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- Edema - presence of abnormal amounts of fluid in extracellular tissue
spaces
- Joint swelling-blood and joint fluid accumulated immediately following
injury appearance and feel of a water balloon
- Lymphedema- swelling in subcutaneous tissues results from excessive
accumulation of lymph occuring over several hours following injury
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- As plasma and plasma proteins escape from small blood vessels they are
picked up by lymphatic system and returned to blood circulation
- Lymphatic system acts as a safety valve for fluid overload thus a sudden local increase in the
interstitial fluid casues pitting edema
- Maintains homeostasis of extracellular environment by removing excess
protein molecules and waste from the interstitial fluid
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- Cleanses interstitial fluid and provides a blockade to spread of
infection or malignant cells in lymph nodes
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- Closed vascular system of endothelial cell lined tubes that parallel
arterial and nervous system
- Lymphatic capillaries
made of single layered endothelial cells with fibrils radiating from
junctions of endothelial cells
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- Fibrils support lymphatic capillaries and anchor them to surrounding
connective tissue
- Capillary is surrounded
by interstitial
fluid
- Lymphatic capillaries
- called terminal lymphatics provide entry way into lymphatic system for
excess interstitial fluid and plasma proteins
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- These lymphatic capillaries join together in network of lymphatic vessels
that eventually lead to larger collecting vessels in extremities
- Collecting vessels connect with thoracic duct or right lymphatic duct
which join the venous system in the left and right cervical area
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- Fluid moving into interstitial spaces pushes or pulls fibrils supporting
terminal lymphatics forcing endothelial cells to gap apart creating an
opening in terminal lymphatics for entry of interstitial fluid, cellular
waste, large protein molecules, plasma proteins, extracellular
particles, and cells into lymphatic channels
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- Once the interstitial fluid
and proteins enter these
channels they become lymph
- If no tissue activity or interstitial volume increase takes place junctions
remain closed
- Muscle activity, active and passive movements, elevated positions,
respiration and blood vessel pulsation, all aid in the movement of lymph
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- Local edema formed by plasma, plasma proteins and cell debris from damaged
cells all move into interstitial spaces
- Hormones released by injured cells stimulate small anterioles,
capillaries and venules to vasodialate separating endothelial cells in
vessel wall
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- Increased permeability allows more plasma, plasma proteins, and leucocytes
to escape into local area
- Fluid in the form of a gel is trapped by fibers and proteoglycan
molecules
- Gel prevents the free flow of fluid and is referred to as pitting edema
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- If edema causes an overdistention of lymph capillaries, entry pores
become ineffective and lymphedema results
- Constriction of lymph capillaries or larger lymphatic vessels from
increased pressure will also discourage lymph flow and cause
intercellular fluid to increase
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- Edema compounds extent of injury by causing secondary hypoxic cellular
death in surrounding tissues
- Other ill effects of edema include
- Physical separation of torn tissue ends
- Pain
- Restricted joint range of motion.
- Prolonged recovery times
- Interstitial fibrosis
- Reflex sympathetic dystrophy
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- Immediate first aid following injury can minimize edema
- Use of ice, compression, electricity, elevation and early gentle motion
retards accumulation of fluid and keeps lymphatic system functioning at
an optimum level
- Any treatment that encourages lymph flow will decrease plasma protein
content in intercellular spaces and decrease edema
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- Elevation
- Compression
- Weight bearing exercise
- Cryotherapy
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- Gravity can be used to augment normal lymph flow by encouraging its
movement
- The higher the elevation, the greater the effect on the lymph flow
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- Rhythmic internal compression provided by muscle contraction will
squeeze lymph through lymph vessels improving its flow back to the
vascular system M
- Muscle contraction can be accomplished through isometric or active
exercise or through electrically induced muscle contraction
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- External pressure can be used to increase lymph flow. Massage, elastic
compression, and intermittent pressure devices are most often used
external pressure devices
- External compression not only moves lymph along but also may spread
intercellular edema over a larger area, enabling more lymph capillaries
to become involved in removing plasma proteins
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- Weight bearing activities activate a venous pump
- Mediated by release of an endothelial-derived relaxing factor (EDRF)
and is not related to muscular activity of the limb.
- EDRF is liberated by sudden pressure changes and it diffuses locally
- Major action is to relax the smooth muscle and stimulate blood flow
rates in the veins
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- Addition of cryotherapy to intermittent compression has shown the best
results in the reduction of post acute injury edema
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- Inflation Pressure
- On/Off Time Sequence
- Total Treatment Time
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- Therapeutic pressure settings loosely correlated with blood pressure
- A pressure approximating diastolic blood pressure used in most
treatment protocols
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- Arterial capillary pressures are 30 mm Hg
- Any pressure that exceeds this should encourage reabsorption of the
edema and movement of lymph
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- Maximum pressure should correspond to diastolic blood pressure
- More may not necessarily be better
- Enough pressure is needed to squeeze lymphatic vessels and force lymph
to move
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- On and off time sequences are variable
- In lymphatic massage shorter on-off time sequences may have an advantage
- Athlete comfort should be a primary deciding factor
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- Clinical studies show significant gains in limb volume reduction after
30 minutes of compression
- A 10- to 30-minute treatment seems adequate unless edema is overwhelming
in volume or is resistant to treatment
- More treatment times per day may also be an advantage in controlling and
reducing edema
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- Compression sleeves come as either half-leg, full-leg, full-arm, or half-arm
- Deflated compression sleeve is connected to compression unit via a rubber hose and
connecting valve
- On time should be adjusted between 30 to 120 seconds
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- Off time is left at 0 until the sleeve is inflated and treatment
pressure is reached then adjusted between 0 and 120 seconds
- When unit cycles off patient instructed to move extremity
- 30-seconds-on/ 30-seconds-off setting is effective and comfortable
- Treatment should last between 20 and 30 min
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- Combination of cold and compression has been shown to be clinically effective
in treating some edema conditions
- Jobst Cryotemp – controlled cold/compression unit
- Temperature adjustment ranges between 10 - 25oC
- Cooling accomplished by circulating cold water through sleeve
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- Cryo-Cuff is anotherdevice which makes use of a combination of cold and
compression which provides an inexpensive means of treating edema
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- Cryo-Press is another device which makes use of a combination of cold
and compression
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- Intermittent compression may also be used in conjunction with a low-frequency
pulsed or surging electrical stimulating current to produce muscle
pumping contractions
- Facilitates resorption of injury byproducts by lymphatic system
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- Incorporate sequentially inflated multiple compartment designs
- Designs have included a programmable
gradient design
- Linear pumps incorporate massage effects of a distal to proximal
pressure with a gradual decrease in pressure gradient
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- Highest pressure in distal sleeve and is determined by mean value of
systolic diastolic pressure
- Middle cell is set at 20 mm lower than the distal cell, proximal cell
pressure is reduced an additional 20 mm
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- Length of each pressure cycle is 120 seconds
- Distal cell is pressurized initially and continues pressurization for 90
sec.
- 20 seconds later middle cell inflates and after another 20 seconds the
proximal cell inflates
- A final 30-second period allows pressure in all three cells to return to
0 after which the cycle repeats
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- Intermittent compression has been recommended for
- Lymphedema
- Traumatic edema
- Chronic edema
- Swelling
- Intermittent claudications
- Postoperatively to reduce the possibility of developing a deep vein
thrombosis
- Facilitate wound healing following surgery by reducing swelling
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