Massage Therapists’ Association of British Columbia

Massage Therapists’ Association

of British Columbia

Clinical Case Report Competition

West Coast College of Massage Therapy,
Victoria

Spring 2010

First Place Winner

Alana C. Diening
Reducing edema in the legs of a pregnant
patient with an intact lymphatic system using
manual lymph drainage: A case report

P: 604.873.4467
F: 604.873.6211
[email protected]
massagetherapy.bc.ca MTABC 2010
Reducing edema in the legs of a pregnant patient with an
intact lymphatic system using manual lymph drainage: A
case report

(1)

Alana C. Diening, 09D, RMT candidate, WCCMT Victoria Campus

Contact Info: WCCMT, 637 Bay St, Victoria, BC, V8T 5L2, Canada
To the author’s knowledge, no conflict of interest exists.

Table of Contents

Abstract 1
Introduction 2
Case Report 3
Diagnosis 5
Treatment 5
Differential Diagnosis 7
Results 7
Discussion 11
Conclusion 13
Acknowledgement 14
References 15
Bibliography 15

Appendix A - Blood pressure pre treatment 16

Appendix B - Circumference measurements right 17
Appendix C - Circumference measurements left 19
Appendix D - Fatigue scale 21
Appendix E - Water Displacement 22
Appendix F - Record of treatments and patient consultation forms 23
Reducing edema in the legs of a pregnant patient with an
intact lymphatic system using manual lymph drainage: A
case report
1. Abstract

Objective:
To evaluate the effectiveness of manual lymph drainage (MLD) on the edematous ankles
of a pregnant patient.

Clinical Features:
A pregnant women in her early 30’s. Patient observed significant swelling of ankles at
four months of pregnancy, including palpation, and discomfort wearing shoes. Levels of
edema varied daily. Edema with pregnancy is familial for patient. Patient complained of
“heavy”, “thick”, and fatigued legs.

Intervention and outcome:

Seven, 45minute treatments of Basic level Dr. Vodder’s MLD sequences for the neck and
legs. Compression stockings considered but decided against unless edema had become
more severe. Edema decreased in the ankles and positive subjective feedback was
recorded at the completion of each treatment. Treatment effects were short term.

Conclusion:
A temporary decrease in edema of the ankles may be accomplished by using Dr.
Vodder’s Manual Lymph Drainage. Compression stockings would be indicated if the
edema were to become severe. MLD can provide temporary relief and possibility of
preventing severity.

Key Words: Massage Therapy, Manual Lymph Drainage, MLD, Pregnancy, Intact
lymphatic system, Dr. Vodder, Edema.

1
Introduction:

Edema is common at any time during a pregnancy due to the retention of fluid. As the
pregnancy advances, edema occurs in up to 40 percent of women. Edema with pregnancy
is most commonly caused by mechanical obstruction to the Inferior Vena Cava, and
increased fluids within the body resulting in low blood osmolarity. (2)

MLD is effective in increasing lymph drainage. However once severe edema has
occurred it is irreversible on it’s own and compressions stocking are a daily necessity. If
edema is kept to a minimum the lymph system will most likely be able recuperate. (3)

A clinician should understand the directions of the lymph system. Beginning by opening
the terminus during the neck sequence and continuing to work the affected area in the
direction of lymph flow as demonstrated below. (3)

Fig. 1 Direction of flow in the lymph system. (1)

* Please note small black arrows directing from peripheral to proximal groupings of
lymph nodes.

It seems likely that MLD has a systemic effect on the lymphatic system and that it may
improve flow from otherwise normal tissues. (4) Using a control where the conditions of a
MLD treatment were approximated but no actual treatment was applied, proved to have a
mild effect but not nearly as pronounced as with treatment. (3-4) The hypothesis of this
study was that MLD can ease the edematous ankles in a pregnant patient.

2
 Anatomical Considerations
• Structure of Lymphatic system.
Lymphatic vessels are an additional vascular network connecting the tissues with the
venous system. In evolutionary terms, they develop from primordial veins. Very fine
lymphatic capillaries start blind in the tissue. They flow into larger transport vessels and
finally into the right and left venous arch. (3)

• Direction of lymphatic flow.

