Managing Edema: Compression Techniques Post-Injury

Introduction 

Acute injuries happen suddenly, such as twisting an ankle or from a fall. Chronic injuries develop over a longer period (weeks or even months), which are often a result of overuse or build-up of damage in the body. Signs of injury often start with pain and then oedema. Oedemas can also exacerbate several symptoms, including pain, reducing the ability to move, and any other underlying health conditions. It is important to notice these and get appropriate treatment to prevent further deterioration and to promote effective healing. The treatment depends on the type and severity of the injury. Minor injuries often require treatment at home through rest, ice, compression, and elevation (R.I.C.E). Correct use of compression techniques can help reduce oedemas, promote effective healing, and improve the quality of life. However, for more severe injuries, a healthcare provider may incorporate further effective treatment plans. This may include rehabilitation, fitting a cast, brace or splint.^{1, 2} This article focuses on compression techniques to manage oedemas after injury. 

Understanding edema

Definition and common causes

So, what exactly is an oedema? 60% of our total body mass consists of water. Fluid movement and storage are largely well-regulated by the body.³ Edema, in other words, is known as swelling. It is a medical condition notable for the abnormal excess accumulation of fluid in the body tissues. The accumulation of fluid can occur in various body parts, such as the legs, ankles, hands or feet. Edemas can occur as a natural reaction after an injury, such as fractures, sprains, or strains. One common cause is after an injury, but oedema can also occur for various causes, including infections, fluid retention during pregnancy, and heart, kidney, or liver conditions.⁶ There are also many different types of oedemas which are dependent on the cause(s), such as haematomas (abnormal pooling of blood outside the blood vessels), lymphedema (a chronic condition caused by damage in the lymphatic system), cardiogenic oedema (due to heart problems) and many more. Therefore, it is vital to identify and address the underlying cause of oedema, as the treatment can vary depending on the specific cause.⁶

Note: this article focuses on compression techniques for post-injury oedema and does not advise on how to distinguish what injury or type of oedema. Therefore, if there are any concerns or suspect any of the following symptoms, please consult with your healthcare provider immediately for the best-personalised treatment plan:^1,2,10,11

• Unbearable or severe pain and/or bruising 
• Worsening of symptoms, such as increasing swelling or pain 
• Unsettled swelling for more than a couple of days
• Any broken bones or ruptured ligaments
• Any deformation, fracture or dislocation after injury 
• Any discolouration of the skin indicating signs of loss of circulation - such as pale, bluish skin, with numbness and/or cold to touch and feel. 
• Unstable movement or power, even after the swelling has reduced 

Overview of post-injury oedemas 

Oedemas are a common and natural reaction that appears several hours after injury and often lasts temporarily. Our body’s protective inflammatory response is to send many white blood cells to the area of injury to start the healing process. This means that more volume of blood is being transported to the area, which causes an increase in fluid, resulting in swelling and heat. The extra fluid in the area can also affect the nerve, which can further contribute to the pain. As the injury heals and the inflammatory response subsides, the excess fluid is drained out by the lymphatic system, eventually reducing the swelling and returning the tissue to its normal state. However, any notable excessive or prolonged swelling requires medical attention as it can cause more harm than good, including prolonged pain, reduced ability to move, muscle weakness and possibly further complications.⁵

Recognising oedema symptoms 

As briefly mentioned, oedemas are notable by the following symptoms:^4,5

• Swelling - depending on the extent of the injury
• Pain - from the injury itself and swelling can add pressure on the nerves and tissues, leading to more pain and discomfort. 
• Redness and warmth - as there is more blood flow to the area of injury 
• Pitting oedema - when the swollen area is pressed by a finger, there can be a temporary “pit” indentation. This is due to oedemas.
• Reduce in range of motion - the injury itself, with pain and oedemas, can limit movement and function of the area affected. 

Post-injury management 

R.I.C.E protocol

R.I.C.E has been the gold standard in post-injury management. It is most effective when started as soon as possible, within the first 48 hours after your injury and for the first couple of days.^11,12 The steps include:

1. Rest - stop the activity causing the injury and protect your body from further damage. 
2. Ice - wrap an ice pack or, e.g., a frozen bag of peas in a towel (to prevent ice burn on your skin) and apply on the injured area for approximately 10 to 20 minutes; repeat every two to three hours throughout the first two to three days. The cold is suggested to reduce the blood flow to the injury, which may help reduce the pain, bruising and swelling. Once the swelling goes down, this can be switched to heat instead to promote normal blood flow and continue the healing process. 
3. Compression - use compression technique(s). Note: do not apply ice and compression at the same time. 
4. Elevation - if possible, keep the injured area raised to or above your heart level. This is to help reduce any swelling. For example, putting your leg up on a cushion when you are lying down or using a sling for your arm. 

