Download Effects of Lymphatic Drainage on the Symptom Management of

A Case Study:
Effects of Lymphatic Drainage on
the Symptom Management of Fibromyalgia
REBECCA GORGITZA
1005 West Bay Rd, Gambier Island, BC V0N 1V0
250-308-9214
[email protected]
Okanagan Valley College of Massage Therapy
200 - 3400 30th Avenue
Vernon BC V1T 2E2
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ACKNOWLEDGEMENTS
I would like to thank all those at who supported me in the completion of
this case study: Lana Henry, who gave me the green light to start this project and
instructor / marker, Leslie Bryant-MacLean. Heartfelt thanks to Megan Pocock,
Marlaina Meinzinger, and Sarah Leslie for advice, moral support and
encouragement when times got tough and stressful. A special thank you to
Shanson Lunny who helped me with computer challenges and graphs. And last,
but not least, I am grateful to my patient for her co-operation and for sharing her
story with me. Without her, this study would not have been possible.
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TABLE OF CONTENTS
Acknowledgements ........................................................................................ 2
Abstract …………………………………………………………………….. 4
Introduction …………………………………………………………………. 5
What is Fibromyalgia?........................................................................ 5
Pharmacology ..................................................................................... 7
TENS ………………………………………………………………… 8
Physical Activity ……………………………………………………... 9
Massage Therapy …………………………………………………… 10
Methods ……………………………………………………………………….. 14
Study Design …………………………………………………………… 14
Participant ……………………………………………………………… 14
Outcome Measures……………………………………………………… 15
Measurement Instruments ……………………………………………… 16
Control …………………………………………………………………. 18
Lymphatic Drainage Intervention ...……………………………………. 19
Outcomes ………..……………………………………………………………... 22
Discussion ……..………………………………………………………………. 26
Conclusion …………………..…………………………………………………. 28
References …………………………..…………………………………………. 29
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ABSTRACT
Objective: This study aimed to determine whether or not lymphatic drainage has a
beneficial effect on symptom management of fibromyalgia.
Methods: The study design was a 6-session case study. A female participant with
fibromyalgia was selected to complete the study. She underwent six 1-hour long
sessions of full body lymphatic drainage, with sessions every other day. The
Widespread Pain Index and Symptom Severity questionnaires were used as
outcome measures to be completed weekly before and after the intervention, and
at shorter increments of time during the intervention.
Results: The participant experienced fewer painful areas, fewer symptoms, and
less symptom severity during the intervention compared to before. In the time
monitored after the intervention, the number of painful areas, symptoms, and
symptom severity remained decreased compared to before the intervention.
Discussion and Conclusion: Overall, the participant of the study reported a
significant decrease in symptom severity and tender points on the WPI alongside
some negative effects directly after treatment. More research into the benefits of
lymphatic drainage needs to be done to rule out biases of this study such as data
collection time.
Keywords: fibromyalgia, lymphatic drainage, massage, chronic pain, case study
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INTRODUCTION
What is Fibromyalgia?
Fibromyalgia (FM) is a chronic pain syndrome
characterized by diffuse, widespread muscle and joint
tenderness and stiffness. Symptoms accompanying physical
Locations of tender point in the
body image a
pain may include exhaustion, fatigue, headaches, cognitive
issues, anxiety, and depression. The American College of
Rheumatology(ACR) has defined the system of diagnosis for this
condition as follows: “The patient must present with chronic
widespread pain in all 4 quadrants of the body for at least 3 months, as well as
localized pain at 11 of the 18 tender points (TP).” (Crofford, 2013) This condition
may go through phases of remission and exacerbation though complete remission
is rare.
