MY new website!

I'm undergoing something of a transformation at the moment (just like a butterfly) and from now on my new blog posts will be at www.mldphysio.com
Please go over and check out my new site, lots of exciting stuff coming soon!
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FG-MLD - A patient perspective.

Since the end of July I have been using the technique of Fluoroscopy Guided Manual Lymphatic Drainage (FG-MLD) in practice.  I wrote a post about it when I had finished the training.  At that time, I hadn't used it on real people with real lymphoedema.  Now, after seeing the amazing results I get with it I really believe it is the BEST method of MLD available.  The old technique worked well, so I am not taking away from the traditional forms of MLD, but having used FG-MLD clinically, I really cannot go back to the old way. My clients are feeling and seeing the difference too and recently I asked one of them if they would write me a wee testimonial.  So here it is, completely unabridged and unedited.

I got swelling in my leg 12 years ago, fairly soon after I had extensive surgery to treat cancer.  I had glands taken from my groin and my leg blew up within a few months of the surgery.  Since that time I have had some treatment for my lymphoedema.  I’ve attended a number of MLD therapists and had the bandaging done – they all told me they had got a good result, but I really didn’t think so.  My leg was massive, I’d say at least twice as big as my good one, and even after treatment, it was still huge.  I wear a stocking everyday, my leg was heavy and I felt it was getting worse, so in August I rung Joanne Brennan on the recommendation of a friend who had been raving about how good she was.  I am a complete sceptic, I really didn’t think that anything could be done for me that hadn’t already been tried.  I was probably just going to have to put up with this leg for the rest of my life.
I met Joanne and she assessed me – asked me all the same questions I had answered a million times before, and I thought to myself here we go again.  But then she explained that the technique of MLD she used was brand new.  She explained the science behind it and I thought to myself that really makes a lot of sense, I just hope it works for me.  Well, I have to say that I think it is an amazing technique.  It feels a lot stronger than the treatments I've had before, but that makes it feel like it’s actually working.  I would describe the other treatments I’ve had more like a tickle in comparison.  At the end of the first session I could see a thinner ankle and my leg felt lighter.  After 5 sessions my leg feels and looks brilliant.  It still swells as the day goes on, but when I wake up in the morning and I compare it to the other side there’s very little difference.  I haven’t seen my leg looking as good as it does now since before the surgery.  I can walk much further without getting tired, my energy is increased and I am sleeping much better.  I’ve told Joanne she has magic hands and I would be extremely happy to recommend her treatment to anyone else who suffers with lymphoedema like I do. 

I have been told that I have 'magic hands', I'm performing miracles and even sorcery!! But it is none of those, it is just the use of a brilliant technique which is based on the knowledge that we now have of how the lymphatic system works thanks to the work of Professor Jean-Paul Belgrado and his team.  

Scary Neuro-Surgeons!

For as long as I can remember I've been obsessed with the workings of the human body (hence my career choice) and my favourite bit of anatomy has to be the brain! When I was training as a physio I loved anything to do with the brain and nervous system, and when I got the chance to do my final year elective placement with one of the UK's leading neuro-physio's I jumped at it.  My first job was at Salford Royal Hospitals NHS Trust - AKA Hope Hospital, the Neuro-surgical Centre of excellence for the North West of England and I purposefully selected my junior rotation posts so as to make the most of being in the presence of neuro experts so I could learn from them.  From the very beginning Neuro-rehab was a big part of what I did.  When I started working at the Christie Cancer Treatment Centre, I was able to tie my two passions together when I took up the post of Senior Neuro-oncology physio, a job that I loved every single second of.
Despite my love of everything 'brain-ey', I did find the neuro-surgical wards a scary place to be.  Of all the patients in the hospital, these were some of the most critically ill I would ever come across.  I learnt very quickly that the line between life and death is a very fine one. I also learnt that the phrase 'a fate worse than death' has real truth in it, when I think of some of the patients I have treated who have had massive brain injuries and have been left severely disabled and debilitated but alive.  I can remember the tangible fear of the junior doctors on the wards at rounds time as they waited for the Consultant Neuro-surgeon to arrive.  As a junior physio I remember being made to feel completely inadequate when discussing patients with neuro-surgical nurses who had years of experience in the field and probably could treat the chest of an acutely ill patient far better than I could.  If it was my night to be 'on call', I would actually pray that neuro-surgery wouldn't call me,  and if in the middle of the night the pager would bleep (before mobile phones!) and I'd see their extension number I'd almost get sick to my stomach.  I felt that neuro-surgeons where scary, egocentric genius's with a very definite God complex, but I've always been intrigued by them and I suppose in awe of them,and in 2007, when a neuro-surgeon saved my mothers life, that particular surgeon got elevated to 'Legend' status!  So when I recently came across Consultant Neuro-surgeon Mr Henry Marsh's book 'Do No Harm', I had to read it.  And I am so glad I did. It gives a fascinating insight not just into the world of neuro-surgery, it also reveals the humanity behind that 'scary' façade  - a humanity which enables them to perform what must arguably be the most difficult and risky surgical procedures for the good of their patients.  They have to have the God complex, they have to believe that they are the best because if they make a mistake someone dies or worse can suffer a 'fate worse than death'.  Please God, I never have to go under the knife of a neuro-surgeon, but if I did I want him or her to be the scariest, most egoncentric genius I have ever met.  I'd highly recommend the book!

