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When to take a lymphatic drainage approach to orthopedic patients.

Written by:

Baylee Noe OTR/L, CLT

VHSF Fellow '23/'24

I know we all have come across diagnoses where the patient has been accompanied by a lot of swelling. Not every patient presents the same post-injury, and some can be very puzzling. I can speak for many of us, especially new OTs in the hand therapy setting, and say that patients with persistent edema can be very challenging.

I recall one of my first patients ever to begin my OT hand therapy career who had this persistent edema. They had called me after hours to say that their hands had swelled up severely after their first session with me. I was thinking to myself, what did I do wrong? I followed the protocol exactly. I was trying to remember everything that I did as soon as we ended our conversation. I had access to our EMR from home and reviewed for a third or fourth time their case and I knew for a fact it wasn’t my fault. This patient’s case had been a traumatic fracture and underwent surgery and was placed in a tight case afterward. This caused the development of symptoms corresponding with onset of CRPS. I thought, oh no, not the dreaded CRPS. We were so behind on protocol because of this edema that took hold of their entire hand. I threw everything at it, isotoner gloves, retrograde massage, elevation, contrast baths, NMES to get some sort of muscle contraction pumping. Nothing really worked. Then Ktape was applied in the “lymphatic drainage” webbing-like design, and this was the treatment that was the most effective. This patient called me in such excitement. This led me to an understanding of how important the lymphatic system is in recovery.



How Does the Lymphatic System Relate to Orthopedic Injuries?

The lymphatic system is one to not be ignored with patients with orthopedic injuries. In my OT school, the lymphatic system wasn’t discussed a lot. I always knew what it was, but not exactly how it applied to me or recognize when this system needed specific attention. In my class to become a certified lymphedema therapist (CLT), it was discussed that medical school curriculums don’t really talk about it either. The Lymphatic system is now becoming more appreciated in the medical fields and other healthcare practices. In the orthopedic world, we see a lot of patients who have experienced traumatic events. As seen in the diagram below, we have many lymphatic vessels throughout our body. It is very likely that vessels can be damaged and thus require time to heal and grow back. Some of the lymphatic structures do not grow back. For example, the lymph nodes do not have the ability to regrow (Bond, 2024). In the hand therapy world, we do not have to worry too much about it because there are not any lymph nodes in the hand, but there is still a likelihood of lymphatic backup as there are lymph nodes that can get overwhelmed located at the level of the elbow where the cubital lymph nodes are found (Bond, 2024).

 

 Physiology Review of Lymphatic System


The lymphatic system is a huge network of vessels that absorb fluid and place it back into the circulatory system (Villeco, 2012). With post-traumatic swelling there is an exchange of fluids, nutrients, and cellular waste occurring in the interstitial space (Villeco, 2012). This exchange happens by diffusion which is a passive method that moves these particles along into circulation (Bond, 2024). Larger particles, such as proteins, that cannot circulate back into the blood by diffusion must enter via the lymphatic system. First, the initial lymphatics have anchor filaments that open and close depending on the interstitial pressures and allow water and larger molecules to enter (Bond, 2024). When this protein-rich fluid enters the lymphatics, it is then called lymph (Bond, 2024). You can probably see when an increase in swelling can become a problem. If there is too much fluid or contents to be either diffused or reabsorbed, there is excess interstitial fluid. This then causes gaps in between the anchoring filaments where fluid just free flows in and out of the lymphatic vessels and the interstitial space (Bond, 2024). There is no regulation at this point. This fluid then becomes protein-rich because protein is hydrophilic and loves water (Bond, 2024). With high protein content edema being kept in the interstitial space, the skin can get brawny and fibrous therefore becoming very tight and stiff (Villeco, 2012).

In addition, the primary role of our lymphatic system is immunity (Bond,2024). If our lymphatic system is not working properly, we lose apart of our abilities to fight infection. It is not uncommon for patients to have wounds that do not heal because of an inefficient lymphatic system (Bond, 2024).


Timing is Crucial

You can be surprised how quickly this can turn bad. As we know, a lot of factors come into our patients’ cases that can have a negative impact on edema management. My patient case for example, they had a very traumatic and painful experience. Their swelling began with that acute phase of swelling which then turned subacute and there we have the battle of either finding the most effective methods of edema management before it becomes secondary lymphedema. I haven’t talked about primary and secondary lymphedema, but long story short, primary lymphedema is when a patients lymph nodes have been surgically removed. Secondary lymphedema is every other reason why a patient gets what is also called dynamic insufficiency edema (Bond, 2024). My experience with patients who come to me with subacute edema is trying very hard to find what works for them in the least amount of time possible. Time is of the essence because at around 8 weeks after surgery or trauma, their tissue can become fibrotic or enters stage 2 (Bond, 2024).  


