What is lymphoedema?

Lymphedema is a chronic swelling of the subcutaneous tissue resulting from impaired function of the lymphatic system and usually affects a limb. There is no known cure for lymphedema, however with proper treatment it can be kept under control and a reasonable limb shape and size can be maintained.

The lymphatic system is responsible for the removal of excess fluid and proteins from the tissues and their transportation via lymph vessels to the venous circulation. Tiny lymphatic capillaries, found in almost all parts of the body, are the start of the lymphatic system. They join to form larger lymphatic vessels which travel up the limbs and into the body where a large lymphatic trunk pumps lymph fluid into the veins entering the heart.

Acute swelling (edema) due to injury will usually return to normal as the healthy lymphatics drain away the excess fluid and protein and the damaged tissues heal.

If the lymphatic system is dysfunctional due to damage or incomplete development, excess fluid and proteins will continue to accumulate in the tissues causing chronic swelling which may be complicated by inflammation and infection. These create additional damage thus setting up a viscous circle. In the absence of treatment the affected limb gradually enlarges and may become deformed limiting daily function and affecting life quality.

Lymphedema severity is assessed by the size of the limb in relation to the normal side. A mild swelling may disappear when the limb is elevated for a period of time. Skin thickening and hardening indicates a worsening lymphedema while skin changes (warts, bumps, blisters) appear in long standing and severe lymphedema.

By international consensus the four stage classification system of the International Society of Lymphology is recommended for lymphedema assessment.

Lymphoedema Framework Best Practice for the Management of Lymphoedema, International consensus.

Stage 0 exists when lymphatic function has been disturbed but there is no visible swelling. Over time there may be further deterioration causing swelling even many years after the initial insult. Stage 1 is early swelling which is reversible when the limb is elevated or after lying down. Pressure on the skin leaves a mark of indentation. Stage 2 swelling does not improve with limb elevation. The skin becomes thicker and indentations may or may not appear with pressure. Stage 3 lymphedema is a swelling in which skin changes, such as thickening, discoloration, warty outgrowths and skin folds, appear. The limb may become greatly enlarged.

Secondary lymphedema is swelling as a result of damage to some part of the lymphatic system. For example, surgical removal of lymph nodes, cancer, radiotherapy, trauma, infection and venous insufficiency may result in harm to the normal lymphatic function. Secondary lymphedema is usually suspected when limb swelling appears and tests will be performed to seek out the cause.

If all possible causes have been excluded an inherent defect in the lymphatic system is the problem and a diagnosis of primary lymphedema is made. Some forms of primary lymphedema cause swelling to appear at birth and in others it may appear at later stages of life. Commonly the swelling appears during adolescence and usually affects the lower part of the leg first with gradual involvement of the rest of the leg.

What is the Casley-Smith method of treatment?

The method of decongestive lymphatic therapy to treat lymphoedema which Judith and John taught, have similar components to the protocol of Complete Decongestive Therapy developed by their colleagues Michael and Ethel Foeldi, in Germany.

Judith held (holds) a particularly strong view that treatment needs to be tailored to the individual, and that therapists must not be mechanical in their approach to treatment, and should be creative in responding to the changing needs of the individual. They did not teach a prescribed way of working, but taught sound principles that become a solid foundation for choice of techniques in approaching a case.

With Australian towns being spread far and wide, the Casley-Smith’s also put a strong emphasis on self-care following treatment.

The significant differences and advances in their methods, lie particularly in Judith’s method of manual lymph drainage which drew on her intimate knowledge of the microanatomy of the lymphatic system, and on Kubik’s concept of lymphotomes. It uses very simple strokes so that patients or family members can learn to do self manual-drainage.

The exercise sequences that Judith designed were put onto video tapes for people to use at home. She introduced the concept of following a sequence similar to that of Manual Lymphatic Drainage (MLD). The sequences also incorporated deep breathing and self-MLD. Lymphoedema sufferers were taught to think about daily activities as opportunities to perform movements similar to those in the exercise sequences, and that doing so, could perhaps reduce formal exercise sessions.

The Casley-Smiths kept current and abreast of the latest bandaging materials, and new designs of compression garments and aids used in compression therapy. Their bandaging method emphasized the achievement of a pressure gradient and the creative use of protective and anti-fibrosis padding.

