Swelling and Edema

• Transfer of fluids from the body’s blood stream to interstitial tissue 
• The body’s natural and initial response to injury or trauma 
• Can be localized or diffused
• Important to treat as quick as possible to prevent permanent disability

Early swelling 

• Keep the extremity elevated and in a compressive dressing 

If swelling continues

• The surrounding joints, tendons, and ligaments may be affected
  • For the hand, this results in reduced mobility, flattening of the arches, tissue atrophy, and further disuse 
• Increased stiffness and pain 
• Scar adhesions 
• If left untreated, these losses may become permanent 

Types of Edema

Type	Duration	Meaning
Pitting	Acute	When the swollen part of the body is pressed, there is pit or dimple created.
Brawny [non-pitting]	Chronic	There is no pitting or dimple created when the swollen part of the body is pressed.

Evaluation and Assessment 

• Measuring at different times of the day can measure the effect of resting, activity, orthotics, or intervention being utilized 
• Always take a measurement before and after intervention 
• Utilize grading scale for pitting edema
• More information about edema evaluation can be found here.

Grading Scale for Pitting Edema 

Grade	Severity	Time	Depth
1+	Mild	Barely perceptible indention	Less than ¼ inch pitting
2+	Moderate	Easily identified depression; returns to normal within 15 seconds	¼ to ½ inch pitting
3+	Severe	Depression takes 15-30 seconds to rebound	½ to 1 inch pitting
4+	Very severe	Depression lasts for 30 seconds or more	More than 1 inch pitting

• Measure the circumference of affected area
  • Use measuring tape to measure swollen area 
  • Can also use Jeweler’s ring size standards to measure an individual finger or joint 
  • For wrist and hand edema: use a tape measure wrapped in a figure-of-eight pattern
    • Figure-of eight-method to measure the entire hand 
    • https://youtu.be/gwZA2pn2Sxw

• For hand edema, measure the hand and arm mass
  • Use volumeter 
  • Always utilize a leveled surface for accuracy 
  • Patient immerses hand and lowers it until it rests gently on the dowel rod between the 3^rd and 4^th digits
• Hand remains still until no more water drips into the beaker through the spout (Pedretti)
• The spilled water from the volumeter is then poured into a graduated cylinder for a final reading
  • Water measurement of more than 10mL is considered significant 

Edema Reduction Techniques

• Elevation
  • Place affected extremity above the heart to support blood flow
    • Be mindful of slings that position hand below the heart which may reduce blood flow 
  • For hands, safe to utilize the hand within limitations of resistance prescribed by the physician including light ADLs that can be accomplished while in dressing 
  • Contraindicated if patient has circulation problems 
• Manual edema mobilization
  • Activates lymphatic system to remove edema 
  • Contraindicated when cardiac edema is present 
• Retrograde massage
  • Assists return of blood and lymphatic fluids to the venous system 
  • Stroking is applied in centripetal direction 
  • Massage should be done with the extremity elevated
  • Contraindicated when cardiac edema is present 
• Compression garments
  • Light compression will help control swelling, especially at night 
  • Prevents re-accumulation of fluids following retrograde massage 
  • Wrapping digits – always wrap distal to proximal 
  • Avoid too much tension
• Cold packs
  • Best when combined with elevation
  • Monitor vascular status when using cold packs 
• Contrast baths
  • Immerse extremity in warm temperature water then cold temperature water 
• Active Range of Motion
  • Utilize maximal available ROM and providing firm movement
    • Muscle activity support blood flow 

Precautions and Contraindications

These interventions are not recommended if:

• the patient has an infection
• the patient has grafts or wounds 
• the patient has vascular damage
• the patient has unstable fractures
• the patient has cardiac problems including congestive heart failure 
• utilizing heat as a modality is contraindicated
  • if it is needed for intervention and a patient has a mild case of edema, it can be cautiously used while monitoring the patient and combining it with elevation 

References: 

• Therapy Ed National OT Certification Exam Review and Study Guide 8^th Edition (pp. 979-980; 991-992)
• Pedretti’s Occupational Therapy: Practice Skills for Physical Dysfunction 8^th Edition (pp. 233; 303-304)
• San Pedro College – PT Department. (2019, January 4). Figure of Eight Measurement [Video]. YouTube. https://youtu.be/gwZA2pn2Sxw