Effect of Lymph Drainage, Superficial Fascial Release & Circulatory Petrissage Massage Techniques in Conjunction with Hydrotherapy and Structured Homecare on Lower Leg Edema Secondary to Varicose Veins; A Case Study
Andrea Francis Woodhead, BScR
2ndYear Massage Therapy Student,
Okanagan Valley College of Massage Therapy (OVCMT)
1(250)299-3793
#2 – 1946 Tranquille Rd, Kamloops, BC V2B 3M5
July 15, 2015
Table of Contents
Abstract………………………………………………………………………………………………………………3
Introduction…………………………………………………………………………..…………………………..5
Subject Case History……………………………………………………………………………………………8
Assessment...………………………………………………………………………….………………………..11
Treatment Plan………………………………………………………………………………………………...12
Outcomes………………………………………………………………………………………………………...17
Discussion and Conclusion…………………………………………………………..……………………25
References……………………………………………………………………………………………..………..29
Appendix
A: Pre & Post Assessment Measurements Table…...…………………..…………30
B: Pre & Post Treatment Images…...………………………………………………………31
C: Homecare Tracking Table…….……………………………………………………………36
Abstract
Objective: This case study was designed to investigate the effectiveness of using lymph drainage, superficial fascial release and circulatory petrissage massage techniques in conjunction with hydrotherapy and structured homecare to treat lower leg edema that is present secondary to varicose veins to decrease girth measurement, increase range of motion and decrease feeling of fullness in the limb.
Background: The patient being treated is a 62 year old female who developed edema in her lower legs after she developed varicose veins while pregnant with her second child in 1987. She experiences an increase in symptoms after long days of sitting at work or on very hot days.
Method: 8 - 60 minute massage treatments were done over a 2-3 week period (one treatment every 2 – 3 days). Prevs. post treatment assessments were done including: girth measurements, active & passive range of motion of the talocrural joint, patient’s report of feeling of fullness (1-10 scale) and the pitted edema test. Visual images were also taken to show the effectiveness of treatment. Treatment included: basic lymph drainage techniques, superficial fascial release and circulatory petrissage strokes performed over the whole anterior and posterior lower extremity. Hydrotherapy was applied during treatment and the patient was given structured homecare to do between treatments.
Results: As a result of the massage treatments and homecare the patient’s lower leg girth measurements decreased by 9.1% - 12.5% and the patients reported feeling of fullness decreased from 8/10 to 3-4/10. Also seen, was a change in the tissue colour on the patient’s right medial malleolus, from purple to a faded red hue.
Conclusion:The results show that the combination of lymph drainage, superficial fascial release, circulatory petrissage, and hydrotherapy in tandem with structured homecare is an effective treatment for decreasing symptoms causedby edema in the lower leg secondary to varicose veins.
Keyword List
Lymph drainage, superficial fascial release, circulatory petrissage, hydrotherapy, homecare, varicose veins, edema, lower limb, girth measurements, massage.
Introduction
Edema is the local or general accumulation of fluid in the interstitial spaces (Rattray, 2000).This accumulation of excess fluid builds up as it is pumped into the capillary bed from the circulatory system and not reabsorbed. Once this fluid is in the lymph system it is referred to as lymph; lymph is made up of white blood cells, plasma proteins, fats and debris suspended in a watery fluid (Rattray, 2000). Lymph vessels have minor contractile ability; the majority of lymph movement around the body, and back to the heart, is driven by skeletal muscle and respiratory (diaphragm) pumps (Rattray, 2000).
When lymph pools or accumulates in the interstitial spaces it can be as a result of increased permeability of the capillaries in an area, increase capillary pressure, decrease in plasma proteins or an obstruction to a part of the lymphatic system (Rattray, 2000). This pooling, or edema, can cause swelling, pain, discomfort and loss of function in the affected area (Rattray, 2000). Anybody can develop edema and it can develop anywhere in the body. Those who have had a traumatic injury are more likely to have edema caused by damage to the lymphatic system. Surgical removal of nodes is also a common cause of edema, for example:lymph nodes and tissues are commonly damaged or removed during a mastectomy. Edema can also be caused by any increase in venous pressure due to:heart disease, pregnancy, localized infection or an allergic reaction. Edema can also be secondary to kidney disease as well as extensive tissue damage or burns which cause an increase in plasma proteins (Rattray, 2000).