The etiology of FM is unknown though there are many theories. The ACR
proposes that genetics combined with triggers such as stress or physical injury are
related to the condition. A hyperactivity of the neurotransmitter ‘substance P’ in
cerebrospinal fluid, neuroendrocrine, psychological, nutritional, or sleep
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disturbances and deficiencies are all theories that have been outlined in various
studies. (Crofford, 2013)
FM affects women more than men (9:1), and it has a greater incidence
with increased age - over 50 being the highest incidence. Traumatic experiences
that occur in the early years of life, lifestyle choices, and previous episodes of
depression are all things that may put a person at risk of developing fibromyalgia.
Thus far, no piece of research can fully prove any of these theories, and there is
no “cure” or “quick fix” for the disorder. (Alnigenisis et al., 2001)
With no cure and a lot of pain and exhaustion, fibromyalgia patients
experience a lessened quality of life. It is stated that the symptoms and disability
created by FM can have a negative impact on all aspects of life: activities,
abilities, self-esteem, and generally health-related quality of life (Dragoi et al.,
2012). Many patients are forced to reduce work hours or leave work because of
the symptoms they combat (Dragoi et al., 2012).
Sleep disturbances are related to FM and they influence everyday
lifestyles of FM patients (Theadom, 2010). Lack of sleep can affect productivity
rates, lead to difficulty maintaining relationships, and may exacerbate FM
symptoms. This cycle of sleeplessness, FM symptoms and pain affect not only
health-related quality of life, but also has negative social, functional, and personal
implications (Theadom, 2010).
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Since there is no remedy and complete remission is rare, pain
management and symptomatic relief are the options for treatment. Medication,
TENS, massage, and physical training are some of the methods out there for
sufferers to utilize (Ekici et al., 2009)
Pharmacology
There are plenty of pharmacological options to treat this condition: a range
of various antidepressants, muscle relaxants, benzodiazepines, local anesthetics,
tricyclic antidepressants (TCA), selective serotonin reuptake inhibitors (SSRI),
serotonin and noradrenaline reuptake inhibitors (SNRI), and other drugs such as
Tramadol are used to combat fatigue, depression, and pain. Gabapentin and
pregabalin are also commonly prescribed for pain and sleep disturbances
associated with FM. These drugs have been tested and have been found to be
more effective than a placebo in decreasing FM symptoms (Kim et al., 2003).
Each drug class has a different rate of effectiveness combined with
different adverse effects. TCAs and SNRIs are considered to be much more
effective than SSRIs in controlling chronic pain syndromes although it is difficult
to say which medication is most successful in decreasing pain and other FM
symptoms. Furthermore, pharmacological methods have been found to normalize
sleep patterns, decrease sympathetic tone, and combat exacerbations of pain, thus
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affecting the symptoms of FM. However, alongside these benefits are the adverse
effects of the medications which may include mild to severe: dizziness, weight
gain, nausea, and insomnia. The effectiveness of pharmacological methods is
approximately 30% symptom reduction, stated by Staud and thus these methods
are often combined with other therapies (Staud, 2010).
TENS
Transcutaneous Electrical Nerve Stimulation (TENS) is a therapy form
that electrically stimulates the skin in order to provide “descending inhibition”
pain control. Nociceptive neurons, or pain receptors, are inhibited by the
activation of descending inhibitory pathways from the midbrain brainstem. This
means that pain coming from pain receptors does not make it to the brain.
Noehren notes that TENS best inhibits pain associated with ongoing noxious
stimuli such as movement but is less effective in curbing pain at rest. This is
significant to improve quality of living and to decrease pain associated with
functional activities, when used appropriately (Noehren et al., 2015).
For best results TENS should be applied daily over a long period of time.
The amount of time TENS should be applied varies and can range from less than
one hour to several hours per day. Dailey concluded that the pain relief is most
significant during the active TENS or directly after, with pain levels returning to
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normal post-treatment (2013). Kaye has stated that in the beginning stages of
treatment, TENS can decrease pain by up to 80%, however, this rate of
effectiveness decreases over a period of a few months. (2002)
Physical Activity
Physical training is yet another alternative therapy for fibromyalgia.