Complete Decongestive Therapy

There are a lot of things we cannot control as therapists when it comes to getting patients referred. For example, I just evaluated a patient who was in a car wreck that fractured their 5th metacarpal and radial styloid. They could not get in to see the orthopedic doctor because they didn’t have a car and were left in a cast for about a month. They were nervous about starting therapy and moving their wrist and hand. Their hand measured about 10cm larger than the contralateral side. We needed to take a lymphatic approach. Complete decongestive therapy (CDT) is the gold standard for treating primary lymphedema but can be used for secondary lymphedema. CDT is a four-component treatment approach. The four components include manual lymphatic therapy (MLT) (or called manual lymphatic drainage massage if you have been trained using the Vodder method), compression, exercise, and skincare. For secondary lymphedema, you do not have to use all four but can customize the treatment based on patient's needs. For example, this patient might only need compression and exercise. The compression is also temporary once the swelling goes down to normal size. A patient with primary lymphedema must wear compression for long term since their lymphatic system is permanently compromised.

Let us talk about the components a little more.


1.     Manual lymphatic treatment (or drainage).

a.     The drain, clear and flow method. The idea is to first drain the lymph nodes that the swelling needs to end up. Next is to clear the desired pathway that the swelling needs to travel. The clearing goes from a proximal to distal direction. Lastly is the flow where the fluid Is coaxed into the direction of the lymph nodes. This is the distal to proximal direction. This massage is very light. Stretching the skin is enough to excite the lymphatic vessels to begin their peristaltic-like process. Teach your patient this technique as well. Do it daily.

b.     Begin with diaphragmatic breathing. The lymphatic system works best during our parasympathetic nervous response. This can be tricky since our patients may be living a very stressful and high-anxiety life during their healing journey.




c.      Exercise:

                 i.     Our patients are also limited when it comes to doing activities that they enjoy. It is still important to educate patients about maintaining an active lifestyle. Using an exercise bike or walking is a great way to fire up the lymphatics. If the patient likes to swim and they do not have open wounds or if their protocol says otherwise, this is a very beneficial exercise route.

                 ii.     Active, and passive range of motion (as indicated during the patient’s protocol and healing timeline) is critical to allow muscle pumping. I like to use gripping and proximal joint motion in part of the MLT and in their home exercise program.

d. Skincare.

                 i.     It must not go without saying but making sure they are taking care of wounds and their skin. Educating them to not wear tight jewelry and to try to wear light or loose-fitting clothing.




e.     Compression:

                 i.     It is thought that compression garments need to be tight. About 70mmhg is said to be too tight and presses into the lymphatic vessels too much making it counterproductive. 20-30 or 30-40 mmHg is enough to contain state 2 swelling. Compression doesn’t get rid of swelling. Compression contains swelling and does not decongest.  There is a technique for wrapping just the hand and fingers using a short stretch bandage that can aid in decongesting. Use elastomul wrapping or an isotoner glove is fine. Sometimes you will need to do the wrapping technique if pain is too great limiting tolerance to the isotoner glove. The wrapping is meant to create a distal to proximal compression to soften indurated tissue via neutral warmth.


Conclusion

Just like every part of our career as hand therapists and OTs our treatments are holistic and have many factors that contribute to patient symptoms. Patients with chronic swelling are no exception and everyone is different. Like my first patient whose swelling did not budge to conventional methods, but the Ktape was the thing that did the trick. Then my other patient was experiencing too much pain to put on an isotoner glove. This blog post is meant to put more tools in your toolbox so that you can help improve patient care and outcomes.  

 

 

 

 

 

References

Bond, M. (2024, April 15). Lymphatic Anatomy/Physiology [Conference]. Lymphedema 1: Comprehensive Lymph and Venous Edema Management, Wisconsin.

Villeco, P. J. (2012). Edema: A silent but important factor. Journal of Hand Therapy, 25(2), 153-161. https://doi.org/10.1016/j.jht.2011.09.008

 

 

 

 

 

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