Complex Physical Therapy
…specialists in lymphology health care…
What is Complex Physical Therapy (CPT)
The Complex Physical Therapy is a non-invasive therapy known as the Casley-Smith method for treating chronic oedemas.
The Casley-Smith method is the original Australian evidence-based treatment method of managing chronic oedema including conditions such as lymphoedema, lipoedema, venous disease, and other forms of chronic swelling. The therapy helps with the dysfunction of the Lymphatic System.
What is the Lymphatic System?
The Lymphatic System’s primary role is to collect excess fluid from the tissues, purify it, and return it to the bloodstream. If your lymphatic system fails to sweep up these excess fluids, they can accumulate, cause swelling and potentially increase the risk of infection. An efficient lymphatic system helps to defend your body against bacteria, viruses & fungi that may cause illness. The lymphatic system is part of both the immune and circulatory systems.
| Complex Physical Therapy involves four aspects: | |
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Skin Care |
Skin care treatment of any infection. |
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Massage |
A special form of massage known as Manual Lymphatic Drainage (MLD). |
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Compression Styles |
Compression bandaging, SIPC pumps or Prescribed Garments. |
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Exercises |
Decongestive exercises that complement the MLD massage. |
| Complex Physical Therapy involves 3 phases: | |
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Decongestive Phase |
A treatment course of up to 4 weeks or more whereby fluid, fibrosis and fat
aim to be addressed. |
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2. Transitional Phase |
The transition phase aims to consolidate the effects of the decongestive
treatment phase, to maintain oedema reduction, and to ease the person into
the long term management phase. |
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3. Maintenanace Phase |
Maintaining the reduction by continuing with compression. |
What is Oedema
Oedema (or edema) means swelling. Chronic oedema is defined as swelling lasting for more than 3 months. All chronic oedemas represent a failure of the lymphatic system to cope with removing fluid sitting in the tissues.
| How do I know Oedema is present? | |
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A simple clinical test is called the pitting test. When oedema is compressed it will “squish” away from the area leaving a fingerprint or divot. This is referred to as “pitting oedema.” |
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| The types of Chronic Oedemas | |
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All chronic oedemas show that the lymphatic system is either: Not coping with the volume of fluid needing to be transported in a given time period OR Not able to function correctly due to reduced transport capacity |
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Lymphoedema |
There is a problem in the lymphatic system. Fluid is the main problem. Over time fibrosis and fatty tissue
become problematic |
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Lipoedema |
There is a problem in the lymphatic system. Fatty tissue is the main problem. |
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Venous disease |
There is a problem in the venous system. |
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Heart failure and kidney failure |
The organs of circulation are overwhelmed and bilateral lower
limb swelling will result. |
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Inflammatory condition |
Some inflammatory conditions, such as rheumatoid arthritis,
cause swelling. |
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Palliative disease |
Severe cancers will block lymphatic flow and impact organ
function |
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Malnutrition or medication related swelling |
Malnutrition and certain medications will result in chronic
swelling. |
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Dependent oedemas |
Post strokes or other neurological conditions, when the muscle
pump is not working, swelling results. |
What does Early Detection of Lymphoedema mean?
At Exotherapy Australia, Women’s Holistic Clinic, plays a vital role in the early detection of Lymphoedema in
women to help them avoid life-long swelling. The current evidence-based recommendations are to screen, educate and detect lymphoedema before physical signs of swelling appear.
Early detection include:
1. Cancer related Lymphoedema patients
Empowering patients in pre-cancer surgery appointments, including prior to a sentinel lymph node biopsy procedure and before neoadjuvant chemotherapy. It is now current best practice that all breast cancer patients be educated and screened for lymphoedema early (in the sub-clinical stage). The sub-clinical phase is crucial. This phase allows for early intervention and reduces both severe and irreversible
symptoms of chronic breast cancer-related lymphoedema.
2. Non-Cancer related Lymphoedema patients
Symptoms of Lymphoedema can include:
Visible tissue swelling
Being unable to fully move the affected limb
Tightness or heaviness in the limb
Skin discolouration
Hardening or thickening of the skin
Pitting of the skin
What is the Bioimpedance Spectrocsopy?
Bioimpedance spectroscopy, also called BIS, is a newer non-invasive technique to measure the volume of fluid in various parts of the body. BIS involves passing an extremely low-strength electrical current through the area and measuring how the flow of the current is slowed by the fluid in the body.
