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
2nd Year Massage Therapy Student,
Okanagan Valley College of Massage Therapy (OVCMT)
[email protected]
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
Effects of Massage on Edema Secondary to Varicose Veins
2
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). Pre vs. 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
Effects of Massage on Edema Secondary to Varicose Veins
3
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 caused
by 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.
Effects of Massage on Edema Secondary to Varicose Veins
4
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
Effects of Massage on Edema Secondary to Varicose Veins
5
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.
Effects of Massage on Edema Secondary to Varicose Veins
6
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 of leg 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
Effects of Massage on Edema Secondary to Varicose Veins
7
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 that using 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 to
determine 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
Effects of Massage on Edema Secondary to Varicose Veins
8
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
Effects of Massage on Edema Secondary to Varicose Veins
9
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
Effects of Massage on Edema Secondary to Varicose Veins
10
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.
Effects of Massage on Edema Secondary to Varicose Veins
11
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:
Effects of Massage on Edema Secondary to Varicose Veins
12
- 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’s
personal goals, the treatment goals and objectives of this case study are to:
1. Decrease Sympathetic Nervous System (SNS) firing to stop pain cycle and
promote full body healing.
2. 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.
3. 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.
4. Increase circulatory flushing to remove metabolites, promote venous
Effects of Massage on Edema Secondary to Varicose Veins
13
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
veins include: 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 drainage techniques (full body or local) following the pattern described in
Rattray and the basic Vodder method and, mid to full passive range of motion to
Effects of Massage on Edema Secondary to Varicose Veins
14
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)
1. Deep Diaphragmatic Breathing (DDB), full body rocking (rock),
compressions (comp) to anterior/posterior legs, shaking to full legs.
2. - 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.
3. Broad cross hands spreading myofascial release (MFR) into restriction
and superficial fascial skin rolling over BL HS, quads, gas/sol, TA muscle
groups.
Effects of Massage on Edema Secondary to Varicose Veins
15
4. 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/fluid return
to heart with the aid of gravity.
-
Hydrotherapy: Heat (Thermaphore) to encourage derivation (drawing
blood/fluid) towards the heart was 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 complete to compliment and maintain the effects of the massage
treatments. These exercises include:
1. 10min walk at lunch time to encourage movement and activate the
Effects of Massage on Edema Secondary to Varicose Veins
16
skeletal muscle pumps that pump blood and lymph back to the heart.
(1x/day)
2. 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)
3. 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
Effects of Massage on Edema Secondary to Varicose Veins
17
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
Girth Measurement @ 9cm Superior
to Medial Maleolus (cm)
12.5% decrease in limb girth.
Figure 1 - Lower Leg Girth Measurements
- Right
29
28
27
26
25
24
23
27.9
27.3
27.3
26.2
26
26.2
27
26.3
26.2
25.3
1
2
3
4
25.8
5
25.4
25.2
24.5
24.4
7
8
25.6
6
Pre Treatment
Measurement
Post Treatment
Measurement
Treatment Number
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.
During treatment 2 the patient was positioned supine and then turned to prone
rather than starting prone. All other treatments were performed with the
patient positioned prone to start and then turned supine; all other treatments
Effects of Massage on Edema Secondary to Varicose Veins
18
measured a decrease in girth measurement, while a .3cm increase resulted
Girth Measurement @ 9cm Superior to
Medial Maleolus (cm)
during treatment 2.
Figure 2 - Lower Leg Girth Measurements
- Left
27.5
27
26.5
27.3
27
26.7 26.7
26.5
26.1
25.8
26
25.5
26
25.9 26
25.6 25.5
25
24.5
25.4
25.2
24.9 24.8
Pre Treatment
Measurement
Post Treatment
Measurement
24
1
2
3
4
5
6
7
8
Treatment Number
Also seen in both figures 1 and 2 the pre treatment girth measurement taken
before treatments 5 and 7 were smaller than the post treatment girth
measurements taken after the treatment prior. There was a decrease of .5cm(R)
and .2cm (L) between treatments 4 and 5 and a decrease of .6cm (BL) between
treatments 6 and 7. Prior to treatment 5 the patient completed 100% of her
homecare and prior to treatment 7 the patient reported spending the
morning/afternoon before treatment gardening at moderate intensity (engaging
skeletal muscle pumps). She also reported having a severe migraine the day
before (patient slept most of the day or relaxing with feet up not allowing
Effects of Massage on Edema Secondary to Varicose Veins
19
fluid/blood to pool in lower leg). This data suggests that the homecare given to
the patient as well as commitment to self-care has a positive effect on
decreasing edema in the lower leg.
