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Lower Limb Edema, Pulmonary Hypertension. Massage Advisable?
Question: Can I massage a 53 yr old patient with oedema in the lower limb due to pulmonary hypertension?
Hello,
Thank you for your query.
Pulmonary hypertension refers to a condition where the pressures in the blood vessels of the lungs are high. There are numerous causes for this including cardiac causes like mitral valve disease, congenital heart diseases, lung causes like chronic obstructive lung disease, other causes like chronic pulmonary thrombo-embolism, hypothyroidism, HIV, portal hypertension, etc. Because of the elevated pressures in the lung circulation, the right side of the heart that pumps blood to the lungs fails and there is an increased pressure reflected in the veins that return blood to the heart from all parts of the body. This in turn leads to an oozing of fluid from inside the vein to the tissues around it. Due to gravity, the lower limbs are the first to show the collection of fluid as edema.
Whether you can perform a massage for such patients would depend on the cause for pulmonary hypertension and whether there are blood clots in the veins due to stagnant blood flow. If there are such clots, the process of massage could result in bits of clots breaking free and going to the lungs resulting in pulmonary embolism. If the clot is sufficiently large to block the main pulmonary artery or a large branch, it could be fatal. Smaller clots, while not fatal, can lead to a worsening of the pulmonary hypertension.
It is often difficult to conclusively show that there is no clot in the veins of the legs. Thus, on the whole, I would say that it would be better to avoid massage in such patients.
I hope this answers your query. Feel free to ask for any further clarifications.
With regards,
Dr RS Varma
Thank you for your query.
Pulmonary hypertension refers to a condition where the pressures in the blood vessels of the lungs are high. There are numerous causes for this including cardiac causes like mitral valve disease, congenital heart diseases, lung causes like chronic obstructive lung disease, other causes like chronic pulmonary thrombo-embolism, hypothyroidism, HIV, portal hypertension, etc. Because of the elevated pressures in the lung circulation, the right side of the heart that pumps blood to the lungs fails and there is an increased pressure reflected in the veins that return blood to the heart from all parts of the body. This in turn leads to an oozing of fluid from inside the vein to the tissues around it. Due to gravity, the lower limbs are the first to show the collection of fluid as edema.
Whether you can perform a massage for such patients would depend on the cause for pulmonary hypertension and whether there are blood clots in the veins due to stagnant blood flow. If there are such clots, the process of massage could result in bits of clots breaking free and going to the lungs resulting in pulmonary embolism. If the clot is sufficiently large to block the main pulmonary artery or a large branch, it could be fatal. Smaller clots, while not fatal, can lead to a worsening of the pulmonary hypertension.
It is often difficult to conclusively show that there is no clot in the veins of the legs. Thus, on the whole, I would say that it would be better to avoid massage in such patients.
I hope this answers your query. Feel free to ask for any further clarifications.
With regards,
Dr RS Varma
Above answer was peer-reviewed by :
Dr. Prasad
Thank you for your answer. I needed confirmation that general massage would be contra-indicated particularly as I had not yet seen the patient. I have subsequently had the opportunity to XXXXXXX this patient & his medical history indicates that the PHT is primary in nature with no indication of DVT. He reports that the right ventricle of the heart is slightly enlarged & his medication is obviously supportive. The lower legs present with severe oedema, are bluish in colour with numerous broken veins, especially around the ankles. The patient complains of extreme 'tightness' in the popliteal region by mid-afternoon which is very uncomfortable. My next question is: would Manual Lymph Drainage also be contra-indicated & if so, would reflexology be useful in that it is non-invasive yet powerful enough to encourage the systems to attain some form of homeostatis.
Hello,
Thank you for the reply.
From your description, it is evident that there is significant edema of the lower legs with stasis of blood in the veins leading to the bluish discoloration and evidence of dilated, congested veins.
This is due to the increased pressures in the venous system secondary to pulmonary hypertension and right ventricular failure.
If no cause of pulmonary hypertension has been established, the only option is to optimize medical treatment.
The patient would probably benefit from an increase in the diuretic dose. A cardiac catheterization study could be done to see the response of the pulmonary artery pressures to nitric oxide, calcium channel blockers, etc. This could determine if treatment with such agents will be useful.
There are also drugs like sildenafil, bosentan etc which have resulted in some clinical benefit to such patients. Oral anti-coagulants have also been given since many of these patients do get thrombosis due to the stasis of blood and the risks of pulmonary thrombo-embolism. As a last resort, cardiac/combined cardiac-lung transplantation is done for selected individuals.
I have no expertise or experience regarding manual lymph drainage and reflexology. Therefore, it would be inappropriate for me to comment on the efficacy of these treatment options.
I hope this answers your query.
With regards,
Dr RS Varma
Thank you for the reply.
From your description, it is evident that there is significant edema of the lower legs with stasis of blood in the veins leading to the bluish discoloration and evidence of dilated, congested veins.
This is due to the increased pressures in the venous system secondary to pulmonary hypertension and right ventricular failure.
If no cause of pulmonary hypertension has been established, the only option is to optimize medical treatment.
The patient would probably benefit from an increase in the diuretic dose. A cardiac catheterization study could be done to see the response of the pulmonary artery pressures to nitric oxide, calcium channel blockers, etc. This could determine if treatment with such agents will be useful.
There are also drugs like sildenafil, bosentan etc which have resulted in some clinical benefit to such patients. Oral anti-coagulants have also been given since many of these patients do get thrombosis due to the stasis of blood and the risks of pulmonary thrombo-embolism. As a last resort, cardiac/combined cardiac-lung transplantation is done for selected individuals.
I have no expertise or experience regarding manual lymph drainage and reflexology. Therefore, it would be inappropriate for me to comment on the efficacy of these treatment options.
I hope this answers your query.
With regards,
Dr RS Varma
Note: For further queries related to coronary artery disease and prevention, click here.
Above answer was peer-reviewed by :
Dr. Radhika
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