Lymphoedema Management
What is Lymphoedema?
Lymphoedema is a chronic, progressive, high-protein form of oedema (swelling) resulting from an abnormality in the lymphatic system.
Primary lymphoedema
Reduced transport capacity occurs when lymph vessels are not formed properly (genetic disorders).
Secondary lymphoedema
Reduced transport capacity occurs when lymph vessels have been cut or damaged, injury, infection, cancer treatment or surgery
What occurs with Lymphoedema?
The swelling or the accumulation of fluid (lymph) containing protein, water and cell debris in the tissue space due to an imbalance between interstitial fluid production and transport capacity
| The investigation stages of Lymphoedema | |||
|---|---|---|---|
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Stage 0
At a subclinical state where swelling is not present, despite impaired lymph transport. This stage may exist for months or years before oedema becomes evident. |
Stage I
This represents early onset of the condition where there is accumulation of tissue fluid that subsides with limb elevation. The oedema may be pitting in this stage. |
Stage II
Limb elevation alone rarely reduces swelling and pitting is manifest Late Stage II There may or may not be pitting as tissue fibrosis is more evident. |
Stage III
The tissue is hard (fibrotic) and pitting is absent. Skin changes such as: thickening, hyper pigmentation, increased skin folds fat deposits develop |
| The treatment stages of Lymphoedema is Complex Physical Therapy (CPT) ( There is no known cure for lympoedema, but it can be managed.) | |
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Stage 0 and Stage I
Scar care, Skin care, A special form of gentle massage known as Manual Lymphatic Drainage (MLD) Exercise. Wear a compression sleeve or stocking |
Stage II and Stage III
Advanced lymphoedema treatments include: Compression therapy (such as bandaging, pumps and more complex garments), Manual lymphatic drainage (MLD) Skin Care Exercise Low level laser treatment Surgery may be warranted including lymph node transplants, lymphovenous anastomoses and liposuction |
What is chronic venous insufficiency (CVI)?
Chronic venous insufficiency (CVI) is the inability of a person’s vein valves to transport blood to the heart.
What occurs with chronic venous insufficiency?
When chronic venous insufficiency occurs, it is because of a problem with the vein valves resulting in backwards blood flow. This indicates the veins are damaged and that blood will begin to pool in the veins, most commonly in the legs and feet and are unable to function normally.
Initial Symptoms
Symptoms include:
Heaviness in the leg,
Dull aching or throbbing,
Pain
Mobility issues
Tightness
Skin irritation
Muscle cramps
Progression of Chronic Venuous Insufficiency:
Varicose veins
Edoema
Leg and foot swelling and pain.
Chronic Vneous Insufficiency:
Skin discolouration (lipodermatosclerosis)
Pigmentation
Hemosiderin Staining
Popillomatosis
Venous Ulcers
What are the causes of chronic venous insufficiency?
A history of chronic venous insufficiency in the family
Being affected by blood clots or deep vein thrombosis
Having varicose veins
Lack of consistent exercise
Pregnancy
Recent leg operation
Obesity
Consuming tobacco
Being affected by phlebitis (swelling of superficial veins)
Prolonged standing or being in a sitting position for a long period of time
Treatment for Chronic Venous Insufficiency (CVI)
Complex Physical Therapy is a non-invasive treatment recommended for CVI
What is Lipoedema?
Lipoedema is a chronic and incurable condition. It involves abnormal fatty tissue being laid down in the tissues resulting in painful legs. Lipedema, also known as adiposis dolorosa, is a prevalent adipose tissue condition. Lipoedema fat buildup on both sides of your lower body (thighs, buttocks, legs) usually in the legs. But it can also be in the upper arms. Lipoedema does not respond to diet and exercise like ordinary fat. There is no current cure for Lipoedema, but non-invasive treatments such as, Complex Physical Therapy can help you feel better. You may inherit this condition during: puberty, pregnancy or menopause.
What occurs with Lipoedema?
Lipoedema is loose connective tissue characterized by hypertrophic adipocytes, inflammatory cells and dilated leaky blood and lymphatic vessels.
Typically a clinical diagnosis is made based on signs and symptoms.
Bruising
Painful on light touch
Develope spider veins
Daily activities are difficult
Bilateral (both legs) presentation that is symmetrical
Signs of fatty tissue laydown
Non pitting
Increase swelling of the calf
Not usually associated with wounds or discolouration of the lower legs (as for venous disease)
Usually diagnosed in women
Different presentation to obesity with specific areas of fatty tissue laydown
Negative Stemmer’s sign
How is lipoedema treated?