Lipoedema Case Study

I have recently been treating a client with intensive decongestive lymphatic therapy (DLT) who has lipoedema.  The lady is 37 years of age.  Her history and examination reveals that she ticks a lot of lipoedema boxes:

• bilateral symmetrical 'big' legs, disproportionate for waist/trunk size
• history of bruising easily
• endless attempts to lose weight and when she has lost weight it hasn't gone from the legs
• 'orange peel' effect on the legs
• feet are not affected and look 'skinny' in comparison to her ankles
• non-specific achy feelings and heaviness in the legs
• strong family history of thyroid disorders
• other female relatives have similar big legs
• her legs were overly tender to light pressure
• her symptoms were exacerbated during pregnancy

The photo below shows her pre and post Delfin Moisture Metre readings along with her limb volumes. 

This is an ongoing case, I am still seeing this lady, the above post measurements are taken on day 5 of treatment. 

Subjectively the lady is feeling immense benefits from the treatment.  She says that her legs feel so much lighter than they have ever done, she doesn't have the aches and soreness that she was so used to and she is loving the fact that she herself can see her "ankle bones" and has shape in her calves.  

I sincerely hope that we can maintain these improvements as we continue to work together.  

I am plagued by questions as to what was/is going on in her legs based on the objective findings and putting that together with the knowledge I have gained during my recent Fluoroscopy Guided Manual Lymphatic Drainage (FG-MLD) training.  And I am specifically looking at area 'A' in the diagram.  On initial assessment there was definitely higher Moisture Metre readings in that are in her left leg. The left:right ratio difference in area A is averaging 1.3.  Her left leg did have a slightly higher volume and after 5 days had a reduction of 1370mls when compared to 805mls on the right.  But what interested me more is that the Moisture Meter readings were very much reduced on the left and more equal to those on the right - leading me to conclude that we had gotten rid of the excess fluid in that area.  But I then ask why was there more fluid just in that specific area?????? On assessing women with very early stage lipoedema, this area typically is where we can palpate the rubbery fat nodules, and is commonly an area that ladies identify as where they can see the abnormal fat in their legs.
So, when I think about what I learnt in my FG-MLD training recently - commonly there is an area just below the knee - roughly around area 'A' where we find our 'fill' spots.......I don't know where this is going but I am sure there is a research question in there somewhere, I just don't know what it is.  

I would love to get other therapists views on this - any thoughts?????

Lipoedema

Recently I gave a talk on Lipoedema explaining what it is, how it is diagnosed and how it is treated and managed.  Here is the slide show, a lot of it is self explanatory but I'm happy to answer any questions if you comment below.

FG-MLD....challenging and changing what we know about lymphoedema!

I've just spent the weekend in Cork doing some training with Jane Wigg of The Lymphoedema Training Academy, learning all about the new Fluoroscopy Guided Manual Lymphatic Drainage (FG-MLD) technique. I first did my MLD training with Jane in 2009 and ever since have been using it to great effect with clients who present with lymphoedema and chronic swelling. There is no doubt in my mind that MLD works – we know that, we see limbs shrink in volume, we feel fibrosis soften and we hear what difference that is making to patients. There are different schools of MLD, all using slightly different techniques but with broadly similar treatment aims – to re-educate the lymphatic system to take fluid away from where it is collecting to an area where it can be drained effectively. A problem that we have though in the field of MLD is that up until very recently, we didn't know for sure exactly how it works and the 'it just does' view has little value in the inquisitive and evidence based medical world. There is very little published research evidence available to prove that MLD works. We can set our hypotheses but actually testing them at the most vigorous level is difficult. So my mind has been well and truly blown over the last few days when I have learnt about some of the most recent work being done in lymphology to strengthen the evidence base and to finally answer with conviction the 'how it works' question. Professor Jean Paul Belgrado's work using an infrared camera to view the lymphatic system in living people is further building on Professor Leduc's anatomical work on cadavers from the 1970's. The evidence is compelling. Now we can see lymphatic flow in action in real life, we can see the impact that a compromised lymphatic system is having on that flow and we can see exactly how our hand placements, stroke movements and pressures applied can be adapted to maximise the effectiveness of the MLD technique, and that is what Jane Wigg, Professor Belgrado and his team have done with the creation of FG-MLD. I actually think that this new knowledge will have a massive impact on how we manage lymphoedema now and in the future and in my mind it is a significant medical breakthrough that will have life-changing consequences. Think about how Watson and Crick impacted on our knowledge of genetics or Fleming contributed to fighting infection – I think FG-MLD is the double helix or the penicillin of today!