Physical training encompasses a wide variety of aquatic or land-based
strengthening, stretching, aerobics, balance and postural exercises. It can improve
quality of life by decreasing fibromyalgia symptoms, as well as improving overall
fitness. Different exercise groups can affect different changes: for example,
research has associated strength training with improved well-being and physical
function whereas a combination of different forms of exercise decreased pain and
improved physical function. The number of tender points a patient has as well as
the intensity of pain experienced can be decreased by an appropriate physical
training program, and the benefits reaped have been noticed to remain for up to 4
months post training (Dragoi et al., 2012).
A wide array of activities have been studied and suggested to have
positive impact on people suffering fibromyalgia. Bursch found that aerobic and
strength exercise plans as well as Pilates were most beneficial with fibromyalgia
though other forms are effective as well (2011). It is also stated that fibromyalgia
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patients are generally able to do moderate to vigorous levels of activity, but they
may have difficulty adhering to such programs due to pain and other symptoms.
Unique fitness programs must be created for each specific person based on case
history in order to avoid adverse effects. Despite all the benefits shown, adverse
effects such as musculoskeletal complaints and exacerbations of symptoms such
as pain, stiffness, and fatigue are not uncommon with these types of therapy.
Physical training, much like the other therapies described above, is often used in
conjunction with other types of treatments. (Gowans et al., 2013)
Massage Therapy
The effects of massage therapy on fibromyalgia patients are also in
question. Not a lot of research has been done on this topic, and it is difficult to
group all such studies together as the techniques and modalities used are so
varied. For the purpose of this study, lymphatic drainage will be the main focus.
The application of lymphatic drainage defined as light, repetitive
techniques used to pump lymph fluid through superficial lymphatic capillaries.
Each manipulation must be repeated 5+ times, strokes must be towards the heart,
and the principle of ‘proximal to distal’ must be used in order for this technique to
be most effective. No oil is required for this technique because it relies on the
drag of the skin under a pressure of approximately 20-40mmhG to pump the fluid
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and not collapse the vessels. Greater pressure can collapse the superficial vessels
and momentarily prevent drainage. (Rattray, 2000)
Direction of Lymphatic Flow in the Bodyimage b
Typically this modality is used to treat edema and swelling related to
trauma or post-surgery in order to reduce the formation of scar tissue. Lymph
drainage is also effective in decreasing pain perception via gate-control pain
inhibition. It affects the nervous system by inhibiting firing of the sympathetic
nervous system, promoting relaxation and allowing for a faster healing rate. It is
known to help regulate the immune system, clear blockages, eliminate metabolic
waste and toxins from the body. This explains why increased urine output with
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high concentrations of inflammatory and pain mediators excreted post-treatment
has been noted. (Rattray, 2000)
However, there are contraindications. Lymphatic drainage would not be
appropriate for a patient with edema due to heart failure or thrombosis, bacterial,
viral, or fungal infection, or lymphatic obstruction by parasite. Special care must
be taken when working with patients who have had lymph nodes removed, or who
suffer from conditions (eg. toxoplasmosis, sinusitis, bronchitis) which may be
flared up by this technique. This technique is not effective for those with lowprotein edemas (eg. edemas caused by liver or kidney pathologies). Lymphatic
drainage should only be performed proximally and locally to the edemous region;
any distal work is contraindicated. These cautions do not directly apply to
fibromyalgia; however, they must be taken into account with every patient.
Ekici’s comparison study has shown the Vodder’s Method MLD was more
effective in decreasing fibromyalgia symptoms such as anxiety, fatigue, stiffness,
and pain than the deeper connective tissue massage also studied
(2009). Participants receiving MLD reported feeling more well-rested upon
waking in the morning as well as being less tense and less anxious. Lymphatic
drainage affects the physical pain suffered by fibromyalgia patients as well as the
fatigue and secondary symptoms. Adverse effects of this treatment, however, are
the sensation of nausea, feeling ill, and increased frequency of urination. More
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research is needed in this field to determine the longevity and quality of the
benefits (Ekici et al., 2009).