Treatment for lymphoedema

There is no current cure for lymphoedema, however it can be well managed by proper treatment. Internationally it is agreed that the gold standard for treating lymphoedema is a 4-fold combination of therapies. Collectively, they are known as one of the following: Complex Lymphatic Therapy (CLT); Complete Decongestive Therapy (CDT); Decongestive Lymphatic Therapy (DLT) or Complex Physical Therapy (CPT). CLT is safe and non-invasive therapy. Each component will achieve something on its own, but it is optimal to combine them. Therapy may be intensive (2-6 weeks) to achieve a reduction in swelling, or a simplified version may be practiced at home to prevent the re-accumulation of swelling. FAQs for questions on costs, insurance coverage

CLT/CDT/DLT is described in brief, as follows:

Skin care: Skin is regularly moisturised during treatment to keep it supple and prevent skin breaks or tears. This is recommended as a lifelong practice, in order to act against the risk of infection. It is advisable to attend promptly to cuts, abrasions, insect bites etc. Any episode of infection adds to the lymphatic load, potentially worsening the lymphoedema. As most soaps tend to have an alkaline pH which is dehydrating, seek products that are pH neutral or acidic that wont strip the skin of it’s acid barrier and natural oils.

Compression therapy: Compression on a swollen area can be administered in 2 ways either by applying layers of protective padding and bandages over the swollen limb, or by wearing a specially designed garment that has graduated compression. Both types of compression provide high working pressure and a counter force for muscles to contract against. This assists in moving fluid out of the affected region. Both types of compression are effective, but they have a different emphasis.

Compression bandaging is used to drive or evacuate fluid out of the affected limb or region. This style of bandaging is generally referred to as Multi Layered Lymphoedema Bandaging (MLLB), because there are several layers applied to the affected region. The bandages are applied daily in intensive treatment. They are practical to use during this phase, because they conform to the changing shape of the wearer’s limb. A therapist may teach you to bandage your limb, if is considered appropriate for you to continue this practice at home.

Compression garments are useful in preventing the skin from stretching further, thereby delaying further fluid accumulation. Garments become less effective when they start to stretch too easily. Replacing them every 4-6 months is recommended. The graduated compression helps to direct the fluid towards the torso. It is recommended that they be worn daily and particularly when one exercises. Compression garments come in a variety of forms and are either made-to-measure, or purchased off-the-shelf. A garment should be comfortable. If this isn’t the case, it may cause harm and should be checked by an experienced therapist or fitter.

Manual Lymph Drainage: This is often referred to as massage, but does not resemble the common remedial or beautician style of massage that many people may know. Manual drainage is very light, very repetitive, very slow and rather soothing. Its purpose is to decongest swollen areas and to soften hardened tissues. It is common, to work first on functioning areas of the body, which will receive fluid from the oedematous areas. Lymph nodes in these healthy regions are cleared repeatedly. Fluid in the swollen tissues is then manually drained towards the cleared area. If there is hard fibrotic tissue within the swollen area, the strokes may be firmer and deeper. However, manual drainage should not be painful.

Exercise: When the muscles of the body bulge (contract), they help to pump; fluid out of the tissues and vessels. The small lymphatic vessels that lie just below the skin, gain an extra benefit when a compression garment or bandage is worn during exercise, because the graduated compression provides a counter force that helps to move the lymphatic fluid toward the central circulation. Exercising in water also gives this counter force, and has other benefits too (www.aqua-lymphatic-therapy.com). Some exercises are more beneficial than others. The Casley-Smith exercises in part, mimic the order of manual lymph drainage. Each person is different, so it is necessary for each individual to observe what helps and what exacerbates their swelling. For someone returning to exercise after a lengthy lapse, it is advisable to approach exercises gradually in both strength and duration. FAQs or instructions for patients

Education: Finally, education is provided to those with lymphoedema or to their carers. Daily participation in CLT is essential to prevent further swelling, and to maintain a reduction. A modified version of the 4 components of treatment is taught, so that it can be regularly performed.

C-S Technique

In essence, the Casley-Smith techniques used for decongestive lymphatic therapy bear the hallmark of simplicity. This simplicity is a synthesis derived from a strong foundation of knowledge. It has to be said that the Casley-Smith training for lymphoedema therapists is rigorous in this way. The Casley-Smith courses meet or exceed the high standards that are demanded by the international community of lymphology associations. Currently, accredited Casley-Smith courses worldwide, are no less than 135 hours.

True to the Australian spirit, the Casley-Smith approach is devised to be practical, safe and uncomplicated for the lymphoedema sufferer to use. Within the self management regime, a further simplified version of manual drainage, exercise and bandaging is taught to ensure a degree of independence can be maintained.

Casley-Smith therapists are encouraged to continuously seek out up-to-date, and evidence-based science and research, so that therapeutic methods can be a living and evolving process. It is this freshness in approach that can be so captivating in the Casley-Smith method.

Frequently Asked Questions

Can I drive my car home after MLD or do you advise I ask a friend to drive for me?