From periphery to trunk; following intricate lymph vessel pathways.

• Areas of Watersheds.
Lymphatic watersheds delineate skin territories. Between skin territories, there are almost
no cross connections. (3)

CASE REPORT

Clinical Presentation
Patient is an early 30’s RMT who began treatment at 22 weeks of pregnancy (five and a
half months). Patient’s L5-S1 is affected by spina bifida, disc bulging, degeneration, and
osteophytes. Her overall health is very good. The patient is currently participating in
pre-natal yoga and mediation once per week. She began to notice substantial swelling of
ankles at 4 months of pregnancy, mainly by palpation and discomfort with putting on
shoes. Her main complaint is of legs feeling “fatigued’ and ‘heavy”.

Physical Examination
The physical exam was completed objectively by measuring water displacement, and
circumference measurements. Subjective analysis involved using a “fatigue/heaviness”
scale (0/10-zero being no symptoms and 10 being extreme fatigue/heaviness) in the
sitting and standing positions.

Table 1-Explanation of objective measurement tools

Device Measures Method
Water displacement Changes in volume of the Fill a bucket with water and
lower leg. measure the difference between
initial and secondary readings of
volume displacement before and
after treatment. Buckets is filled to
the exact same level each treatment
before measurement.
Manual Circumference of head and Tape measurement
circumference base of metatarsals, smallest
Measurements part of the ankle, and largest
part of the calf.

3
Water Displacement All photos by author
Fig 2. Initial reading Fig. 3 Secondary reading

The initial assessment showed 2 centimeters between the initial and secondary readings
of water displacement. Volume is too difficult to calculate due to irregular shape of
bucket.

Circumference measurements
Fig. 4 Fig. 5
Head of the metatarsals Base of the metatarsals

Fig. 6 Fig. 7
Smallest part of the ankle Largest part of the calf

4
Table 2- Initial circumference measurements
Initial circumference Right leg Left leg
measurements (cm) Pre Treatment 1 Pre Treatment 1
Head of Metatarsals 21.7cm 21.7cm
Prox Metatarsals 22.5cm 22.5cm
Smallest part of ankles 22.5cm 22.5cm
Largest part of calves 39.5cm 39.5cm

Fatigue and heaviness scale was not used during initial assessment but was used from
treatment two to seven.

Diagnosis
Fluid retention in lower extremity due to pregnancy.

Treatment
The primary treatment goals were to decrease the circumference, water displacement, and
fatigue/heaviness scale of the legs.

Informed consent was obtained prior to commencement of treatment. Each treatment

consisted of the exact same routine: Dr. Vodder basic training sequences. Techniques can
be learned by attending a Dr. Vodders basic training class at any locations worldwide. (5)

Treatment was performed with patient supine, legs elevated by four pillows stacked. A
cervical pillow was placed under her right buttock to direct her weight on to her left side.
Treatment consisted of a 10min neck sequence, followed by a 10- 15min leg sequence for
each leg.

I. Treatment of the Neck

1. Effleurage: five fan-shaped strokes with the thumbs from sternum to the axillae. Last
stroke is along the clavicle. (once)
2. Cervical lymph nodes: five stationary circles each over the lymph nodes at profundus,
middle, and terminus. (three repetitions)
3. Occiput: five stationary circles each beginning below the occiput at the base of the
skull, middle of the nape and terminus. (three repetitions)
4. Mandible: five stationary circles each in three positions from the tip of the chin to the
angle of the jaw then continue to profundus, middle, terminus. (three repetitions)
5. Fork technique: five stationary circles each in three positions from the tip of the chin
to the angle of the jaw then continue to profundus, middle, and terminus. (three
repetitions)
6. Shoulders / trapezius: five stationary circles each with the whle hand moving in the
skin over the ball of the shoulder and with four flat fingers in two positions on the
trapezius border then the terminus. (three repetitions)
7. Shoulders / acromion: five stationary circles each starting again at the ball of the
shoulders them the acromion (above the clavicle) an then the terminus. (three
repetitions)