In conclusion, several studies have been completed on each of these forms
of therapy though very few solid outcomes have been reached. It seems that a
combination of these therapies gives the best results and is most often used
clinically. The effect of lymphatic drainage on fibromyalgia symptoms seems to
be a subject with the least amount of research of all topics reflected upon. This
has led to the goal of this study: to collect information on whether lymphatic
drainage is a successful symptom management technique for fibromyalgia.
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METHODS
Study Design:
This is a case study which began October 12, 2014 wherein case history
was collected and an initial relaxation massage was provided to the participant.
The participant filled out measures forms beginning in October, 2014, throughout
the active intervention, and into February 2015. The intervention of lymphatic
drainage was applied for an 11-day period from December 20, 2014 to January 1,
2015, with one-hour long appointments every other day. A total of 7 treatments
were applied including the initial full body relaxation massage. Only data
collected during the December-January treatment period are used in this study.
Participant:
The participant was selected based on a convenience sample of women
diagnosed with fibromyalgia and known to the researcher. Those with active
treatment of the disorder and incompatible schedules for the study were ruled out.
The participant was selected in July, 2014 when the study’s procedures,
requirements, benefits and risks, were outlined, and questions were answered. An
informed consent form was signed. Criteria of the chosen participant are that she
is 58 years old, a non-smoker, rarely takes pain medication, and has a moderate
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and consistent level of activity and a balanced diet. She was first diagnosed with
FM in 1985 after a work-related accident in 1984 and was unable to return to her
job as a flight attendant. She suffered severe back and leg pain, joint pain, neck
and head pain, insomnia, exhaustion, fatigue, anxiety, and depression. In 1993,
she was re-diagnosed by another rheumatologist after an emergency C-section.
Interventions between 1985– 1993 included physiotherapy, TENS, drug therapy,
counselling for chronic pain, chiropractics, naturopathy, dietary changes, massage
and relaxation techniques. After 1993, she was unable to access the intervention
services because of where she lived. She relied on what she had learned in
previous interventions and found relief with light exercise, nutrition, warm baths,
and drug therapy. She has never returned to work, has good days and bad, feels
limited by body pain and lack of sleep, and is frustrated with the condition. With
this therapy the patient is looking for relaxation and less pain.
Outcome Measures:
Primary Outcome:
The primary outcome measured was the number of painful body regions.
Secondary Outcome:
The secondary outcomes measured were the number of secondary
fibromyalgia symptoms including fatigue, cognitive function, and more.
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During the active intervention, the participant’s subjective opinion on
amount of sleep and overall well-being was recorded before each treatment. Pain,
on a 1-10 scale, in the participant’s current area of complaint was recorded preand post-treatment.
Measurement Instruments
The American College of Rheumatology’s diagnostic form for
fibromyalgia was used to collect data. The form is a two-sided page with a
Widespread Pain Index (WPI) and a two-part Symptom Severity score (SSa and
SSb). The WPI and SSa, as well as the pre-treatment interview, were used to
collect data regarding the number of painful body parts and the severity of that
pain. Both parts of the SS were utilized to gather data about the secondary
outcomes. At the end of each section of the form was a tally box to be used by the
patient to determine their ‘score’; the participant of this study was requested to
leave those boxes blank to allow the researcher to interpret the information.
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The WPI and SS form image c
Control:
As this study does not include a separate control group, the participant’s
past history is used as the comparison. The participant was asked a series of
questions on her “norm” during the initial case history and treatment on October
12, 2014. She was also required to fill out the measurement forms weekly from
October 3, 2014 until the beginning of the study December 21, 2015 to provide
baseline information.
Prior to and directly after each treatment session the participant was
interviewed for approximately 5 minutes and filled out a measurements form.