Based on your injury, your healthcare advisor may also recommend incorporating some exercises (to prevent muscle wasting), offering joint support, heat therapy and/or non-steroidal anti-inflammatory drugs (NSAIDs) to further help with the healing and re-strengthening your abilities to move. 

Compression techniques

Importance and advantages of compression in recovery 

Compression works to alleviate oedemsa by using mild external pressure to prevent the pooling of fluid and promote healing:^7,8,10

1. Promoting drainage of excess fluid - the gentle pressure helps movement of the excess fluid out of the tissue into the lymphatic system and venous return of blood to the heart. This also promotes better delivery of essential oxygen and nutrients to the area of injury by improving the circulation of blood and fluid and preventing blood clots.
2. Supporting areas of injury – the compression garments stabilise the tissue in place. This is particularly important in preventing further injury, limiting movement that can exacerbate pain and allow the body to heal.

Things to consider before compression therapy

Before applying the compression technique, the following is important to ensure the appropriate compression technique is used depending on your injury and needs:^10,13

• Measurement of the swelling levels in the affected area.
• Being aware of your pain, discomfort, and range of motion.
• Check your skin condition, especially the colour, temperature, and any signs of irritation.
• Apply dressing on any open wound before proceeding with the compression techniques. 

Individuals with the following medical conditions are advised to consult a healthcare professional before trying compression therapy:^10,14,16

• Skin infection, e.g., cellulitis
• Congestive heart failure
• Ischaemic vascular disease
• Peripheral neuropathy
• Diabetes 
• Rheumatoid arthritis
• Distortion of the limb 
• Pulmonary oedema
• Untreated deep vein thrombosis
• Undergoing chemotherapy or radiotherapy
• Uncontrolled or severe liver, cardiac or renal failure
• Metastatic disease affecting the oedematous region

Types of compression technique

Compression techniques are available in various styles and materials, which are designed to be suitable for your specific needs. Some injuries may require continuous compression, while others may benefit from intermittent compression. As the oedema reduces, reducing the compression level is advised. Consult with your healthcare advisor to check the severity and understand the appropriate level and timing of compression required.^10,11

Compression bandages or wraps

Compression bandages are most effective when applied within the first 24 to 48 hours after an injury. These are stretchable bandages that come in various materials, widths and lengths. Crepe and elasticated bandages are often ideal to use for compression.¹⁵ Depending on the location of the body part, different widths are recommended, such as two inches for children’s arms or legs or adult fingers, three to four inches for adult arms or legs, and six inches for the chest, torso, or thigh.^10,12

Four-layer bandaging is a common method used to maintain the appropriate level of compression. These typically consist of firstly the non-adherent dressing, then the padding layer, then applying a compression bandage and finally, the outer layer with cohesive or elastic bandages. Regardless of where you use the compression bandages and their layers, the steps are similar. Avoid covering the fingers or toes; this is to allow an easier check of the circulation. Apply the bandage firmly but not too tightly:^9,10,12,15

1. Place soft padding around any bone or joint area.
2. Roll up the bandage. The rolled part of the bandage should be kept above the injury, and the unrolled part should be below the injury.
3. Start from the farthest point of the injury (away from the heart). To hold the bandage in place, start by wrapping the bandage twice around the injury.
4. Roll the bandage towards the heart in a figure-eight pattern. Make sure that each new layer covers half of the previous one. 
5. Secure the end with a clip fastener or tape.

If possible, remove the bandage at least twice daily for a few minutes before applying the bandage again. Unless your healthcare advisor specifies, loosen the bandage before bedtime. Ensure hygiene levels by cleaning the bandages between uses, this can be done by hand washing them at 40 degrees celsius with gentle soap and allow it to dry naturally. Replace any damaged or soiled bandages as required [9, 12].

