Edema Assessment A normal consequence of an acute hand injury is localized edema, defined by Brand as “the collection of water and elec- trolytes in the tissues. Tissue fluid may accumulate in the hand because of dependency or diminished muscle action.”!* Hand volume is measured to assess the presence of edema and to determine the effect of treatment and activities. By measuring the volume at different times of the day, the effects of rest ver- sus activity and of splinting or treatment techniques designed to reduce edema may be determined. A commercially available volumeter? may be used to assess hand edema (Figure 30-3). The volumeter has been shown to be accurate to 10 ml! when used in the prescribed manner. Variables that have been shown to decrease the accuracy of the volumeter include (1) the use of a faucet or hose that intro- duces air into the tank during filling; (2) movement of the arm within the tank; (3) inconsistent pressure on the stop rod; and (4) the use of a volumeter in a variety of places. The same level surface should always be used.*> The edema assessment is per- formed as described in Box 30-1.594 PART VII_Clinical Appiations ee stn te sf w 2 y 2 f Sa FO Sas oO Sus Figure 20-1 tsa of meatrement ott ate get mtion (AM nthe hand Figure 30-2 Measuring dance between ge pup and itl pab Figure 30-3 Wolter we omens ou of bah hand for mucre {omporsoninceased vue kates eer Not all paints are cadates fr the yolumeter Patents joints r phalanges. When using tape mesure for he hand who have open wounds, ute, etaples or pas in place or one mut note the exact se and time of day ofthe measure ‘ny quetonableskin condition should mows the volumeter, ments oth maningalcnmparizn can be made In repeat ‘tape measure canbe used to measure pars ofthe hand or assessments forearm, Common measuring ses are around the distal pal- Toasses an individual inger (or when a volumete icon ‘mar creat, around the ulnar yi of the wrist of over the traindiated), «tape measure owl's ing-ie standardsLT) el Volumeter Assessment of Edema . Fill the plastic volumeter until the water reaches spout level. Allow excess water to drip out of the spout. Empty and dry the beaker thoroughly. . Instruct the patient to slowly immerse his or her hand into the plastic volumeter, being careful to keep the hand in the midposi- tion, until the web space between the middle and ring fingers rests gently on the dowel rod. The hand must not press onto the rod. . Keep the hand still and in position until no more water drips into the beaker. . Pour the water from the beaker into a graduated cylinder. . Place the cylinder on a level surface, and read the amount of water displaced. can be used. Measurements should be taken before and after treatment, especially after the application of thermal modali- ties or splinting. When patients report a range of subjective complaints relating to swelling, objective data of circumfer- ence or volume help the therapist assess the response of the tissues to treatment and activity. Edema control techniques are discussed later in this chapter.Goal-Directed Treatment Techniques Edema Reduction Edema is a normal consequence of trauma but must be quickly and aggressively treated to prevent permanent stiff- ness and disability. Within hours of trauma, vasodilation and local edema occur. Early control of edema is ideally achieved through elevation, massage, compression, and AROM. The patient is instructed at the time of injury to keep the hand elevated, and a compres- sive dressing is applied to reduce early swelling. Pitting edema is present early and can be recognized as a bloated swelling that “pits” when pressed by the examiner's finger. This may be more pronounced on the dorsal surface where the skin is looser and where venous and lymphatic systems provide Tei Categories of Functional Outcome Measures* Generic Measures: Canadian Occupational Performance Measure (COPM) Short Form 36 (SF36) Short Musculoskeletal Functional Assessment (SMFA) Regional Measures: Disabilities of the Arm, Shoulder, and Hand (DASH) Michigan Hand Questionnaire (MHQ) Patient-Rated Wrist/Hand Evaluation (PRWHE) Disease-Specific Measures: ‘Arthritis impact Measurement Scales (AIMS2-SF) ‘Australian/Canadian Osteoarthritis Hand Index (AUSCAN) Rotator Cuff Quality of Life (RC-QOL) *This does not represent a fully comprehensive list. From Von Der Heyde R: Assessment of functional outcomes. In Cooper (ed): Fundamentals of hand therapy, St. Louis, 2007, Mosby Elsevier, pp 98-111.600 PART VII_ Clinical Applications return of uid tothe hear. Active motion is expecially impor tantto produce retrograde enous andlmphatic ow: ARON ‘moves this id ack into the geetalcivulatory system, swelling continues, a serofibrinous exit (a Had that ‘ontans both serum and fibvi) invades the area. Fria is ‘eposite inthe spaces surounding dhe juts, tendons, adi laments resultingin reduced mobil, Hateningoftheatchesof the