Twelve hours after the intervention was applied, the participant was asked to
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answer each of the questions on the measurements form again, and the therapist
recorded the data.
Lymphatic Drainage Intervention:
This intervention was provided by the author of this study after learning
the application of lymphatic drainage in a series of three 4-hour long classes and
several practical applications outside of the classroom. The lymphatic drainage
technique uses techniques described in Rattray (2000).
This intervention was to be applied every other day from December 21
until January 1, with a total of 6 treatments. For scheduling reasons, one of the
treatments was spaced 2 days from the previous.
The therapeutic goals of this treatment series were as follows:
1. Promote parasympathetic nervous system firing to encourage restful
sleep at night
2. Promote lymphatic flow/drainage to improve removal of metabolites
from tissue and decrease pain
To achieve these goals deep diaphragmatic breathing techniques as well as
a variety of lymphatic drainage techniques were used. Each of the treatments was
60 minutes in length, and it began with the participant practicing deep
diaphragmatic breathing while the therapist applied terminus pumping. Terminus
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pumping is the gentle press and release across the upper chest where the left and
right thoracic lymphatic ducts converge with the left and right subclavian vein.
Gentle nodal pumping was applied before addressing the limb distally.
After terminus was pumped, the sequence nodes pumped and body parts
addressed is as follows:
Nodes
Regions addressed
Cervical
anterior cervical region, face, head
Axillary
anterior chest, upper arm
Cubital
forearm, hands
Upper abdomen
Inguinal
Popliteal
Lower abdomen, anterior and posterior
Location of Lymphatic Structures in the
thigh, shin
Bodyimage d
Calves
Sacrum, sacral pumping
Lower, middle, upper back, posterior
cervical region
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The principles of addressing lymph nodes before
limbs and working proximal to the node before distal were
followed. Each section of the body was addressed with
stationary circles and local techniques. These modalities
Stationary circles are used to
treat large surface areas. The
palm and fingers of one or both
hands gently press and release in
a circular motion. Pressure is
applied in the direction towards
the lymph node or “upstroke,”
and released on the
“downstroke.”
were repeated 2-4 times per area. For example, when
addressing the arm, the axillary nodes of that arm were pumped,
stationary circles and local techniques were applied sequentially
from the shoulder to the elbow. Then, the techniques were repeated,
starting again at the shoulder and working towards the elbow,
and so on, before moving to the cubital nodes and lower arm.
This process was used for all regions of the body addressed.
Local techniques: Use of the web
of the hand is used for smaller
limbs or distal portions of limbs.
The webspace between the
thumb and index finger of the
therapist’s hand softly wraps
around the limb, and strokes
upwards. Double handed
webspace can be used for larger
limbs. Use of the broad surfaces
of the thumbs is similar to
“stationary circles” on a smaller
scale.
After each treatment, as homecare, the participant was assigned
a warm Epsom salts bath for approximately 20 minutes.
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OUTCOMES
Figure 1 (WPI Scores)
Figure 1, on the left, compares the baseline WPI measurements taken in
the 12 weeks prior the intervention with the follow-up measurements taken in the
5 weeks after the intervention ended. Pre-intervention, it can be seen that there are
many peaks and valleys in the number of painful areas, with the longest period of
consistency being 3 weeks. During the follow-up a more consistent and lower
number of painful regions were noted.
On the right side of Figure 1, the measurements taken each treatment
during the 2-week intervention period are described. During this time, the highest
WPI score remained the highest and most variable of the three assessment times,
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with an average of 10. Directly post intervention as well as 12 hours after, an
average score of 8 was recorded.
The overall trend of Figure 1 shows a decrease in the number of painful
areas recorded through the process of the intervention, and from before to after
the intervention was applied.