Figures 3 (right) and 4 (left) show the pre and post measurements of active and
passive dorsiflexion range of motion at the talocrural (TC) joint. Though the
patient’s range of motion was not severely limited by the edema on either right
or left there was a measureable increase in active TC dorsiflexion pre treatment
measurements on the left (Figure 4) from 10 degrees (pre treatment 1) to 17-20
degrees (pre treatments 7 & 8). There were no other consistent measurable
Range of Motion (Normal = 20
Degrees) Values in Degrees
changes throughout the study in these ranges.
Figure 3 - Talocrural Range of Motion Dorsiflexion - Right
25
20
AROM Pre
AROM Post
15
10
PROM Pre
5
0
1
2
3
4
5
6
7
8
PROM Post
Treatment Number
Effects of Massage on Edema Secondary to Varicose Veins
20
Range of Morion (Normal = 20
Degrees) Values in Degrees
Figure 4 - Talocrural Range of Motion Dorsiflexion - Left
25
20
15
10
5
0
1
2
3
4
5
6
7
8
AROM Pre
AROM Post
PROM Pre
PROM Post
Treatment Number
Figures 5 (Right) and 6 (Left) show the pre and post measurements of active and
passive plantarflexion range of motion at the TC joint. As with dorsiflexion, the
patients’ plantarflexion was not severely limited on the right or left. Upon
assessment the only consistent measureable change was recorded at the left TC
joint (figure 6): active and passive ranges were both increased by 5-10 degrees
Range of Motion (Normal = 50
Degrees) Values in Degrees
pre treatment 2 to post treatment 8.
Figure 5 - Talocrural Range of Motion Plantarflexion - Right
60
40
AROM - Pre
20
AROM - Post
PROM - Pre
0
1
2
3
4
5
6
7
8
PROM - Post
Treatment Number
Effects of Massage on Edema Secondary to Varicose Veins
21
Range of Morion (Normal = 50 degrees)
Values in Degrees
Figure 6 - Talocrural Range of Motion Plantarflexion - Left
60
50
40
AROM - Pre
30
AROM - Post
20
PROM - Pre
10
PROM - Post
0
1
2
3
4
5
6
7
8
Treatment Number
Figure 7 shows a measureable decrease in the patients reported feeling of
fullness, on a scale of 1-10. The greatest decrease was seen pre vs. post
treatment 1 from 8/10 to 5/10. By the end of the study (post treatment 8) there
was a significant decrease in fullness with patient reporting her legs feeling
3/10(left) and 4/10(right) on the fullness scale; decreasing the patients feeling of
fullness by 50 – 62.5% over the course of treatment.
Effects of Massage on Edema Secondary to Varicose Veins
22
Feeling of Fullness Scale
1(low) - 10(high)
Figure 7 - Feeling of Fullness as Reported
by Patient Pre and Post Treatment
(Right and Left)
10
8
6
Right - Pre
4
Right - Post
2
Left - Pre
0
Left - Post
1
2
3
4
5
6
7
8
Treatment Number
No change was seen in the pitted edema test throughout the study. All pre and
post treatment tests were negative for pitted edema.
Figures 1, 2 and 7 show that the treatments were successful in achieving the
goals of decreasing the patient’s lower leg girth and decreasing the patient’s
reported feeling of fullness.
Figures 3 thru 6 showed a small overall increase in active and passive range of
motion at the TC joint even though the patient, unexpectedly, did not start the
study with a significant deficit in these ranges.
Effects of Massage on Edema Secondary to Varicose Veins
23
Shown in the images below is the unexpected effect the treatment had on the
purple tissue discolouration on the patients’ right medial malleolus. The colour
of the tissue faded as treatments progressed from a diffuse purple colour with
multiple darker purple capillaries spread throughout to a dull red hue with very
few darker capillaries scattered throughout.
Post Treatment 2
Post Treatment 6
Pre Treatment 8
See appendix for more pre and post treatment images for visual depiction of
results achieved.