Treating Lipoedema with Complex Physical Therapy is a non-invasive and safe approach to reducing the oedema from developing further. Another form of treatment is liposuction. You should ask your doctor whether liposuction is advisable for you before going ahead.
Manual Lymphatic Drainage Massage (MLD)
What is Manual Lymphatic Massage (MLD)
MLD is a light, skin-stretching massage that helps promote the movement of lymphatic fluid out of the swollen limb. It should not be confused with a traditional massage. MLD is specifically focused on improving and restoring the lymph vessels to help the flow of lymphatic fluid. MLD helps open the remaining functioning lymph collectors and move protein and fluid into them, as well as to help speed up lymph fluid flow through the lymphatics.
The Casley-Smith MLD technique involves the use of gentle and slow effleurage hand movements. The effleurage movements are performed over the “watershed” areas between lymphotomes.
How is the massage performed?
Usually performed with the patient in the lying position Starts and ends with deep diaphragmatic breathing. (but it helps increase movement of fluid towards the heart ) Moves proximal to distal to drain the affected areas Slow and rhythmical movements Uses gentle pressure
Who benefits from MLD?
Therapeutic
Stimulates kidney functions.
Helps with chronic Oedemas
Helps to reduce lymphatic problems.
To increase the body’s own defenses.
Helps to protect your body Immune system against bacteria and viruses
Help to calm the autonomic nervous system.
The parasympathetic system generates a relaxing effect.
Regulates the body’s water balance.
Lowers blood pressure.
Reduces stress
Sports
Helps to prepare your muscles for physical effort, this allows greater performance and better recovery. Reduces pain and inflammation.
After surgical procedures
Post Surgical Lymphatic Drainage Massage helps to:
Eliminate fluids accumulated during and after the procedure.
Help to reduce pain caused by the excess of fluids
Reduces bruises that can appear after a liposuction procedure or other surgical procedures.
Prevents seroma.
Reduces fibrosis.
Speeds up the recovery process.
Reduces swelling.
Post-Mastectomy (breast cancer treatment)
MLD Contraindications
General contraindications:
- Acute cellulitis/erysipelas
- Severe cardiac insufficiency
- Hepatic cirrhosis with abdominal fluid (ascites)
- Unstable hypertension
- Renal failure
- Untreated tuberculosis or malaria
- Superior vena cava obstruction
Compression Therapy
What is compression therapy?
Compressing the muscles helps blood flow through the body more effciently. The compression method prevents blood from pooling in the body.
Uses of Compression Therapy
Blood circulation during frequent flights – the comprerssion garment reduces the aches and pains that come with poor circulation on long flights. Also preventing blood clots, DVT(Deep Vein Thrombosis). Healthy Posture during pregancy – Compression assists pregnant women in the last months of their pregnancy. Compression helps with improving posture, reduce back pain, increase circulation in the legs and improve blood flow. Compression helps with problematic veins by increasing circulation. Treating Lymphoedema to help drain the affected area and promote recovery. Compression helps drain the metabolic wastes more efficiently and this speeds up recovery process. Compression increases the amount of oxygen found in the muscles.
What happens when compression garments are worn?
Compression garments compress the muscles it forces the blood back towards your heart. This makes the muscles feel lighter and relieved discomfort.
Contraindications include:
Organ failure – Heart, Liver,Renal
Untreated DVT or Phlebitis
Severe arterial diseae (ABI.05 or less)
Types of Compression by Prescription
Compression Stockings
Compression Wraps
SIPC (Sequential Intermittent Pneumatic Compression) – Compression Boot or Arm Sleeve device.
How is the massage performed?
Usually performed with the patient in the lying position Starts and ends with deep diaphragmatic breathing. (but it helps increase movement of fluid towards the heart ) Moves proximal to distal to drain the affected areas Slow and rhythmical movements Uses gentle pressure
Who benefits from MLD?
Therapeutic
Stimulates kidney functions.
Helps with chronic Oedemas
Helps to reduce lymphatic problems.
To increase the body’s own defenses.
Helps to protect your body Immune system against bacteria and viruses
Help to calm the autonomic nervous system.
The parasympathetic system generates a relaxing effect.
Regulates the body’s water balance.
Lowers blood pressure.