Figure 2 (SSa Scores)
As seen in Figure 2, across the 19 weeks of data collection, the lowest
levels of fatigue, cognitive symptoms, and unrefreshed waking were recorded
during the intervention (weeks 13 and 14), and after the intervention (weeks 1519). Cognitive symptoms remained consistently low post-lymphatic drainage
application, dropping from an average score of 2 (moderate, considerable, often
problems), to an average of 1 (slight, mild, or intermittent problems). However,
fatigue and unrefreshed waking levels dropped during the intervention weeks and
spiked again in the weeks following.
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Figure 3 (SSa Scores)
A further breakdown of the SSa data taken during the treatment period is
shown in Figure 3. After the first treatment, the overall level of cognitive
symptoms before and after treatments decreased to a score of 1 (slight, mild, or
intermittent problems). After two sessions, fatigue levels consistently remained at
a score of 1. From the 4th session on, the level of waking unrefreshed remained at
a score of 1. Waking unrefreshed was only measured pre-session, based on the
participants experience waking that morning, and 12 hours post-session based on
waking the day after the treatment. The 5th session was performed in the
morning, so only a pre-intervention measurement was taken.
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Figure 4 (SSb Scores)
The top graph Figure 4, the number of symptoms in relation to the
weeks of data collected is shown. The average number of symptoms experienced
in the weeks prior to intervention is 15.75, decreasing to 11 during treatments, and
post intervention is 11.4. On the bottom, is a further breakdown of symptoms
experienced at each treatment session. The average number of symptoms is
highest pre-treatment, 12.5, whereas directly after treatment the average is 7.7,
and 7.3 twelve hours later.
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DISCUSSION
This study explored whether lymphatic drainage is an effective symptom
management technique for fibromyalgia. Measurements of the number of painful
regions (WPI score), severity of symptoms (SSa), and number of symptoms (SSb)
related to fibromyalgia were recorded before, during, and after the intervention
was applied, and this data was compared. Shown in the results section is an
overall decrease of the average WPI, SSa, and SSb scores once the treatment
sessions began in comparison to the 12 weeks prior to treatment. This information
is supported by the results obtained in Ekici’s study (2009).
However, the participant had ended a series of chiropractic appointments
just prior to beginning the intervention but after submitting the pre-intervention
questionnaires. This decreased strain on the body could also have an effect on the
level of symptoms. Since the improvement in condition occurred over a period of
a couple lymphatic drainage treatments, though, it is likely related to the study
intervention.
The decrease in fibromyalgia symptoms remained for at least 5 weeks
after the intervention period ended. Data was only collected for 5 weeks postintervention, and so long-term impact of the treatments can’t be discussed. In
order to better understand the impact of this study, data could have been collected
during equal lengths of time pre- and post-intervention.
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Despite the improvement in symptoms overall, the treatments caused the
participant an increase in discomfort directly after sessions. She reported feeling
groggy, tired, dizzy, nauseous, and/or “mucousy” post-treatment, making it
difficult to fall asleep. These are common adverse effects of lymphatic drainage.
She indicated she felt better and slept longer the night after a morning treatment
rather than after the evening sessions. This should be taken into consideration for
further research. However, her subjective pain levels also decreased after each
session compared the pre-treatment.
To expand this research, a more formal set-up of recording subjective pain
levels could have been used. This study relied completely on the WPI and SS
form, and an interview provided by the practitioner. The interview questions
were inconsistent, and so the data regarding pain levels, hours of sleep per night,
and quality of life have been eliminated from this study. A Visual Analog Scale
(VAS) to measure pain, and a selection of questionnaires on sleep, depression,
activity levels could be used to determine level of quality of life, thus giving a
clearer look into the impact of lymphatic drainage massage on this condition.
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CONCLUSION
Lymphatic drainage may be helpful in the management of fibromyalgia
symptoms, specifically the number of painful areas associated with the conditions
as well as the number and severity of secondary symptoms. However, this
information is case-specific, and more research needs to be done to confidently
state the external validity of this symptoms management method.
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