Throughout the study the patient was given the same daily homecare (outlined
above) and asked to track her completion of each exercise. Overall the patient
completed her homecare 83.8% of the time.
The time the treatments took place had little to no effect on the outcomes of
Effects of Massage on Edema Secondary to Varicose Veins
24
this study as evidenced by no correlation seen in the data between changes in
girth measurements and the time of day the treatment took place.
Ongoing long term assessment was scheduled for 4, 6 and 8 weeks after the
completion of this study to determine the long term effects of the treatment
series as well as help determine the best long term treatment frequency. The
patient was given an ongoing homecare tracking sheet for that time. 4 weeks
post treatment 8 (April 27, 2015) the patient reported that her feeling of fullness
had increased slightly to 4/10 bilaterally, there was no decrease in her talocrural
active and passive range of motion in all ranges, and her girth measurements
were 26.2cm(R) and 26.3cm(L); similar to measurements taken during treatment
4. Though the patient was not diligent on recording the homecare she had
completed during the first 4 weeks after treatment she reported that she did
“about half” of the exercises. 6 and 8 week follow up assessments were unable
to be completed as the patient was traveling unexpectedly during these times.
Included in appendix: table of pre and post measurements, visual images taken
throughout treatment, and patients completed homecare tracking sheet.
Effects of Massage on Edema Secondary to Varicose Veins
25
Discussion and Conclusion
Based on the outcomes achieved in this case study the combined use of lymph
drainage, superficial myofascial release and circulatory petrissage massage
techniques in conjunction with hydrotherapy applications and structured
homecare has a positive effect on decreasing symptoms of lower leg edema
secondary to varicose veins by noticeably decreasing the overall girth
measurements, by 9.1%-12.5%, and decreasing patient reported feeling of
fullness, by 50 - 62.5%, in the lower legs bilaterally.
These techniques were also shown to have an unexpected effect on long
standing tissue discolouration and capillary blood pooling around the patient’s
right medial malleolus. More research should be done to solidify this data. A
significant effect on range of motion (active or passive) at the talocrural was not
shown as the patient being treated did not have significantly decreased initial
ranges. There was also a significant decrease in the visible size and colour of the
varicose veins bilaterally (below).
Effects of Massage on Edema Secondary to Varicose Veins
26
Pre Treatment 1:
Post Treatment 8:
This study also supported the best practice of elevating the feet above the heart
level to aid in blood and fluid return to the heart. It was also noted, through data
collected during treatment 2, that positioning of the patient (Prone to supine vs.
supine to prone) may have an effect on treatment outcomes, more research is
needed to support this.
This case study supports research already done on the effectiveness of lymph
drainage techniques on edema in general (Harris, 2004); it specifically confirms
the technique’s positive effects on lower leg edema secondary to varicose veins.
This study also shows that superficial myofascial techniques, hydrotherapy and
structured homecare have a positive effect on helping treat this condition and
decrease symptoms. It was shown through data collected that when the patient
Effects of Massage on Edema Secondary to Varicose Veins
27
was able to complete all or most of her homecare the results of the massage
treatments were sustained for longer.
Due to the nature of this condition, the edema being as a result of a structural
venous change, it is expected that treatment will need to be ongoing. As an
initial treatment plan this series of 8 treatments with one treatment every 2-3
days was effective but would not be cost effective for long term treatment. It
would be reasonable to expect, from the data collected (similar girth and fullness
measurements throughout the last week of treatment), that the same sustained
results could be obtained by 1 treatment per week if the patient is able to
maintain commitment to her homecare/self-care. These treatments could
become less frequent (1 every 2/3 weeks, or longer) once outcomes were able to
be maintained between treatments with homecare/self-care.
This potential long term care plan was supported by measurements taken 4
weeks after treatment ended; during the weeks post treatment the patient
reported that she was 50% compliant with her homecare/self-care plan. The
patients girth measurements increased by 1.8cm (R) and 1.5cm (L) but still
remained less than original measurements. To determine the best treatment
plan for any patient with this condition factors such as: the patients overall
Effects of Massage on Edema Secondary to Varicose Veins
28
health, budget/benefits package, willingness to comply with homecare
recommendations must be taken into consideration.