5
8. Cervical lymph nodes: five stationary circles each on the profundus, middle, and
terminus as in number two. (once)
9. Final effleurage. (once)

II. Treatment of the Legs

1. Eflleurage: beginning from the foot up the leg. (once)

2. Anterior thigh: pump technique, with both hands alternating (six). (three repetitions)
3. Thigh: pump – push technique distal to proximal over the thigh (six each):
a) on the medial side (over adductors) use inferior hand to pump and superior
hand (fingers only) to push. (three repetitions)
4. Inguinal lymph nodes: five stationary circles using eight flat fingers on a diagonal
upwards. Pressure toward the fingertips with circles releasing toward the head in
three places starting at medial mid-upper thigh (three repetitions)
Then three continuous circles down to the knee with pressure on the upward part of
the stroke making a spiral movement. (once)
5. Knee:
a) Pump-push with six alternating thumb and finger circles along the
“cauliflower”. Fingers are underneath vastus medialis and make 90 degree turns
together with thumb while other hand pushes with thumb only.
b) Scoop technique: five parallel in the popliteal space with eight flat fingers
distal to proximal. (three repetitions)
c) Patella leave the fingers in the popliteal space and now make parallel thumb
circles on each side of the patella. (three repetitions)
d) Pump technique (five) with inferior hand over knee superior hand supports
underneath. (three repetitions)
e) Pes anserinus with six alternating thumb circles. (three repetitions)
6. Lower leg, with knee flexed:
a) Alternate between pump technique with inferior hand over the shin and scoop
with the other hand under the calf (six). (three repetitions)
b) Alternating scoop technique (six) with thumbs running parallel to the tibia one
hand in front the other working up to the popliteal space. (three repetitions)
7. Achilles tendon: extend leg again: five parallel, four-finger spirals on each side of the
Achilles tendon. (three repetitions)
8. Ankle: 6 alternating thumb circles in three lines. Repeat each line. (three repetitions)
9. Dorsum of the foot: with six alternating thumb circles in three lines. Repeat each line.
(three repetitions)
10. Lymph Sea: parallel thumb circles (five) edema-technique, in one position. (three
repetitions)
11. Transverse arch: pressing with fingers underneath. (three repetitions)
12. Final effleurage: from the foot up the leg. (once)

Homecare for the patient consisted of taking circumference measurements in the morning
as well as using cool water to complete each shower to encourage vasoconstriction. (2)

6
Differential Diagnosis

Congestive heart failure, deep vein thrombosis, pre-eclampsia, and eclampsia were
considered and removed as possibilities due to lack of pitting edema, lack of pain or
redness, and normal blood pressure respectively.

Results of Treatment
Table 3- Differences between initial physical exam pre treatment and final physical exam
pre treatment.
Initial assessment Final Assessment
Pre-Treatment Pre-Treatment
(Treatment 1) (Treatment 7)
Water displacement 2cm 1.7 cm
Circumference measurements
Right
Head of Metatarsals 21.7cm 22cm
Prox Metatarsals 22.5cm 22.5cm
Smallest part of ankles 22.5cm 22.8cm
Largest part of calves 39.5cm 39.5cm
Circumference measurements
Left
Head of Metatarsals 21.7cm 22.2cm
Prox Metatarsals 22.5cm 22.5cm
Smallest part of ankles 22.5cm 22.7cm
Largest part of calves 39.5cm 39.5cm
Fatigue/Heaviness scale
(starting treatment 2)
sitting 4 1
standing 2 0.5

Water Displacement shows a decrease in the total water displacement by three

millimeters. Circumference measurements increased or stayed the same.
Fatigue/Heaviness scale demonstrates a significant decrease in subjective feedback with a
difference of three numbers for sitting and one and a half for standing.

Symptoms at the beginning of each treatment in all three categories of measurements

mentioned above varied substantially each week with no obvious pattern (see appendix).
Therefore the rest of the results section will focus specifically on pre versus post
treatment as oppose assessing the progress from treatment one to seven.

