Massage effects on edema secondary to varicose … · Web viewAbstractObjective: This case study...

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

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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

Effects of Massage on Edema Secondary to Varicose Veins

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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


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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.


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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


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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.


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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

assisting against gravity. Some edema is also treated with the use of medications


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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

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


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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


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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


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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


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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)


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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

return and increase tissue health in bilateral (BL) lower extremity.


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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

increase circulation and tissue health.


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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.

4. Circulatory petrissage (Effleurage, Open-C, Wringing) to BL anterior and

posterior lower extremity (HS, quads, gas/sol, TA muscle groups & feet) –


16

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

skeletal muscle pumps that pump blood and lymph back to the heart.

(1x/day)


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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

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.


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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 measured

a decrease in girth measurement, while a .3cm increase resulted during

treatment 2.

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)


1 2 3 4 5 6 7 823242526272829

27.927.3 27.3

26.2 26 26.225.4 25.2

2726.3

25.326.2 25.8 25.6

24.5 24.4

Figure 1 - Lower Leg Girth Measurements - Right

Pre Treatment MeasurementPost Treatment Measurement

Treatment NumberGirt

h M

easu

rem

ent @

9cm

Sup

erio

r to

Med

ial M

aleo

lus (

cm)

19

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

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


1 2 3 4 5 6 7 824

24.525

25.526

26.527

27.5 27.3

26.7

26.126.5

25.9 26

25.2 25.4

26.727

25.8 2625.6 25.5

24.9 24.8

Figure 2 - Lower Leg Girth Measurements - Left

Pre Treatment MeasurementPost Treatment Measurement

Treatment NumberGirt

h M

easu

rem

ent @

9cm

Sup

erio

r to

Med

ial M

aleo

lus (

cm)

20

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

changes throughout the study in these ranges.

1 2 3 4 5 6 7 805

10152025

Figure 3 - Talocrural Range of Motion - Dorsiflexion - Right

AROM - Pre

AROM - Post

PROM - Pre

PROM - Post

Treatment NumberRang

e of

Moti

on (N

orm

al =

20

Degr

ees)

Val

ues i

n De

gree

s

1 2 3 4 5 6 7 805

10152025

Figure 4 - Talocrural Range of Motion - Dorsiflexion - Left

AROM - Pre

AROM - Post

PROM - Pre

PROM - Post

Treatment NumberRang

e of

Mor

ion

(Nor

mal

= 2

0 De

gree

s) V

alue

s in

Degr

ees


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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

pre treatment 2 to post treatment 8.

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.


1 2 3 4 5 6 7 80

102030405060

Figure 5 - Talocrural Range of Motion - Plantarflexion - Right

AROM - PreAROM - PostPROM - PrePROM - Post

Treatment Number

Rang

e of

Moti

on (N

orm

al =

50

Degr

ees)

Val

ues i

n De

gree

s

22

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.

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


1 2 3 4 5 6 7 80123456789

Figure 7 - Feeling of Fullness as Reported by Patient Pre and Post Treatment

(Right and Left)

Right - PreRight - PostLeft - PreLeft - Post

Treatment Number

Feel

ing

of F

ulln

ess S

cale

1(

low

) - 1

0(hi

gh)

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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

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.


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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.

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


25

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).

Pre Treatment 1: Post Treatment 8:


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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

was able to complete all or most of her homecare the results of the massage

treatments were sustained for longer.


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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

health, budget/benefits package, willingness to comply with homecare

recommendations must be taken into consideration.


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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).


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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/varicose-veins/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)


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Appendix A: Pre and Post Measurements of Data Assessed

Datem/d/y

Measurement taken 9cm superior to medial malleolus

Pitted Edema Test

TC ROM – Dorsiflexion

N = 20degrees

TC ROM – PlantarflexionN = 50degrees

Homecare?4

Homecare exercises given per

day

Girth Measurement – Pre

Girth Measurement – Post

R L R L Pre Post Active Passive Active Passive

3/14/15

@1pm

27.9cm 27.3cm 27.0cm(-0.9cm)

26.7cm(-0.6cm)

RNeg

.

RNeg.

R Pre ~15 ~20 ~50 ~50 N/AHomecare & tracker

given to pt.Pos

t~20 ~20 ~50 ~50

Fullness: Pre (8/10 – BL)Post (5/10 – BL)

LNeg

.

LNeg.

L Pre ~10 ~15 ~50 ~55

Post

~20 ~20 ~50 ~55

3/16/15@

5:30pm

27.3cm 26.7cm 26.3cm(-1.0cm)

27.0cm(+0.3cm

)

RNeg

.

RNeg.

R Pre ~15 ~20 ~45 ~505/8

Post

~20 ~20 ~50 ~50


LNeg

.