The patient was surprised and excited about the effect that this type of
treatment had on an issue that she considered to be normal for her and unlikely
to change. The patient is most excited about the change in colour of the tissue
around her right medial malleolus. The patient reports being open and willing to
continue with the ongoing homecare and seeking out this type of massage
treatment on an ongoing basis for maintenance. With the results she has seen
from massage for this condition the patient is also reportedly more willing to
seek massage as a potential treatment for other conditions (migraines).
Effects of Massage on Edema Secondary to Varicose Veins
29
References
1. Rattray, Fiona and Ludwig, Linda, 2000, Clinical Massage Therapy:
Understanding, Assessing and Treating over 70 Conditions, Talus
Incorporated, Ontario, Canada.
2. Varicose Veins Mayo Clinic, January 2013,
http://www.mayoclinic.org/diseases-conditions/varicoseveins/basics/definition/con-20043474
3. Jordan, Kate, NCTMB, 2001, What about Varicose Veins Massage Today,
Volume 1, Issue 5.
4. Harris, R.H. and Piller, N.B., February 29, 2004, Research Shows
Effectiveness With Lymphoedema Patients, Massage Therapy Canada.
5. Magee, David J., 2008 Orthopedic Physical Assessment, (5th edition),
Sanders, Canada.
6. Hertling, Darlene and Kessler, Randolph M., (2005) Management of
Common Musculoskeletal Disorders, (4th edition), Wolters Kluwer.
7. Harris, R.H. and Piller, N.B., 2003, Three case studies indication the
effectiveness of manual lymph drainage on patients with primary and
secondary lymphoedema using objective measuring tools, Journal of
Bodywork and Movement Therapies, 7 (4) 213 – 223.
8. Goats, Geoffrey, 1994, Massage - the scientific basis of an ancient art:
part 2. Physiological and therapeutic effects Br J SP Med, 28(3)
Effects of Massage on Edema Secondary to Varicose Veins
30
Appendix A: Pre and Post Measurements of Data Assessed
Date
m/d/y
3/14/15
@
1pm
Measurement taken 9cm superior to medial
malleolus
Girth Measurement –
Girth Measurement –
Pre
Post
L
R
L
Pre
Post
27.9cm
27.3cm
27.0cm
(-0.9cm)
26.7cm
(-0.6cm)
R
Neg.
R
Neg.
R
L
Neg.
L
Neg.
L
R
Neg.
R
Neg.
R
27.3cm
26.7cm
26.3cm
(-1.0cm)
27.0cm
(+0.3cm)
Fullness: Pre (6/10 – BL)
Post (4/10 – BL)
3/18/15
@
9am
27.3cm
26.1cm
25.3cm
(-2.0cm)
L
Neg.
25.8cm
(-0.3cm)
Fullness: Pre (5/10 – BL)
Post (4/10 – BL)
3/21/15
@
11am
26.2cm
26.5cm
26.2cm
(+/- 0cm)
26.0cm
25.9cm
25.8cm
(-0.2cm)
26.0cm
(-0.5cm)
26.2cm
26.0cm
25.6cm
(-0.6cm)
25.6cm
(-0.3cm)
25.4cm
25.2cm
24.5cm
(-0.9cm)
25.5cm
(-0.5cm)
25.2cm
25.4cm
24.4cm
(-0.8cm)
Fullness: Pre (4-5/10 – BL)
Post (4/10 – R, 3/10 – L)
R
Neg.
L
Neg.
24.9cm
(-0.3cm)
Fullness: Pre (5/10 – BL)
Post (3/10 – R, 4/10 – L)
3/30/15
@
5pm
R
Neg.
L
Neg.
Fullness: Pre (4/10 – BL)
Post (4/10 – R, 3/10 – L)
3/27/15
@
8pm
R
Neg.
L
Neg.
Fullness: Pre ( 5/10 – BL)
Post (4/10 – BL)
3/25/15
@
6:30pm
R
Neg.
L
Neg.
Fullness: Pre (5/10 – BL)
Post (4/10 – R, 3/10 – L)
3/23/15
@
6pm
TC ROM –
Dorsiflexion
N = 20degrees
R
Fullness: Pre (8/10 – BL)
Post (5/10 – BL)
3/16/15
@
5:30pm
Pitted Edema
Test
24.8cm
(-0.6cm)
R
Neg.
L
Neg.
R
Neg.
L
Neg.
R
Neg.
L
Neg.
R
Neg.
L
Neg.
R
Neg.
L
Neg.