Varicose veins are gnarled, enlarged veins that have lost their elasticity and have non-functioning valves (Mayo Clinic, 2013). Veins return blood to the heart through a system of one way valves and skeletal muscle pumps. There are many reasons why a person develops varicose veins but it is most commonly caused by a sustained increase in venous pressure. For that reason, they are most commonly developed in the lower extremity as the blood returning to the heart has to compete with gravity (Mayo Clinic, 2013). Age, sex, family history, obesity, pregnancy and standing or sitting for long periods of time increase a person’s risk of developing varicose veins(Mayo Clinic, 2013). Woman more commonly experience varicose veins (Jordan, 2001). Due to the body’s inability to return blood to the heart adequately, and an increase in venous pressure, with the presence of varicose veins a person is more likely to experience edema distal to the damaged veins as fluid pools into the interstitial spaces.
Though there is not currently any specific research on treating lower leg edema secondary to varicose veins, there has been some research done on treating upper extremity edema and lymphedema secondary to a mastectomy. This research, though related, is different from the condition being treated in this study as the patient’s varicose veins and subsequent medical intervention did not cause any damage to the lymphatic tissues. The few studies that have been found that reference the treatment ofleg lymphedema were completed in 2002 and 2003 and studied the effects of Manual Lymph Drainage and the Vodder method on the lymphedema. These techniques were shown to have a significant effect on the lymphedema present (14-19% reduction in limb volume) (Harris, 2004). Patients in these studies did not have any reported varicose veins. There have been no studies found that address the application of myofascial release techniques or hydrotherapy on the type of edema present in this study but such techniques are indicated as per “Clinical Massage Therapy” by Rattray (2000).
Alternatively to massage both edema and varicose veins are commonly treated using “compression therapy”, the use of compression garments such as socks or sleeves (Rattray, 2000). These garments are used to assist the vessels with returning blood and lymph to the heart by decreasing the capillary pressure and assisting against gravity.Some edema is also treated with the use of medications such as diuretics (Rattray, 2000).
This case study is designed to prove the hypothesis thatusing the combination of lymph drainage, superficial myofascial release and circulatory petrissage massage techniques in conjunction with hydrotherapy applications and structured homecare will have a positive effect on lower leg edema secondary to varicose veins. This positive effect will be assessed by:a decrease in overall girth measurements, increased active and passive range of motion at the talocrural joint and decrease in overall feeling of fullness.
Subject Case History
The patient being treated for this study is a 62 year old female that developed varicose veins in 1987 while pregnant with her second child. Some of the varicose veins were treated in 1995 using medical intervention to help decrease the associated pain; the patient was unable to acquire any medical records todetermine what type of medical intervention was done. The edema that the patient is experiencing has been present since the varicose veins developed in 1987 and has continued since having the procedure done on the veins in 1995 with no change. After speaking with her family doctor, the patient reported, it was very unlikely that any of the surrounding lymph tissues were damaged during the corrective intervention. The patient does not currently use any form of compression garment or diuretic medication to help control the edema in her lower extremities. In the past when the patient used compression garments (socks) for a short time she reports that they were uncomfortable and “did not help the swelling”.
The edema being treated is present in both lower extremities (bilaterally), most significantly in the lower leg, between the ankle (talocrural joint) and knee,and is present at all times. The edema is reportedly worse after long periods of sitting, especially on hot days, and not exercising consistently. The patient is a business owner and spends the majority of her workday sitting at a desk. Though she is very active in the spring/summer in the garden 3-4 days per week she is significantly more sedentary during the fall/winter. The patient reports that what she feels in her legs is better described as “fullness or discomfort” rather than pain.
