Oedema 

Oedema is swelling that occurs when there is an imbalance of capillary pressure or an obstruction to the venous and lymphatic flow. This can arise when a weak or paralysed extremity remains in a dependent position, post surgery or post trauma. If left untreated, the protein-rich fluid can have negative impacts to range of motion, sensation and, ultimately, function.

Why does oedema occur after a spinal cord injury? 

Dependent oedema following spinal cord injury (SCI) is multifactorial but is primarily related to venous insufficiency, also known as venous pooling. Several factors contribute to this condition, including:

1. Loss of lower limb muscle contraction and varying intra-abdominal pressure generation during activity and exercise to aid the mechanical return of
   • peripheral blood volume to the heart via the venous system
   • peripheral lymph fluid to the heart via the lymphatic system
   • loss of sympathetic nervous system input to maintain a baseline of peripheral vasoconstriction to support venous return at rest
2. Increasing blood volume in the periphery increases fluid pressure in the dependent limb, forcing plasma to leak into surrounding tissues and overwhelming the capacity of the lymphatic system to maintain normal limb size and shape.

Oedema assessment  

It is important to conduct a holistic assessment of oedema to identify treatable causes and contributing factors. Ultimately, the goal of management is to alleviate symptoms, optimise function, and prevent further complications.

Goals of oedema management  

• addressing modifiable causative factors 
• reduce and stabilise oedema  
• maintain skin integrity
• reduce pain, and any other symptoms experienced 
• improve positioning and postural support of affected joints/limbs as needed 
• maintain reduction in limb volume and avoid long-term fluctuations in limb volume 
• consideration of supports to monitor and manage the condition ongoing. 

Precautions with management 

• medication management with levels of injury above T6:
  • Frusemide (Lasix) has no/limited evidence for the management of dependent oedema or lymphoedema.
  • People with SCI above T6 have reduced sympathetic drive and therefore rely on the renin-angiotensin-aldosterone system (RAAS) for maintenance of blood pressure.
  • Any medication affecting the RAAS (e.g. frusemide, ACE inhibitors) can significantly drop the blood pressure in people with SCI.  
• consider contraindications or precautions to compression therapy, such as severe peripheral vascular disease or congestive cardiac failure 
• consider medications that can worsen oedema for example Pregabalin, Gabapentin, Calcium channel blockers
• nocturnal polyuria and impact on continence management and sleep quality 
• sensory impairment and using compression garments can increase risk of skin breakdown 
• supports required to don/doff garments and attend skin assessments. 

Management options 

Conservative management options such as fluid intake and elevation can be trialed whilst awaiting follow up with an experienced clinician who manages oedema.  

• Upper Limb vs Lower Limb: Principles of management are similar for upper and lower limb. 
• Hydration: Ensure at least 1.5 – 2 litres of water are consumed daily, unless advised otherwise.  
• Management of hyponatraemia.  
• Passive and active assisted movements: General oedema management recommendations are for whole limb/body exercise and activity. Aquatic therapy is effective if it supports whole limb/body exercise activating the muscle pump and/or reducing pain — otherwise any hydrostatic benefits re oedema are only temporary. Neuromuscular electrical stimulation can be considered with clinician guidance.  
• Elevation of the limb, preferably above heart level; this may need to be repeated during the day. When considering the use of elevating leg rests on wheelchairs, hamstring range will need to be assessed. Reduced range can cause the person to slide forward. This can increase the risk of injury to the skin from shear and friction as well as increased care supports to assist with repositioning if the person is unable to do this independently. The leg rest also increase the length of the wheelchair and increased risk of damage to the chair and/or injury to the person if they don’t accommodate for this. 
• Skin Care: Attend daily skin care and apply moisturiser to dry skin as needed. The skin will be at greater risk of damage or injury and should be checked at least twice a day.  
• Deep lymphatic breathing:  Requires therapist training, awareness of positioning and may be less effective if there is impairment of full respiratory function  
• Clothing and shoe choice: To make sure there is allowance for fluid that may collect during the day, and that shoe sizes may need to be up to two sizes bigger, and shoelaces left loose. Clothing needs to be loose, stretchy and comfortable, especially if the person is seated all day.  
• Compression therapy: this includes compression bandaging for initial reduction and appropriately measured compression garments to maintain the reductions achieved.  
• Review and adjustment to seating, posture and positioning of limbs. 
• Manual lymphatic drainage: requires therapist training, effective positioning and consideration of skin condition.  
• Exercise and activity either on land or in water that promotes activation of the heart, breathing and muscle pump, plus promotes the joint/s to move through the available range of motion to prevent contractures and reduce pain from immobilisation. 
• Aquatic therapy where the person can stand in the water up to chest height for best compression from the water pressure.