The massage can make some people feel very relaxed or even sleepy for a while after treatment. It is a good idea to ask someone else to drive you home if this is a practical option for you, otherwise your therapist may suggest that you take some exercise and fresh air before you drive. It is also advised that you check your car insurance policy to ensure that you are covered while undergoing medical treatment.

Why do I feel so sleepy after MLD?

The gentle massage, comfortable positioning and gentle breathing exercises can have a deep relaxing effect on the body, releasing tension and relieving anxiety putting the body in a calm and sleepy state.

What special arrangements do I need to make at home if I am going to receive Decongestive Lymphatic Therapy/Complex Decongestive Therapy?

Your swollen limb may have many bandages covering it during the treatment period and some daily activities may be difficult. Consider how you are going to bathe, get dressed and carry out your daily chores. You will be encouraged to keep active however, it is not a time to sit and do nothing. Your therapist has a great deal of experience and will be able to advise you.

How much manual drainage should I have?

This is a much asked question and not easy to answer in a general way, because there are so many variables. For example, one person may exercise a lot and another not at all, or lymphoedema may have just become visible, or it may have been there for many years. In essence, it’s a very individual need and choice. Some people will continue a regular routine all their lives with professionally administered MLD. Others might need a few sessions only. Much depends on the body’s response to the combination of all components of treatment.

How do I know my therapist has done the proper training to carry out this technique?

Ask your therapist where they trained, who their teacher was and when they last updated their skills. Through this website you can check the names of listed therapists who have trained in Casley-Smith technique in each country or you will find the name of a person to contact who will check the list for you.

Will I need a new compression garment after DLT/CDT?

If you already wear a compression garment you may find that at the end of a treatment period your limb is a different size/shape. Your therapist may recommend a new garment and you should clarify with your therapist whether this is included in the cost of treatment or reimbursable.

What general exercise can I do and what precautions should I take?

Maintaining fitness and normal body weight is important for people with lymphoedema, so a healthy exercise program should be part of daily life in addition to the exercise included in the lymphoedema reduction therapy program. What we know about exercise and lymphoedema is based mainly on studies on breast cancer related lymphoedema. Some of this knowledge may be applied to lymphoedema due to other causes. Weight lifting exercise after breast cancer treatments is thought to be safe and may even reduce the risk of developing arm lymphoedema. The exercise program should performed under supervision and start when the lymphoedema is stable (i.e. infection free and the volume has not changed over three months). Initially very low weights are used and gradually progressed. Wearing a well fitting compression garment is recommended. It is best to be consistent with the exercise, or after a break of a week to reduce the weight and after a longer break to return to the starting weight. Irregular exercise may cause injury with detrimental effect to the lymphoedema. Aerobic exercise does not seem to have an adverse effect on lymphoedema but more research needs to be done in this area before any clear statements can be made. Exercise such as Tai Chi, Qigong, yoga and Pilates are popular and have health benefits but their effects on lymphoedema are not known.

Additional precautions that people with lymphoedema should consider when exercising are:

  • to develop self-monitoring techniques with the help of a lymphedema therapist
  • to avoid wrapping weights tightly around the limb or clothes which may constrict part of the limb or body
  • to drink sufficiently while exercising
  • to exercise in a cool environment
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    Is water based exercise helpful?

    In general, the answer to this is yes, and research has verified this. Some useful factors regarding exercising in water can be that it helps with buoyancy; it offers a comfortable resistance to movement; a body of water can also act like compression; it may help to cool you down, which is useful in a hot climate, and so on. There are safety issues to consider before you â??plunge into exercise based water and it's best to check with a therapist to work out whether you need supervision or guidelines. Risk of infection from public pools should also be considered. As with all exercise, doing too much water exercise may start to counteract the benefits.

    What should I do if I need to have surgery done on my affected arm/leg?

    Plastic pink alert bracelets are available to warn that your limb is affected. Your therapist should be able to direct you to where these are available. Some people like to have MLD or some bandaging prior to surgery to reduce the amount of fluid in the limb. As inflammation/swelling is one of the side effects of surgery the benefit of the MLD may be very short lived and even be questionable. Following surgery and as soon as it is safe, the practices of lymphoedema management should be embarked upon.

    How can I prevent an infection?

    The guidelines for this are to practice very regular skin care, and to be proactive with preventative measures.Daily moisturising will assist in preventing the skin from becoming dehydrated and more fragile. If breaks in the skin do occur, acting quickly is recommended. Some times carrying a prescription for antibiotics, is given to a person with recurring infection.

    Will my lymphoedema go away?

    The symptoms of lymphoedema can be managed but the condition cannot be cured. If treatment for your lymphoedema reduces the condition to almost, or very near normal, it is wise to understand that the risk still exists, and that you should still be cautious about those activities that may act as a trigger.