hand, tse atrophy. and further disuse ™ Normal ing ‘ofthe tiaues reduced, and siffess and pain inthe hand oe res Scar adhesion ar likey to form apd further it ise ‘mobility untreated, thes losses may become permanent ary recognition of persistent edema through volume and tested edema control techniques may be necessary. Elevation ary elevation with the hand above the ear is essential. Slings should be avoided if possible because they tend (0 redice blood flow because ofthe flexed elbow posture and ‘may ead to shoulder stifness aswel Resting the hand on pi lows while seated or lying down i efetive. Resting the hand ‘ontop of the head or using devices that elevate the hand with the elbow in extension have ben suggested. Suspension sings may be purchase or fabricated “The patent souk use the injured hand for ADL within the imitations of resistance prescribed bythe physician Light [ADL that canbe accomplished while the hand is inthe des ingare permitted because these facitat gente active ROM. ‘contrast Baths Contrast baths, immersing the hand alternately in warm veer and then cold wate, have traditionally been used by many therapist to help reduce edema and faite ROM in hand injured patient. The alternating of warm and col eater wil cause vaseiation and vasoconstriction, resulting ina pumping action on the edema. Many patients eport that they lke contrast baths, Although the technique is described in textbooks, litle research has ben done on is eetvencs ‘A recent sptemati review? n the flctivenss of contrast baths concludes that although contrast baths may increase skin temperature and superficial blood lw thee ite ei dence that they aft edema and even les evidence that ROM ‘or function is improved. Practitioners ae urged to study the Tteratre and make an informed decision before using this tweatment strategy the OTA shoul const with the supers: ing OT. Retrograde Massage “The practioner may perform retrograde masag, which an also be taught tothe patient (and caregiver or faraiy member) to thatitean be done frequent throughout the day The ma sage assists in blood andiymph flow, Sart the massage distally tnd stoke smoothly and gly in proximal direction with the extremity in elevation.” Active motion shold follow the massage if posible, bt avoid muscle fatigue. In more severe cases when the hand and forearm are Involved, retrograde masage ia two-stage procedure ist, it beins proximally (Le. midforcar) to cmpty the proximal body part. Next, the hand, or distal pars massage so that this kd nay be emptied ito an available space Manual Edema Mobilization In 1997 Artaberpet® described massage technique she developed based on manual Iymphatic treatment (MLT), a treatment technique used for peopl with Iymphedema, She ‘modified MLT and coined the term Manual Edensa Mobil zation (MEM) for this new technique and began to use it 08 subacute hand patents with some success. MEM is used in cases where the impairment ofthe Iymph system is tempo: rary (edema) rather than cased by damage tothe lymphatic system (Iymphedema). This technique is grounded ina thor- tough understanding of the anatomy and physiology of the Iymphati ster, as wells rescarch data Although the tech niques described inthe erature? therapy practitioners are encouraged to study and ake hands-on continuing education courses to become skilled in this massage technique. Although [MEM canbe hlpflin educing edema, it must be usd sl: tively wath appropriate putiens to avoid medial complica tions. Again the OTA must be service competent and follow OF direction. Pressure Wraps {ight compression may be applied throughout the day with light Cabaa wrap, an Tsotoner glove, or «custom-made ga ment by Bioconceps or lbs (Figure 308). Wrapping with Coban elastic may be used to reduce edema (Figure 308) Starting distally the finger is wrapped snugly with Coban Care must be taken not to pull the Coban too tightly because 1 can restrict circulation. Each involved finger should be ‘wrapped distal to proximal until the wrap is proximal othe Ssdema. The weap remains in place for 5 mites and then is removed. Active exercise may be done while the finger is ‘wrapped or immediately after eaurement shouldbe taken before and after tcatment to document an increas it ROM. and a decrease in edema. The wraping may be repeated three mes dy. ‘Any method of compression should not be constricting and must be dcontind if iachemia reat. Eastic Ace ban ages maybe used for larger ates. An elastic bandage f 8 or ‘inches width may be used when the entre hand and fore- ‘rm requitea gentle pressure wrap. Avant of pressure wraps fre sed by hand centers Tubular gauze and Dighleeves? provide compression oa speci finger- No single metho is fupeiorto theater. A combination of echnique sed tdi ferent stage of healing and according to patient comfort may be mont eetPhysical Agent Modalities Two modalities are particularly helpful in the reduction of edema: neuromuscular electrical stimulation (NMES) and high-voltage pulsed current stimulation (HVPC). Both modalities are applied in such a way as to facilitate a muscle contraction, thereby improving the muscle’s ability to pump. Improved pumping action will boost lymphatic return, which will reduce edema.” In OT treatment, these modalities must be used in conjunction with purposeful activity and may be used only by an occupational therapist with documented competency. Active Range of Motion Normal blood flow depends on muscle activity, Active motion does not mean wiggling the fingers but rather maximum avail- able ROM done firmly and with purpose. Casts and splints must allow mobility of uninjured parts while protecting newly injured structures. The shoulder and elbow should be moved several times a day. The importance of AROM for edema control, tendon gliding, and tissue nutrition cannot be overemphasized.What is Crush Injury? “Complex injuries to the hand are defined as injuries involv-ing more than one group of tissues. The tissue systems involved may include bone, joint, tendon, ligament, vessel, nerve, and skin. n See air he ee RR Cee ye Ur alas) ce"The integrated tissue systems each serve a purpose in allowing the hand to be used. Bee ae Pita celina ee emule ma UE UR OMe UUM cena uc ll tability of the joints. CUE UR eC Uru Ce URC eee CBeeaN Re eae SR eee OE Re Ue RC elle ace the brain, PU ee Ue eae eu ee mic Rf nuke cso Orla Be TRU RU RUC Ur ee aL BaurCause for Crush Injury : aU T ue aul) Pal ee CR aiid Sea aC | ay Pau icse ucla nCategories of Injuries Pere] a mis s0) 8 10 1) 3) Bete) Burns Degloving injuries @Tendon injury _. extensor tendons D GeBoE ee Um enc at laa “> SKELETAL INJURIES Sarl ccd Bole olNo ization of Sensation As an injury to the hand resolves, the hand or a portion of it may be either hypersensitive or hyposensitive, having either too much or too little sensation. For example, after trauma toa peripheral or digital nerve, sensibility can be expected to return in a certain order.’ To facilitate the return of func- tion to the peripheral or digital nerve, a program of sensory reeducation may be used. Alternatively, a patient may have a hypersensitive area, one that is excessively sensitive to even the lightest touch, making it almost impossible for that person to manipulate ordinary items. In this case, a program of sensory desensitization is indicated. Sensory Reeducation Evaluation of sensibility has been described earlier in this chapter. The occupational therapist would use this informa- tion to prepare a program of sensory reeducation after nerve repair. When a nerve is repaired, regeneration is not perfect, resulting in fewer and smaller nerve fibers and receptors distal to the repair. The goal of sensory reeducation is to maximize the functional level of sensation. All programs emphasize a variety of stimuli used in a repetitive manner to bombard the sensory receptors. A sequence of eyes-closed, eyes-open, eyes-closed is used to provide feedback during the train ing process. Sessions are limited in length to avoid fatigue and frustration. To avoid further trauma, objects must not be potentially harmful to insensate areas. A home program should be provided to reinforce learning that occurs in the clinical setting. Several authors*"°5 have found that sensory reeduca- tion can result in improved functional sensibility in motivated patients, Objective measurement of sensation after reeduca- tion must be performed and then compared with initial test- ing to accurately assess the success of the program. A programof sensory reeducation does not begin until the patient has at least protective sensibility. Sensory Desensitization Sensory desensitization techniques are based on the theory that nerve fibers that carry pain sensation can be positively influenced through the use of pressure, rubbing, vibration, transcutaneous electrical nerve stimulation (TENS), percus- sion, and active motion. Hypersensitivity is sometimes the result of a lacerated nerve, but a too tight cast or splint may also cause nerve irritation requiring a program of sensory desensitization.*° Yerxa and colleagues!’ have described a desensitization program that “employs short periods of contact with three sensory modalities: dowel textures, immersion or contact par- ticles, and vibration.” This program allows the patient to rank 10 dowel textures and 10 immersion textures on the degree of irritation produced by the stimulus. Treatment begins with a stimulus that is irritating but tolerable. The stimulus is applied for 10 minutes three or four times a day. The vibration hierar- chy is predetermined and is based on cycles per second (cps) of vibration, the placement of the vibrator, and the duration of the treatment. The Downey Hand Center hand sensitivity test can be used to establish a desensitization treatment program and to measure progress in decreasing hypersensitivity.'”