The patient has never been treated using any manual therapy (including massage) for this condition. She is not currently seeing any other practitioners for treatment of this or any other condition other than her family Doctor for regular checkups. The patient does not have any other known risk factors for developing edema (ex. Kidney failure, heart disease, extensive tissue damage or burns, etc…) and is not currently on any medications other than a daily multivitamin, an antidepressant for mild anxiety and Zomig for recurrent, long standing, migraines (40+ years).
Currently, the patient does not do anything specific, or consistently, to help decrease the swelling and edema in her legs, she does report that sitting in the evening with her feet on a foot stool helps sometimes. The patient reports that the edema does not currently affect her activities of daily living (ADL’s) that she can pinpoint; though, she does report that on very hot summer days she cannot stop and start activity (gardening or walking) as her legs will swell during the breaks and it is uncomfortable to continue.
The patient is hoping to have a decrease in the feeling of fullness in her lower legs as a result of the treatment throughout this case study. She also reports that there is a cold, purple area of tissue around her right medial malleolus that she has never had diagnosed or treated. The patient reports she has always “been curious and a little concerned about it” and is “curious if these treatments will have an effect on the area”.Upon observation the area indicated appears to be a cluster of spider veins. This area will be monitored for change but is not the main focus of this study as it has not been diagnosed by a medical professional.
Below are images of the patient’s lower legs showing the varicose veins and present edema prior to starting treatment.
Assessment
As per Rattray (2000), the presence and treatment of edema can be assessed in a number of different ways. Edema will be evident during observation with noticeable swelling and on palpation where the tissues can feel taut, boggy or “squishy”. The patient may also exhibit limited range of motion (ROM) with potentially boggy end feels at passive over pressure depending on the severity. Tissue may be hot (in acute stage) or cool (in chronic stage) due to ischemia. Girth measurements may also be used to determine amount of swelling, these measurements can be compared bilaterally and/or as a pre/post objective assessment tool. Therapists may also use the pitted edema test to test for the presence of pitted vs. non pitted edema (Rattray, 2000).
To measure the effectiveness of this study, using the combined use of lymph drainage, superficial myofascial release and circulatory petrissage techniques in conjunction with hydrotherapy applications and structured homecare on lower leg edema secondary to varicose veins,a combination of objective and subjective data will be assessed.
Objective data to be measured and assessed:
- Girth Measurements of the lower leg (9cm above the medial malleolus, where the edema is most observable and palpable)
- Active and passive range of motion - dorsiflexion and plantarflexion at the talocrural (ankle) joint
- Pitted Edema Test
- Observed change in colour of tissue around right medial malleolus
Subjective data to be measured and assessed:
- Fullness Scale (Scale of 1(low) – 10(high), as reported by the patient)
All data will be collected pre and post each treatment and in the same location(if applicable). Images will also be taken throughout treatment to visually depict the treatment outcomes.
Treatment Plan
Based on the assessment of the patient’s physical presentation and the patient’spersonal goals, the treatment goals and objectives of this case study are to:
- Decrease Sympathetic Nervous System (SNS) firing to stop pain cycle and promote full body healing.
- Decrease edema in bilateral(BL) lower legs to decrease girth measurement, increase active(A) and passive(P) range of motion(ROM) at the talocrural(TC) joint and decrease feeling of fullness.
- Decrease superficial fascial restrictions in/over bilateral(BL) hamstrings(HS), quadriceps(quads), Gastrocs(gas), soleus(sol) and tibialis anterior(TA) muscle groups to decrease compression of lymph vessels and increase fluid mobility.
- Increase circulatory flushing to remove metabolites, promote venous return and increase tissue health in bilateral(BL) lower extremity.
As per previous studies of similar conditions there have not been best practices established related to the ideal number of treatments,or duration of treatments,that is most effective for this condition. In this case study a total of 8 – 60 minute treatments will be performed every 2 or 3 days, for 2-3 weeks. The time of each treatment will be recorded to see if there is any correlation between outcomes and time of treatment. A structured homecare plan will be given to the patient, with a tracking sheet to complete, to determine the effect of the homecare on maintaining the outcomes achieved.