R
Neg.
L
R
Passive
Active
Passive
Pre
~15
~20
~50
~50
Post
~20
~20
~50
~50
Pre
~10
~15
~50
~55
Post
~20
~20
~50
~55
Pre
~15
~20
~45
~50
Post
~20
~20
~50
~50
N/A
Homecare
& tracker
given to pt.
Pre
~15
~17
~40
~45
Post
~20
~20
~45
~45
Pre
~17
~20
~45
~50
Post
~20
~20
~50
~50
Pre
~15
~15
~40
~45
Post
~20
~20
~45
~50
6/8
L
R
Pre
~20
~20
~50
~50
Post
~20
~20
~50
~50
Pre
~15
~15
~45
~45
Post
~20
~20
~45
~50
10/12
L
R
Pre
~15
~20
~45
~50
Post
~20
~20
~50
~50
8/8
L
R
L
R
L
Neg.
L
R
Neg.
R
Neg.
R
L
Neg.
Active
Homecare?
4 Homecare
exercises
given per
day
5/8
L
Neg.
L
Neg.
TC ROM –
Plantarflexion
N = 50degrees
Pre
~15
~17
~45
~50
Post
~20
~20
~50
~50
Pre
~20
~20
~45
~45
Post
~20
~20
~50
~50
Pre
~17
~20
~45
~45
Post
~20
~20
~50
~50
Pre
~20
~20
~50
~50
Post
~20
~22
~55
~55
Pre
~20
~20
~50
~50
Post
~20
~25
~55
~55
Pre
~15
~17
~45
~50
Post
~20
~20
~50
~50
Pre
~17
~20
~50
~50
Post
~20
~20
~55
~55
6/8
Unable to
walk d/t
work
demands
5/8
Migraine
yesterday –
severe
Gardening
today
10/12
L
Effects of Massage on Edema Secondary to Varicose Veins
31
Appendix B: Pre & Post Treatment Images
#1: March 14, 2015 @ 1pm
Pre:
Post
#2: March 16, 2015 @ 5:30pm
Pre
Effects of Massage on Edema Secondary to Varicose Veins
32
Post
#3: March 18, 2015 @ 9am
Pre – No images Available
Post
#4: March 21, 2015 @ 11am
Pre
Effects of Massage on Edema Secondary to Varicose Veins
33
Post
#5: March 23, 2015 @ 6pm
Pre – No Images Available
Post
#6: March 25, 2015 @ 6:30pm
Pre
Effects of Massage on Edema Secondary to Varicose Veins
34
Post
#7: March 27, 2015 @ 8pm
Pre
Post
Effects of Massage on Edema Secondary to Varicose Veins
35
#8: March 30, 2015 @ 5pm
Pre
Post
Effects of Massage on Edema Secondary to Varicose Veins
36
Appendix C: Homecare Tracking
Date
Mar 14/15
10min
Walk
@lunch
X
Feet elevated
w/ cool towel
(15mins)
-
Alphabet
Tracing
(2x/day)
X
-
Mar 15/15
X
X
X
X
Mar 16/15
X
-
X
X
Notes:
(notes are regarding daily
homecare modifications unless
otherwise stated)
Treatment 1: Cross fiber
frictions around edema pocket
@ BL lateral malleolus
No cold towel when
feet elevated
Treatment 2: No cold
towel on feet as per patient
request; positioned supine to
start treatment
Mar 17/15
Mar 18/15
X
X
X
X
X
X
X
No cold towel,
Treatment 3: No cold
towel on feet as per patient
request
Mar 19/15
Mar 20/15
Mar 21/15
X
X
X
X
-
X
X
X
X
X
X
Mar 22/15
Mar 23/15
X
X
X
X
X
X
X
X
No cold towel
Treatment 4: no
modifications
Treatment 5: no
modifications
Mar 24/15
Mar 25/15
-
X
X
X
X
X
X
No cold towel,
Treatment 6: No cold
towel on feet as per patient
request
Mar 26/15
Mar 27/15
X
X
X
X
X
X
No cold towel
Treatment 7: no
modifications
Mar 28/15
Mar 29/15
Mar 30/15
X
X
X
X
X
X
X
X
X
X
Treatment 8: no
modifications
X = complete
- = incomplete
Effects of Massage on Edema Secondary to Varicose Veins
37
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