Electrotherapy

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Intermittent
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and Edema Management
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Objectives:
At the end of this lecture the student should be able to:

1. Define edema and its types.

2. Describe the structure of the lymphatic system
3. Discuss the mechanism of edema formation following injury.
4. Describe methods of edema management.
5. Appraise the effectiveness of external compression on the accumulation and the reabsorption of edema following
injury.

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 Intermittent compression and edema management

Definition of edema:
1. Edema: is the presence of abnormal excessive amounts of fluid in the extracellular spaces.

Types of edema following injury:

1. Joint swelling;
a. It is the accumulation of blood and/or excess joint fluids in the joint capsule.
b. It has the appearance and feel of a water balloon.
c. If we press on the swelled joint, the fluid will move away and immediately return
back when the pressure is released.

2. Lymphedema
a. It is excessive accumulation of fluids and lymph in the extracellular spaces.
b. It is subdivided into:
i. Pitting edema:
 It is accumulation of excess proteins and fluids
in the extracellular spaces.
 When the skin is pressed a pit (hole or
depression) is formed on the skin and when
pressure is released the pit stays for a long time
afterwards. (Figure: 10.01)

Fig. 10.01: Pitting edema.

ii. Non-pitting edema:

 It is accumulation of excess fluids only in the extracellular spaces.
 When the skin is pressed a pit is formed on the skin which disappears as soon as
the pressure is released.

The lymphatic system and lymphedema:

1. Structure of the lymphatic system:
a. Lymphatic and circulatory systems act to control post-traumatic edema.

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 b. The lymphatic system is a closed vascular system that runs parallel to the arterial
and nervous system.
c. It starts in the peripheral parts of the body as lymphatic capillaries.
d. The lymphatic capillaries are made of single-layered endothelial cells with
fibrils radiating from the junctions of these endothelial cells. (Figure: 10.02)
e. The fibrils support the lymphatic capillaries in their place.
f. Lymphatic capillaries run between tissue cells to collect the excess extracellular fluid
and plasma proteins.
g. These lymphatic capillaries collect together into larger collecting vessels in the
extremities then collect into the right lymphatic duct or the thoracic duct (Figure:
10.03) which drain into the venous system through the superior vena cava.
h. Larger collecting vessels are multi-layered vessels with valves to prevent
lymphatic stagnation or returning back in vessels.
i. The lymphatic vessels pass through one or more lymph nodes.
j. The lymph nodes are collected around joints and act to remove any foreign
substances from the lymph.
k. Lymph is moved through the lymphatic system by:
i. Skeletal muscle contraction.
ii. Respiration.
iii. Elevation (using gravity).

Fig. 10.02: Lymphatic capillaries. Fig. 10.03: Lymphatic drainage.

2. Formation of pitting edema following injury:

a. The direct effects of injury include;
i. Cell death and bleeding.
ii. Release of chemical mediators (e.g., histamine-like substance) to start the healing
process.
b. Histamine-like substance forms local edema at the site of injury through the
following steps;
i. Vasodilatation of small capillaries which slows down local blood flow and
increases the pressure inside the blood vessels.

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 ii. Increased vessels' permeability which allows plasma, plasma proteins and
leucocytes to move into extracellular spaces and increase their osmotic pressure.
iii. The increased osmotic pressure will pull more fluid into the injury site forming
tissue edema. (Figure: 10.04)

c. To remove edema;
i. The accumulated fluids pull the fibrils of the lymphatic capillaries to open the
pores between the endothelial cells and allow the fluids to enter the capillary.
ii. The lymph will flow centrally and new amount of fluids enters the capillary.

d. The lymphatic system will NOT remove the formed edema (and lymph flow will
stop) in the following conditions;
i. If the edema is collected too quickly.
ii. If the lymphatic capillaries are over-distended or compressed.
iii. This will result in accumulation of excessive fluids and formation of lymphedema.
iv. Pitting edema is formed if excessive plasma and plasma proteins are accumulated
in the tissue.
v. If edema remains for a long time, it will result in;
 Pain.
 Decreases joint range of motion and impaired function.
 Delayed healing.

Fig. 10.04: Formation and resolution of edema in the Fig. 10.05: Ankle with elastic wrap
interstitial spaces. compression in an elevated position.

Treatment of edema:
In acute lesions we usually use the Rest, Ice, Compression and Elevation (RICE
approach) to prevent edema formation;

1. Ice application or Cryotherapy:

a. If combined with compression, it decreases acute edema and inflammation.
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 2. Compression or external pressure:
a. Mechanism of action:
i. Increasing extracellular pressure will push plasma and proteins inside lymphatic
capillaries.
ii. Increasing lymphatic flow.
iii. Spreading the edema over larger area to include more lymph capillaries in
removing the plasma and plasma proteins.

b. Methods of compression:
i. Lymphatic drainage (lymphatic massage).
ii. Elastic bandage. (Figure: 10.05)
iii. Intermittent compression devices.

3. Elevation above heart level:

a. Gravity increases lymphatic flow.

4. Muscle contraction: (OR muscle pump)

a. It squeezes lymphatic vessels, which moves lymph centrally.
b. It can be produced by isometric exercises, active exercises, electrically induced
muscle contraction or weight-bearing exercises.

Intermittent compression devices:

1. Parameters of intermittent compression:
a. Pressure;
i. It should be around the capillary pressure, i.e., 30-40 mm Hg.
ii. Never to reach systolic blood pressure.

b. ON-OFF time sequence; best time sequences are:

i. 30 second ON : 30 seconds OFF.
ii. 4 minutes ON : 1 minute OFF.

c. Session duration;
i. 10-30 minutes/session.
ii. 3-4 hours/day.

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Indications of intermittent compression:
1. Lymphedema.
2. Traumatic and post-operative edema.
3. Chronic edema secondary to neurologic disorders or inactivity.

Contraindications of intermittent compression:

1. Deep vein thrombosis (DVT).
2. Severe cardiovascular and pulmonary problems.
3. Renal insufficiency.
4. Local infection.
5. Fractures.

References:
1. Prentice WE, Quillen WS, Underwood F.: Therapeutic Modalities for Physical Therapists,
2nd Ed. New York, The McGraw-Hill Companies, 2002; Pp: 394-414.

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