As outlined in Rattray (2000), and throughout the research,some techniques that are indicated to treat chronic lower leg edema that is secondary to varicose veinsinclude: warm/cool hydrotherapy to increase/decrease blood flow to and from the area of congestion, putting the legs on an incline elevated above the heart to aid in venous return, releasing myofascial restrictions to increase venous/lymph return/flow, Swedish/petrissage circulatory strokes in the direction of the heart moving from distal to proximal to enhance venous return, lymph drainagetechniques (full body or local) following the pattern described in Rattray and the basic Vodder method and, mid to full passive range of motion to increase circulation and tissue health.
Based on the techniques proven to be effective, throughout this case study the following treatment procedure was used to address the treatment goals as outlined above:
(Procedures 1-4 relate directly to goals 1-4 above)
- Deep Diaphragmatic Breathing(DDB), full body rocking(rock), compressions(comp) to anterior/posterior legs, shaking to full legs.
- - Lymph Drainage techniques (as outlined in Rattray): Node pumping (Sacrum, BL popliteal fossa, BL inguinal triangle – 7x), Broad hand scooping inferior to superior towards superior nodes (5-7 repetitions/scoops at each hand placement moving superior to inferior down the limb, 2 full cycles over anterior and posterior full leg BL).
- Mid-range PROM of Hip(flexion, internal/external rotation, abduction/adduction)/Knee(flexion/extension)/TC(dorsiflexion/plantarflexion) 3-5 repetitions in each direction. - Broad cross hands spreading myofascial release(MFR) into restriction and superficial fascial skin rolling over BL HS, quads, gas/sol, TA muscle groups.
- Circulatory petrissage (Effleurage, Open-C, Wringing) to BL anterior and posterior lower extremity (HS, quads, gas/sol, TA muscle groups & feet) – flushing strokes done in direction of the heart. Ending with ~3 long distal to proximal effleurage strokes.
-Patient was positioned prone and turned to supine with ankles pillowed above heart level throughout the study to encourage blood/fluidreturn to heart with the aid of gravity.
-Hydrotherapy: Heat (Thermaphore) to encourage derivation (drawing blood/fluid) towards the heartwas applied to low back (prone) and abdomen (supine), cold towels to encourage retrostasis (pushing/driving blood/fluid) towards heart were applied to feet throughout treatment.
-Procedures 2-4 were repeated in order to BL posterior legs then to BL anterior legs.
As part of this case study the patient was given a series of daily homecare exercises to completeto compliment and maintain the effects of the massage treatments. These exercises include:
- 10min walk at lunch time to encourage movement and activate the skeletal muscle pumps that pump blood and lymph back to the heart. (1x/day)
- Elevate feet and legs above heart level with cold towel on feet for 15mins to encourage blood and fluid drainage from legs to heart using retrostasis and gravity. (1x/day)
- Active ROM of TC joint “drawing alphabet with big toe” to encourage joint movement and activate skeletal muscle pump to help return blood to the heart via venous system and encourage lymph return. (2x/day – morning & evening)
Throughout the 8 treatments some modifications were made based on the needs and requests of the patient and findings in previous or current treatment, as noted in Appendix C.
Outcomes
The most significant change in the patient’s lower leg edema was observed in the data collected of pre and post treatment girth measurements. All girth measurements were taken bilaterally at 9cm above the medial malleolus where the initial edema was most observable and palpable. Figure 1 shows a plot graph of pre and post girth measurements taken of the right lower leg. After 8 treatments performed, as outlined above, there was a successful decrease in girth of 3.5cm from pre treatment 1 to post treatment 8 measurements; equal to 12.5% decrease in limb girth.
Figure 2 shows the pre and post girth measurements taken of the left lower limb at the same level as the right leg. Similar to the right leg, the left leg decreased in overall girth measurement. Girth measurements on the left decreased by 2.5cm, or 9.1% of limb girth.