'm surprised at how well they work, right? You do them and you're like, that is incredible. I would have never thought that little bag of foam would really do the trick like that, but it really does. And you can do it on the volar surface. You can do it on the dorsal surface.
00:05:44
Speaker
Yeah, yeah. And it's something that a lot of times if they're a discharge fracture, they need to be in a splint. And so it's hard to interface those two. And so I'm just kind of like waiting, like hoping the edema goes away. But if it doesn't, as soon as that splint is discharged, and maybe I'll even have them like, you know, if you're just gonna sit down and watch TV, here's a chip bag to put in there, do some light movement. But if you're going to get up and go do something, then put the splint back on. Obviously you take the chip bag out, but I don't really ever make a splint over the chip
Integrating Chip Bags with Splints
00:06:11
Speaker
bag. Do you do that?
00:06:12
Speaker
Sometimes we will, like if, especially if they have significant edema, but then we know that that splint is probably going to need to be re-modified, right? So as soon as we get some of their edema down, then we're re-modifying and making it a lot smaller where we don't have to accommodate the chip bag. Yeah. Because our dysteritis fracture patients usually get an ulnar-based near circumferential that covers the dorsum, so if the patient's really significantly involved, I might do a volar base so that the chip bag can fit underneath there, but yeah, just another option for that. Yeah.
00:06:42
Speaker
What other exercises do you maybe do to help manage some of that edema?
Exercises and Snacks for Movement
00:06:46
Speaker
Um, so basically any type of, like we talked about big movement patterns, um, we'll do some of the tendon glides. I always am educating the patients, you know, as those muscles are working in your hand, they're starting to help bring the fluids out. So as you're, if you're really sedentary or that patient's sedentary and afraid of movement, then we know they're just going to continue just well. And so I made him say, Hey, you're fine to go on like a little walk, you know, around your neighborhood. But when you're doing that, I want you to do, you know, some of those like apple picker exercises while you're
00:07:16
Speaker
out there doing it. So just getting some good movement, some good breathing in. I would say that's probably one of my my favorites in terms of edema management. Yeah.
00:07:25
Speaker
And assuming there's no contraindications for it, I like giving patients super simple little like what we'll call serial opposition where I give them like pennies or cotton balls or something they'll have at home and I'll say get a little bowl and dump these things on the table and just one at a time alternate through your fingers and pick one up with index and thumb and then middle finger and thumb and then ring finger and just put those things in.
00:07:46
Speaker
as much so they're not in that early kind of guarding, protecting kind of CRPS where they're nervous about it, not using it. A little bit of movement is certainly helpful, but then it gets them conditioned to using it in a comfortable, healthy, active, functional way.
00:08:01
Speaker
Yeah. And sometimes like with that, I'll tell them if they don't have any wounds, of course, I'll be like, Oh, you know, grab some grapes or something you kind of enjoy eating or popcorn and then, you know, use that and then bring it to your mouth and feed yourself because then you kind of change the whole experience, right? They're not like experiencing, they're not thinking, Oh, this is painful. I'm actually getting like something tasty or fulfilling a little bit out of it as opposed to just doing some movement. Yeah. Yeah. I like that. I used to say imitums, but I've had to put in some healthier options.
00:08:30
Speaker
We don't want to be encouraging our diabetic patients to be popping M&Ms to work their edema. I'll have patients suggest things like, oh, you should bring donuts in for us on a day. And like, I got a lot of patients with diabetes. That's maybe not the best reinforcer.
Measuring and Tracking Edema
00:08:45
Speaker
When we do have patients with pitting edema, we always want to measure things. What measurements do you use for identifying edema and tracking it?
00:08:53
Speaker
So typically, you know, we don't, I don't really ever do the volometer, the volume displacement because it's so cumbersome to set up and then, you know, you have to get the fingers to everything just right. So I usually do circumferential measurements and I'll do the figure of eight measurement. And then I do go ahead and measure the circumference of the proximal phalanx oftentimes as well. That way we're just doing it, but I don't have a specific, I think you use one for like if it's pitting, but I'm not familiar with those.