*Full data in appendix

7
Water displacement

Fig. 8 Results of water displacement measurements

On days four and seven there was an increase of volume within the leg and on day six
there was a decrease of 1.6cm.

Circumference Measurements

Fig.9 Results-Right Fig.10 Results -Left

The right foot showed an increase in the sum of differences of circumference

measurements on days one and three. Each treatment there was a decrease in the sum of
circumference of the left foot.

8
Fig. 11– *Please note veins, shape of ankle, shapes of toes.
Pre Treatment Seven – All photos by author

Fig. 12
Post Treatment Seven

9
Fatigue/Heaviness Scale

Fig 13 - Subjective – Fatigue/Heaviness scale (0/10) seated

-Data not recorded treatment one pre/post and treatment four post

Fig 14 – Subjective – Fatigue/heaviness scale (0/10) standing

-Data not recorded treatment one pre/post and treatment four post

10
Discussion

Water Displacement
Water displacement measurements indicate that treatment four and seven resulted in an
increase in volume within the lower extremity. Only increments greater than three
millimeters (mm ) were mentioned as significant. Both of these measurements were three
mm or less and therefore not considered significant. A three mm buffer is used to
account for measurement errors.

Treatment six had a water displacement difference measurement decrease of 1.6cm. It is

interesting to note that the patient complained of increased sensation of edema in the
ankles and foot as opposed to the thighs and knees on this day compared to other days.
This finding suggests that the height of the bucket may account for the lack of findings
using water displacement; as the fluids were moving from the whole leg and not just the
ankles.

Circumference measurements

When comparing circumference measurements pre treatment one to pre treatment seven
it is important to consider that the pregnancy was progressing, therefore fluids within the
body and edema were increasing. This could account for why the circumference
measurements increased over the seven treatments.

Before looking at pre measurements versus post for each treatment, one must take into
account a relative picture of the findings. If you imagine taking off a sock that is three
mm thick, than taking a section of that sock and squeezing it together. The total space
taken up is a significant amount even though when evenly distributed it would appear as
though it is not.

The right leg demonstrated that on treatment one and three there was an increase in the
sum of differences by three mm. Allowing three mm of error it is still significant to note
that these are the lowest findings of change within the case report. Also significant is that
the therapist only had time to treat half of the right leg on those two days due to being a
novice therapist. The left leg was treated fully and did decrease in size. This example is
consistent with findings of other papers mentioned within the introduction that state “It
seems likely that MLD has a systemic effect on the lymphatic system… Using a control
where the conditions of MLD were approximated but no actual treatment was applied,
proved to have a mild effect but not nearly as pronounced as with treatment.”. (2-3)

The left leg consistently showed a decrease in the sum of the differences of
circumference and was always treated with the full leg sequence.

Measurements that the patient took in the morning each day were very similar, therefore
an average of these numbers would be a suitable number to refer to as a baseline
measurement. When comparing the circumference measurements taken in the morning to
the measurements taken pre treatment there are no significant changes in both the

11
measurements of the head and base of the metatarsals, or the ankle for both the left and
right leg. However there is consistently a dramatic increase in the size of the calf
throughout the day of one to two centimeters. (see appendix B1, B4 & C1, C4). This
indicates that the calf is the structure within the areas being measured where the largest
amount of edema is collecting. This furthers the conclusion that the use of water
displacement covering the ankles and some of the lower leg would not accurately cover
the area most affected by the edema.

Fatigue/heaviness scale
Fatigue/heaviness scale consistently shows a decrease in subjective feedback post each
treatment. The initial symptoms vary treatment to treatment with no consistent
progression. The patient described the results as effective until the next day after work,
when symptoms would return.

MLD appears to have short term effects on the edematous legs of a pregnant patient,
providing temporary relief.

If one were to replicate this case presentation, a larger bucket would be indicated,
covering higher up the leg and using one where volume could be determined would be
helpful. More effective measurement tools are indicated to have a more accurate
representation of edema including use of tonometery, perometry, and/or Bio-impedance.