Reduces stress
Sports
Helps to prepare your muscles for physical effort, this allows greater performance and better recovery. Reduces pain and inflammation.
After surgical procedures
Post Surgical Lymphatic Drainage Massage helps to:
Eliminate fluids accumulated during and after the procedure.
Help to reduce pain caused by the excess of fluids
Reduces bruises that can appear after a liposuction procedure or other surgical procedures.
Prevents seroma.
Reduces fibrosis.
Speeds up the recovery process.
Reduces swelling.
Post-Mastectomy (breast cancer treatment)
MLD Contraindications
General contraindications:
- Acute cellulitis/erysipelas
- Severe cardiac insufficiency
- Hepatic cirrhosis with abdominal fluid (ascites)
- Unstable hypertension
- Renal failure
- Untreated tuberculosis or malaria
- Superior vena cava obstruction
Skin Care for Lymphoedema
Applying skin care products helps to recover the skin from compression therapy and protect from infections. The skin care regime is part of the decongestive phase and maintenance phase. When the patient is wearing compression garments the skin becomes dry and prone to skin injuries ie scratches. Therefore, there is an increase of bacteria entering your skin and may cause infection. Some patients who develop deep folds due to swelling also increase the risk of infection.
Good skin care with Lymphoedema includes:
Keep the area clean by washing with mild soaps or hypo-allergenic moisturises
Dry the area carefully around skin folds
Apply emollients against water loss
Avoid perfumed products that irriate the skin
Disinfect wounds from cuts or bites
Avoid unnecessary injuries
Nail care is essential to avoid infections
Sunscreen
Exercise and Lymphoedema
Exercise and movement increase the lymphatic flow and improve your overall health. This is part of the Decongestive and Maintenance Phase. Regular exercise increase your muscle pump and improves the movement of the Lymphatic flow. Compression garments are crucial while exercising to reduce swelling.
What kind of Exercise works best for Lymphoedema?
Decongestive exercises are part of the CPT therapy
Scar Tissue Management
What is Scar Tissue Management?
Scar Tissue Therapy is the treatment of improving the health of the tissue. Scar Therapy is most helpful when treating patients with dysfunctional or problematic scar formation.
Who will benefit from Scar Treatment?
Patient’s receiving higher doses of radiotherapy and chemotherapy.
Symptoms of dysfunctional scars may include pain, sensitivity, oedema, reduction in flexibility, palpable bulky fibrous tissue and scar adhesions.
What method is used to treat Scars?
A variety of Scar Therapy approaches are available utilising manual treatment or a laser device to promote softening of the fibrosis and to stimulate tissue repair. Scar treatment can be a helpful non-medicalised therapeutic touch to promote healing emotionally as well as physically. Each approach may differ slightly in its technique and application.
CPT Education
CPT Exercise Classes
CPT Clinical Treatments and Outcomes
Manual Lymphatic Drainage
Case History
Patient: Aged 73
Condition:
Lymphoedema Stage II and Venous Insufficiency.
Treatment Protocol
Manual Lymphatic Drainage Massage
Outcome:
After 45 mins, the patient notice significant reduction of fluid from the lower extremities. The patient attended the bathroom 3 times within the session.
Maintenance Home Care Protocol
The patient was shown decongestive exercises to perform at home.
Case History
Patient: Aged 100
Condition:
Lymphoedema Stage II and Venous Insufficiency.
Treatment Protocol
Manual Lymphatic Drainage Massage
Outcome:
After 45 mins, the patient notice significant reduction of fluid from the lower extremities. The patient attended the bathroom 2 times within the session.
Maintenance Home Care Protocol
The patient was shown decongestive exercises to perform at home.
Care History
Patient: Ages 71
Condition:
Lympoedema Stage II and Venous Insufficiency
Treatment Protocol
Decongestive Phase – Decongestion Bandaging
Outcome :
After 11 days, within two bandaging sessions the patient’s leg circumference reduced significant in size. The patient also was assisted with a prescription to reduce her fibrotic tissue.
Maintenance Home Care Protocol
The patient was shown decongestive exercises to perform at home.
CPT - Complex Physical Therapy
(Casley-Smith Method)
MLD - Manual Lumphatic Drainage
What is the Lymphatic System?
Your lymphatic system’s primary role is to collect excess fluid from the tissues, purify it, and return it to the bloodstream.
If your lymphatic system fails to sweep up these excess fluids, they can accumulate, cause swelling and potentially increase the risk of infection. An efficient lymphatic system helps to defend your body against germs such as bacteria, viruses & fungi that may cause illness.