LNeg.

L Pre ~15 ~17 ~40 ~45

Post

~20 ~20 ~45 ~45

3/18/15@

9am

27.3cm 26.1cm 25.3cm(-2.0cm)

25.8cm(-0.3cm)

RNeg

.

RNeg.

R Pre ~17 ~20 ~45 ~506/8

Post

~20 ~20 ~50 ~50


LNeg

.

LNeg.

L Pre ~15 ~15 ~40 ~45

Post

~20 ~20 ~45 ~50

3/21/15@

11am

26.2cm 26.5cm 26.2cm (+/- 0cm)

26.0cm(-0.5cm)

RNeg

.

RNeg.

R Pre ~20 ~20 ~50 ~5010/12

Post

~20 ~20 ~50 ~50

Fullness: Pre (5/10 – BL)Post (4/10 – R, 3/10 – L)

LNeg

.

LNeg.

L Pre ~15 ~15 ~45 ~45

Post

~20 ~20 ~45 ~50

3/23/15

@6pm

26.0cm 25.9cm 25.8cm(-0.2cm)

25.6cm(-0.3cm)

RNeg

.

RNeg.

R Pre ~15 ~20 ~45 ~508/8

Post

~20 ~20 ~50 ~50

Fullness: Pre ( 5/10 – BL)Post (4/10 – BL)

LNeg

.

LNeg.

L Pre ~15 ~17 ~45 ~50

Post

~20 ~20 ~50 ~50

3/25/15@

6:30pm

26.2cm 26.0cm 25.6cm(-0.6cm)

25.5cm(-0.5cm)

RNeg

.

RNeg.

R Pre ~20 ~20 ~45 ~45 6/8Unable to walk d/t

work demands

Post

~20 ~20 ~50 ~50


LNeg

.

LNeg.

L Pre ~17 ~20 ~45 ~45

Post

~20 ~20 ~50 ~50

3/27/15@

8pm

25.4cm 25.2cm 24.5cm(-0.9cm)

24.9cm(-0.3cm)

RNeg

.

RNeg.

R Pre ~20 ~20 ~50 ~50 5/8Migraine

yesterday – severe

Gardening today

Post

~20 ~22 ~55 ~55


LNeg

.

LNeg.

L Pre ~20 ~20 ~50 ~50

Post

~20 ~25 ~55 ~55

3/30/15@

5pm

25.2cm 25.4cm 24.4cm(-0.8cm)

24.8cm(-0.6cm)

RNeg

.

RNeg.

R Pre ~15 ~17 ~45 ~5010/12

Post

~20 ~20 ~50 ~50

Fullness: Pre (4-5/10 – BL)Post (4/10 – R, 3/10 – L)

LNeg

.

LNeg.

L Pre ~17 ~20 ~50 ~50

Post

~20 ~20 ~55 ~55

Appendix B: Pre & Post Treatment Images


31

#1: March 14, 2015 @ 1pm

Pre:

Post

#2: March 16, 2015 @ 5:30pm

Pre

Post


32

#3: March 18, 2015 @ 9am

Pre – No images Available

Post

#4: March 21, 2015 @ 11am

Pre

Post


33

#5: March 23, 2015 @ 6pm

Pre – No Images Available

Post

#6: March 25, 2015 @ 6:30pm

Pre

Post


34

#7: March 27, 2015 @ 8pm

Pre

Post

#8: March 30, 2015 @ 5pm

Pre


35

Post


36

Appendix C: Homecare Tracking

Date 10min Walk

@lunch

Feet elevated w/ cool towel

(15mins)

Alphabet Tracing

(2x/day)

Notes:(notes are regarding daily

homecare modifications unless otherwise stated)

Mar 14/15 X - X - Treatment 1: Cross fiber frictions around edema pocket

@ BL lateral malleolus

Mar 15/15 X X X X No cold towel when feet elevated

Mar 16/15 X - X X Treatment 2: No cold towel on feet as per patient

request; positioned supine to start treatment

Mar 17/15 X - X XMar 18/15 X X X X No cold towel,

Treatment 3: No cold towel on feet as per patient

request

Mar 19/15 X X X XMar 20/15 - X X X No cold towelMar 21/15 X - X X Treatment 4: no

modifications

Mar 22/15 X X X XMar 23/15 X X X X Treatment 5: no

modifications

Mar 24/15 - X X XMar 25/15 - X X X No cold towel,

Treatment 6: No cold towel on feet as per patient

request

Mar 26/15 - X X - No cold towelMar 27/15 X X X X Treatment 7: no

modifications

Mar 28/15 - X X XMar 29/15 - X X XMar 30/15 X X X X Treatment 8: no

modifications

X = complete - = incomplete


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