A controlled trial where circumstances were approximated but no MLD was applied
would be appropriate un the future. Experimentation in this case was inappropriate
because of time constraints and the primary goal was to provide the patient with relief of
symptoms.

MLD is not well documented. The most current and up to date research are the pilot
studies mentioned earlier.

The tissue of the patient was very tight and increasing in tightness. This made MLD
increasingly difficult to perform and may have decreased effectiveness. The author noted
that at the final treatment tissue was very resistant to stretch.

The patient described that some patterns within her symptomatic presentation were linked
to temperature outside. The hotter it was the more edematous her legs became. Heat
should not be used during treatment as it increases edema of the area.

It should be noted that it would be valuable to take measurements four times per day
during the treatment period as well as completing a diary of symptoms to furthur
document the effects of MLD and outside contributing factors. Although this would be
time consuming and patients may be resistant to such extensive homecare. As each
treatment progressed, the therapist became more efficient and precise with the MLD
techniques.

12
Conclusion

MLD had a positive effect on the edema in the legs of a pregnant patient in this case. A
temporary decrease in edema of the ankles may be accomplished by using Dr. Vodder’s
Manual Lymph Drainage. Compression stockings would be indicated if the edema were
to become severe. Performing MLD may provide temporary relief and the possibility of
preventing severity. No firm conclusions can be made based on the results of a single
study. Although it does suggest that MLD may provide a reduction in lower extremity
edema resulting from pregnancy. This approach should be considered in patients with
similar conditions. Further studies are encouraged.

13
Acknowledgment

I would like to sincerely thank the patient for their time and effort put forth. I really
appreciate her commitment and openness to treatment. As well as a grand thank you for
the support of Robert Harris for teaching MLD, aiding in developing the idea for the
project, and finding supporting research. Thanks to Nicole Scovill for over seeing this
project and Clarck Konzack for his excellent guidance in the Research and Statistics
classroom.

14
References

1. The lymphoedema site for healthcare professionals and patients [Online]. [1995?]
[cited 2009 Aug 10]; Available from: URL:http://www.lymphoedema.org/lsn/lsn140.htm

2. Rattray F, Ludwig L. Clinical Massage Therapy. Toronto (Ont): Talus Incorporated;

2000. p. 217-230.

3. Harris R, Piller N. Three case studies indicating the effectiveness of manual lymph
drainage on patients with primary and secondary lymphedema using objective measuring
tools. J Bodyw Mov Ther 2003 Oct; 7(4):213-221

4. Harris R, Piller N. A pilot study if the effect of a single Manual Lymph Drainage
treatment on patients with post mastectomy lymphoedema. (unpublished)

5. Dr. Vodder School International [Online]. [1993?] [cited 2009 Aug 31].
Available from: URL:http://www.vodderschool.com/

Bibliography

1. Koul R, Dufan T, Russell C, Guenther W, Nugent Z, Sun X et al. Efficacy of complete

decongestive therapy and manual lymphatic drainage on treatment-related lymphedema
in breast cancer. Int J Radiat Oncol Biol Phys. 2006 Sept 11.

2. Wittlinger G, Wittlinger H. Textbook of Dr. Vodder’s Manual Lymph Drainage. 7th ed.
Stuttgart (Germany): Druckhaus Beltz; 2004. (Basic Course; vol 1).

15
Appendix A – Blood Pressure Pre Treatment

A.1
Blood pressure pre treatment
Blood
Treatment pressure Pulse
1 100/70 60
2 110/65 60
3 105/70 66
4 100/50 54
5 95/60 56
6 105/65 84
7 110/70 60

16
Appendix B- Circumference Measurements Right

B.1
Circumference Measurements
Pre treatment- right
Head of Proximal Smallest part Largest part
Treatment Metatarsals Metatarsals of the ankles of the calves
1 21.7 22.5 22.5 39.5
2 22 22.5 22.5 38.5
3 21.5 21.5 22.2 38.5
4 22 22.1 22.9 39
5 22.4 22.5 22.5 39
6 21.9 22.1 23 39.2
7 22 22.5 22.8 39.5