Symptoms of lymphedema include:
- Pain
- Skin discoloration
- Tissue swelling
- Heaviness in the limbs
- Weakness
- Hardening or thickening of the skin
- Recurring infections
What is Manual Lymphatic Drainage?
Manual Lymphatic Drainage (MLD) is a gentle rhythmical but powerful treatment which improves or restores the activity of the lymph vessels. This technique can reduce or prevent fluid retention, enhance the removal of toxins from body tissue and support the immune system.
Lymphatic Drainage extraordinarily effective in helping to restore lymph function, reduce pain and improve wound healing.
Lymphatic Drainage is developed as a cancer after care treatment but in meantime it is used as a standard treatment after nearly every major surgery in hospitals and clinics because of the huge benefits.
Who benefits from a Lymphatic Drainage Massage Lymph
Lymphatic massage aims to increase the efficiency of your lymphatic and circulatory system by reducing the volume of retained fluid in the tissues. This type of massage aims to help the body maintain proper blood circulation, body fluid balance, and immune functions.
What causes Lymphedema
People with lymphedema ( swelling) is generally in one of your legs or arms. The swelling is caused by lymph fluid that’s collected in the soft tissues, due to genetic disorders, injury, infection, cancer treatment, or surgery
What Conditions May Benefit from a Lymphatic Massage
Some of the conditions that may benefit from lymphatic drainage massage include:
Chronic fluid retention in legs or arms.
Swelling of a limb: pre or post-surgery.
Lymphoedema.
What is Lipeodema
Lipoedema is a chronic and incurable condition due to deposits of fat under the skin. It typically affects the thighs, buttocks and lower legs, and sometimes the arms, and may, although not always, cause considerable tissue enlargement, swelling and pain.
MLD Contraindications
General contraindications:
- Acute cellulitis/erysipelas
- Severe cardiac insufficiency
- Hepatic cirrhosis with abdominal fluid (ascites)
- Unstable hypertension
- Renal failure
- Untreated tuberculosis or malaria
- Superior vena cava obstruction
What is Chronic venous insufficiency (CVI).
Chronic venous insufficiency is when the valves or walls of the veins that are in the legs don’t work correctly. This makes it hard for the blood to flow back to the heart from the legs. Lymphatic drainage massage can help increase the speed of blood flow in people with CVI.
Do I need medical compression garments?
After your massage, your massage therapist may recommend compression garments.
CLINICAL TREATMENTS AND OUTCOMES
Myofascial Cupping
The following patients all visited the clinic, to receive a treatment to reduce their back pain discomfort. After reviewing each patient’s medical history it was clearly evident, that they all suffered from cold and dampness ie standing underneath an air-conditioning vent, sleeping with a fan over their bed or standing in a draft. The technique of Myofascial Cupping draws to the surface and expels pathogenic factors such as dampness and cold.
Patient 1
This patient left shoulder was exposed to an air conditioning vent while working on her computer at work, as opposed to her right shoulder which was not exposed to any air-conditioning vent, while working on her computer. After treatment her working environment was modified to eliminate any further discomfort.
Patient 2
This patient’s left shoulder was exposed to a fan over their bed.
Patient 3
This patient’s upper back was exposed to air-conditioning vent and open window draft.
Patient 4
This patient slept with the window open, wet hair and fan on top of their bed. Prior to the treatment the patient felt severe discomfort and following the treatment felt complete relief.
Patient 5
This patient furiniture was directly underneath an air-conditioning vent.
| Manual Lymphatic Drainage | |
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Case History Patient: Aged 73 Condition: Lymphoedema Stage II and Venous Insuffiency. Treatment Protocol Manual Lymphatic Drainage Massage Outcome: After 45 mins, the patient notice significant reduction of fluid from the lower extremities. The patient attended the toilet 3 times during the session. Maintenance Home Care Protocol The patient was shown massage techniques to perform at home to maintain their lymphoedema. |
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| Manual Lymphatic Drainage | |
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Case History Patient: Aged 100 Condition: Lymphoedema Stage II and Venous Insuffiency. Treatment Protocol Manual Lymphatic Drainage Massage Outcome: After 45 mins, the patient notice significant reduction of fluid from the lower extremities. The patient attended the toilet 2 times within the session. Maintenance Home Care Protocol The patient was shown massage techniques to perform at home to maintain their lymphoedema |
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