Compression garments

Compression garments are appropriate for long-term usage to minimise oedema recurrence, and some individuals also use it in normal day-to-day life. Compression garments come in various levels based on the pressure they provide. The level you may need depends on the severity of your oedema. The levels generally range from 15-20 mmHg (mild compression) for mild oedema to 30-40 mmHg or higher (firm compression) for severe oedema. Garment levels higher than 20 mmHg are only available via prescription. Your healthcare provider can help with your fitting.¹⁰

Advice on usage:¹²

• Get accurate measurements and fittings for compression garments. If you gain or lose weight, get fitted again so that you are wearing the correct size.
• Follow instructions from the manufacturer and your healthcare provider.
• It is recommended to wear compression garments early in the morning, as this is the time when your body is less swollen. 
• Ensure the area of your body is dry before putting on the garment.
• Have a firm grip on your garment before pulling or rolling it into place to minimise any tear of the garment. 
• It may be helpful to wear rubber gloves to help you grip the fabric.
• Hand wash your compression garments with gentle soap and water at about 40 degrees Celsius and allow it to dry naturally. Do not use bleach or fabric softener. 
• Replace your compression garments at least every three to six months or if you notice any damage or loss of elasticity. 

Unless your healthcare advisor specifically states, it is usually recommended to avoid wearing compression garments during sleep. Over time, compression garments may lose their elasticity and effectiveness; therefore, regularly assess and replace them as needed to maintain optimal compression.^10,13 

Devices 

Healthcare providers may recommend devices such as intermittent pneumatic compression devices. This method is recommended for individuals who are bedridden or physically less active, such as after surgery or stroke. These are often performed at the hospital and sometimes at home. The intermittent pneumatic compression sleeves are attached to the compression machine. You wear the device when you are resting in bed or sitting in a chair. During use, the sleeves inflate and deflate every 20-60 seconds ranging from low pressure to high pressure. However, it is not recommended anymore once you are able to stand and move properly. If compression therapy is still required, your healthcare provider may recommend another compression technique, such as compression garments, for long-term use.¹⁸

Risk and monitoring compression therapy 

Compression therapies can be counterproductive if they are not done properly. Loosen or remove the compression and contact a healthcare provider immediately for review if any of the following is noticed:^9,10

• Numbness
• More pain
• Tingling 
• Abnormal skin changes - bluish skin, irritation, allergies or sores
• Increased swelling - can be done by measuring and comparing the length of the injured area
• Feeling colder in the injury or extremities 
• Pulse that is weak or out of rhythm
• More reduced range of motion
• Cramps
• Difficulty breathing or abnormally increased breathing

Preventing edema recurrence 

Alongside compression techniques, there are general preventative measures involved to manage the underlying cause, adopting a healthy lifestyle and taking precautions to minimise edema recurrence:¹²

• Staying hydrated and limiting alcohol and caffeine intake - helps maintain proper fluid balance in your body, as dehydration can lead to fluid retention. 
• Limit salt intake - high salt intake can promote more water retention in your body.
• Regular exercises or guided physiotherapy - strengthening your muscles will help improve circulation and reduce the risk of edema.
• Maintaining a healthy weight - being overweight can increase the risk of edema, especially in the legs.
• Avoid tight clothing - especially around the waist, thighs or calves as it can restrict blood flow and promote blood pooling.
• Elevate your limbs - elevate to or above heart level, especially while resting or when not using compression techniques. 
• Avoid prolonged sitting or standing.
• Managing medication - be aware that there are certain medications, which have side effects leading to edema. Consult a healthcare advisor to discuss any alternatives.
• Managing other underlying medical conditions - such as heart or kidney disease or venous insufficiency. Consult a healthcare advisor to effectively manage these conditions.
• Wear protective gear and use proper equipment, for example, during any contact sports.
• Reorganising your environment, such as secure rugs or carpets and no loose wires on the floor to minimise your risk of injuries from slipping or tripping. 

Key takeaway 

Understanding and properly using the appropriate compression techniques should help manage post-injury oedema. It is beneficial to seek appropriate healthcare professional advice for personalised guidance on when and how frequently to apply compression based on your injury or condition. Proper compression technique, including duration of use and level of pressure, can vary in different injuries, individual needs (e.g., sizes) and preferences. If the oedema is severe or persistent, it is essential to receive a further review by your medical provider for guidance to an accurate diagnosis and best management. 

Summary

After experiencing an injury, managing edema or swelling is crucial for effective healing and preventing further complications. Compression techniques play a vital role in reducing edema post-injury by promoting fluid drainage and providing support to the affected area. These techniques include compression bandages or wraps, compression garments, and devices like intermittent pneumatic compression devices. 

Proper measurement, fitting, and monitoring are essential for the safe and effective use of compression therapy. Alongside compression, implementing preventive measures such as hydration, exercise, weight management, and environmental adjustments can help prevent edema recurrence. Seeking advice from healthcare professionals is recommended for personalized guidance on compression techniques and overall injury management.