B.2
Circumference measurement
post treatment- right
Head of Proximal Smallest part Largest part
Treatment Metatarsals Metatarsals of the ankles of the calves
1 22.5 22.5 22.5 39
2 21.3 22.2 22.5 38
3 22 22 22 38
4 22 22.1 22.6 38.4
5 22.5 22.4 22 38.4
6 22 22.2 22.5 38.5
7 22.3 22.4 23 39

B.3
Differences of circumference
measurements for the- Right
Head of Prox Smallest part Largest Part
Treatment metatarsals metatarsals of ankle of calves sum
1 0.8 0 0 -0.5 0.3
2 -0.7 -0.3 0 -0.5 -1.5
3 0.5 0.5 -0.2 -0.5 0.3
4 0 0 -0.3 -0.6 -0.9
5 0.1 -0.1 -0.5 -0.6 -1.1
6 0.1 0.1 -0.5 -0.7 -1
7 0.3 -0.1 0.2 -0.5 -0.1
-yellow highlight indicates increases in circumference

17
B.4
Circumference measurements in the
morning-right
Head of Prox Smallest part Largest Part
Treatment metatarsals metatarsals of ankle of calves
1
2 22.5 23 22.5 37
3 22 23 22.3 37.5
4
5 22 22.8 22 37.5
6 22.8 23 22.5 38
7 22.5 23 22.7 38
Average 22.36 22.96 22.4 37.6

18
Appendix C – Circumference measurements Left

C.1
Circumference measurements
Pre treatment-Left
Head of Prox Smallest part Largest part
Treatment metatarsals Metatarsals of ankles of calves
1 21.7 22.5 22.5 39.5
2 21.5 22.3 22.5 38.5
3 21.5 22 22.5 39
4 22 22.4 22.5 38.2
5 22.5 23.5 22.5 39
6 22.4 22.5 22.5 39
7 22.2 22.5 22.7 39.5

C.2
Circumference measurements
Post treatment left
Head of Prox Smallest part Largest part
Treatment metatarsals Metatarsals of ankles of calves
1 21.5 22.5 22.5 38.5
2 21.8 22.1 22.3 38
3 21.5 22.3 22 38
4 21.9 22.6 22.3 38.1
5 22.3 23 22.5 38.5
6 22.2 22.6 22.3 38.7
7 22.2 22.1 22.2 39

C.3
Circumference Differences Left
Head of Prox Smallest part Largest part
Treatment metatarsals Metatarsals of ankles of calves sum
1 -0.2 0 0 -1 -1.2
2 0.3 -0.2 -0.2 -0.5 -0.6
3 0 0.3 -0.5 -1 -1.2
4 -0.1 0.2 -0.2 -0.1 -0.2
5 -0.2 -0.5 0 -0.5 -1.2
6 -0.2 0.1 -0.2 -0.3 -0.6
7 0 -0.4 -0.5 -0.5 -1.4
-yellow highlight indicates increases in circumference

19
C.4
Circumference measurements in the
morning- left
Head of Prox Smallest part Largest Part
Treatment metatarsals metatarsals of ankle of calves
1
2 22.5 23 22.5 37.5
3 22 22.7 21.8 37.5
4
5 22.5 22.7 21.6 36.8
6 22 22.8 21.5 37
7 22 22.5 22.3 37.7
Average 22.2 22.7 21.9 37.3

20
Appendix D - Fatigue scale

D.1
Fatigue scale - Pre and post treatment in sitting and standing
Pre Pre Post Post
Fatigue
scale sit stand sit stand
1
2 4 2 0.5 0
3 2 0 1 0
4 6 5 - -
5 1 0 0 0
6 3 1 1 0.5
7 1 0.5 0.5 0.5

21
Appendix E- Water Displacement

E.1
Water displacement differences between initial reading
and secondary reading
Treatment Pre Post Diff
1 2 2 0
2 2 2 0
3 2 2 0
4 1.6 1.9 0.3
5 2 2 0
6 3.5 1.9 -1.6
7 1.7 1.9 0.2
-yellow highlight indicates increases in circumference

22
Appendix F - Record of treatments and patient consultation forms

23