As many of you know, EDUCATA and the Oncology Section of the APTA have recently launched a major course on the management of edema. This course is also a key component of the Certificate of Achievement in Oncology PT (CAOPT) program from the Oncology Section. We are now very pleased to bring you the lead educator in this series, the distinguished Marisa Perdomo PT, DPT, CLT-Foldi, CES, and faculty at the University of Southern California. In this series, she discusses a specific edema case in three parts. So enjoy! And please join with your input in response to her provocative questions.
— Marilyn Pink, PT, Ph.D.
You can earn CE credits by reading all three posts in this series! To earn two hours of credit, you will also need to read the below articles, purchase the course, and take the pre- and post-tests to earn your two credit hours!
MANAGING A CASE OF ORTHOPEDIC EDEMA
Peripheral edema is a common impairment after surgery and injury, and, in particular, total joint replacement surgery. Peripheral edema causes pain and tightness, as well as loss of joint motion; it inhibits muscle recruitment and therefore impedes muscle strengthening and function. Additionally, the presence of peripheral edema slows the healing process and may result in an increased number of physical therapy visits. In other words, the prolonged presence of peripheral edema negatively impacts an individual’s ability to return to full pain-free activities.
The causes of peripheral edema can be very straight forward, such as in post-surgical edema. However, peripheral edema can also be caused by many systemic conditions, for example, RA and chronic venous insufficiency. Additional impairments to various organs, such as undiagnosed congestive heart failure, as well as liver and kidney dysfunction, can also lead to peripheral edema. All of these “systemic conditions” may also contribute to the amount of edema present following a typical orthopedic surgery.
The following case presentation:
- Demonstrates the potential complexity in determining treatment interventions for peripheral edema in a “simple” total hip case, and
- Discusses how the combined interventions of manual lymphatic drainage, exercise, and home program can significantly reduce post-operative peripheral edema in a short amount of time. These techniques can be used across the continuum of care in any stage of healing and in any patient setting.
Setting: Home Health Physical Therapy
Mark is a 59-year-old male who underwent a right total hip replacement 10 days ago. PT referral: evaluate and treat: total hip protocol with posterior-lateral approach; weight bearing as tolerated; limit hip adduction to neutral, and flexion < 90 degrees.
Mark has a 10-year history of bilateral hip OA with the left hip replacement 8 years ago.
The initial evaluation revealed:
- ADL: Stand-by assistance with all bed mobility activities; manual support to right leg during supine to sit to stand to sit transfers.
- Gait: Independent household ambulation ~ 100 feet with walker and partial weight-bearing on right lower extremity.
- Equipment: Raised toilet seat, shower handle, cane, walker, reacher and hook.
- Medications: Tramadol, Acetaminophen, Coumadin and Omeprazole.
- Social History: Married, two college-age children. Wife has taken two weeks off of work to take care of Mark.
- Employment: Certified Public Accountant.
- Observation: Incision with staples, edematous with serious drainage and dressing; no signs or symptoms of infection. Edema present @ the incision, buttock and upper thigh/groin region on right.
- Nursing: 3 visits scheduled for assessment of incision and to perform dressing changes; scheduled blood draws for INR.
- Functional Strength Assessment:
- Unable to perform a right straight leg raise; + extensor lag on right.
- Able to perform a partial bridge.
Comments: This is a straightforward clinical presentation of an individual s/p THR. Mark knew what to expect as a result of his previous left total hip replacement and was not fearful of challenging himself to be as independent as possible.
Before you move on…
Dr. Perdomo recommends reading the following articles to gain a deeper understanding of treating orthopedic edema. If you are taking this course for credit (you can purchase the course here), this reading is required.
- Ely JW, Osheroff JA, Chambliss ML, Ebell MH. Approach to leg edema of unclear etiology. J Am Board Fam Med. 2006 Mar-Apr;19(2):148-60.
- Mortimer PS, Levick JR. Chronic peripheral oedema: the critical role of the lymphatic system. Clin Med. 2004 Sep-Oct;4(5):448-53.
- Trayes KP, Studdiford JS, Pickle S, Tully AS. Edema: diagnosis and management. Am Fam Physician. 2013 Jul 15;88(2):102-10.
Now, it’s YOUR turn:
After any orthopedic surgery, edema is expected.
- What interventions or strategies do you presently employ to treat post-operative edema following a total hip procedure in the home health setting?
- After examining the pictures of Mark’s right hip edema, do you consider the amount of edema as expected? Provide your clinical rationale.
Enjoying this case study? Once you’ve had a chance to reflect and comment below, continue to the second part of Dr. Perdomo’s case study.