00:09:23
Speaker
you have something you really like to use? Yeah, I'll like you. I don't use the water displacement. I feel like it's cumbersome if I've got wounds and there's all kinds of concerns. So I'll do circumferential distal polymer crease, distal risk crease. I don't have a great way to measure the thenar eminence edema. The figure eight kind of goes around that. So that's a tough one to measure. If there is pitting edema,
00:09:45
Speaker
When I was back doing neuro stuff and trauma that would measure depth of the pitting or how long it would stay, but there's different metrics. It's not necessarily standardized. So I'll just measure it and document and say, with moderate pressure, pitting was present at three millimeters or a centimeter or whatever. And it persisted for, and I'll do a general time, 30 seconds before I repopulate or something like that. And I'll give
00:10:11
Speaker
description, narrative description, rather than a stage two, stage three. I kind of do that because I have a metric, but I'll document the description. Yeah, that's great.
Challenges in Standardizing Edema Measurements
00:10:21
Speaker
I went looking for one. I spent probably like 20 minutes on it, but not that long. And I was like, Oh, this is really hard to actually find a measurement for that.
00:10:30
Speaker
Yeah. And I've seen variations and some people will use time and some people use depth and some combine them. And so it's not greatly standardized, but a good description where you include the depth and the time to refill gives you a better indication as they progress. Yeah. That's a little more objective. What about massage?
Retrograde Massage for Lymphatic Drainage
00:10:48
Speaker
What type of massage are you doing for these patients?
00:10:51
Speaker
a super simple retrograde massage where I'm just doing lymphatic up the vessels. I learned to do like on the digits, like a folder to dorsal distal to proximal kind of a diagonal or oblique movement along the digits and just kind of through that intermetacarpal space through there and just a light load, nothing too aggressive, but I am by no means a lymphatic specialist. I'm not going to do the lymphedema stuff that's outside my scope. That's not something I've been on classes in.
00:11:20
Speaker
Right. Yeah. I know when I do it, if they're really swollen, I try to open up some of those lymphatic channels and then show them how to do it, you know, by massaging in their elbow crease and in their shoulder just a little bit before. But I feel like active movement can do that as well. So, you know, by having the patients do the active movement first,
00:11:37
Speaker
and then coming in with the dema massage. I think it's a little more beneficial than just doing a dema massage and then exercise. So sometimes patients or students will ask, which order should
Order of Treatment Techniques
00:11:47
Speaker
we do stuff in? And a lot of times I don't think it matters, but I do think it matters with the dema stuff.
00:11:52
Speaker
Yeah, I agree, getting them active. And I do like heat for that if they're an appropriate candidate with sensation and all that. I do like heat, but I like doing maybe in the fluidotherapy or something where they're getting movement during the heat. I think that's helpful too. Yeah, some sort of movement and then maybe follow by cooling it down a
Caution with Co-Ban Application
00:12:08
Speaker
bit. One thing we didn't talk about was co-ban. Are you using any co-ban?
00:12:13
Speaker
I use it very sparingly and I'll use it when a glove is insufficient. Um, if a glove works, I'd prefer that because it's an easy on off. It's easy for them to apply themselves. But if there's some reason where it's like, Oh, it's just a digit or, but I know the risks with that. So I use it very sparingly and I use all kinds of precautions with the patient and I really kind of scared them. I'd rather them under apply it than over apply it by all means. Yeah, same. Yeah. Yeah. We've seen some kind of bad worst case scenarios on that. So we want to avoid that for sure.
00:12:41
Speaker
Yeah. So never wrap the co-ban too tight, make sure they have good sensation, check capillary refill. And I'll have them make sure they're checking their own capillary refill often just in case. Yeah. Every hour or so, check it. And if it's not good, take it off. Yeah. And they really have to be cognitively with it, right? So.
00:12:56
Speaker
Yeah. And, and capable of applying and removing it themselves too. Like if I put them on them in the clinic and sit them on their way and they can't do it ever again until they come in again, it's not effective. Right. And never on a child. Right. Right. Yeah. All right.
Conclusion and Further Resources
00:13:11
Speaker
That's a lot of information. We kind of whizzed through all of it pretty quick, but hopefully that gives you guys a little bit of some pointers, maybe some ideas on how to manage edema in your patients. All right. For more information, check us out at handtherapyacademy.com or Instagram at handtherapyacademy.com.