So, what does this mean to MLD Therapists who are currently effectively treating people with lymphoedema using MLD techniques that have been tried and tested over decades, what does FG-MLD offer us? Well, it means we can have a fuller more informed understanding of what we are doing and why, and have the conviction to be able to say 'This works and we have the evidence to prove it'. It means that we can achieve more, we can have even better outcomes we can be even more effective at moving fluid and softening fibrosis. For patients with lymphoedema it means we can provide you with a researched and evidenced based technique which will reduce your swelling and it will improve your quality of life.

As a therapist I find this incredibly exciting and as I said 'mind-blowing', although at the same time I find myself really challenged. Challenged to change what I am doing, challenged to think differently, challenged to accept a fundamental change in the approach and underlying assumptions to that which we heretofore held about lymphoedema and MLD, challenged to trust this paradigm shift. How comfortable am I with such a high level of challenge? To answer that I have to bring my focus back to why I do what I do. I am a clinician, I want to achieve the best for my clients, I want to make them better, yes the techniques that I am currently using are doing that, but if I can use something that promises to be even better........I can't erase the images in my mind of the fluorescent lymphatic fluid being pushed out of a limb that are there since I saw the video evidence over the weekend. For me its a no-brainer! It's FG-MLD all the way from now on!

So, I actually can't wait to bring this knowledge to my clients. I can't wait to tell them all the new stuff I've learnt (and tell them to forget some of the stuff that I would have told them previously) and I CAN NOT wait to try out the new technique and see the results for myself . The world is revolving and evolving at a fast pace and similarly we have to evolve in our clinical practice. I for one am delighted to be part of this exciting new world of lymphoedema management!

Lymphoedema........is it OK to get a massage?

I'm often asked about getting a massage by people who have lymphoedema or may be at risk of developing it due to treatment over a lymph node area.  The answer to this is not a simple 'Yes' or 'No'.....more of a 'well, you can and you can't' (typical Irish way of answering a question I know!).  So here's my guide to the things to think about...
Most important  - is the person offering the massage qualified to do so, and what are their qualifications.  If you are paying for a massage (as opposed to a family member, partner or friend providing it) then you do need to check out what training they have done.  Gold standard would be they are trained in the lymphatic system by one of the recognised schools of Manual Lymphatic Drainage (Leduc, Foeldi, Vodder, Casley-Smith and the Lymphoedema Training Academy - this is the one I do my training with!).  Any therapist with this training should have a full appreciation of the lymphatic system and what can cause lymphoedema or make it worse and therefore you should be in safe enough hands getting massage from them (it'll probably very likely be an MLD type treatment anyway - which is the best thing for the lymphatics).
There are however many massage therapists available that do not have the above training, and I think I am right in saying that the majority of therapists who work in Spa's, beauty clinics, hotels and sports facilities etc would fall in to this category. So similarly ask them what training they have done in the lymphatic system.  I would tell them that I either have or am at risk of developing lymphoedema and ask them how that would impact on the massage.  I'd then judge by their response would I go ahead with the massage - so I would be looking for them to explain to me how in this situation massage needs to be gentle and that all deep heavy strokes need to be avoided.  I would also be looking for them to ask me for more information in order for them to make a full assessment of me and then to be able to deliver the most appropriate massage for me.  I would have to be assured that I knew that they knew about lymphoedema - if I feel that then grand, if there was any doubts in my mind I wouldn't go ahead.

Strong deep strokes around the part of the body where the lymph nodes are compromised is not recommended. So if it's your armpit that is affected, avoid deep massage in the associated arm, breast, chest and back area.   Massage in that area should be light and gentle and strokes should always go towards the centre of the trunk.  I would strongly advise against getting a 'cupping' massage - where heated glass cups are placed on the body and as they cool they create suction which apparently 'stimulates circulation and healing', think 'lovebite' - cos that's what you end up with -  a series of big dark bruises wherever the suction was applied.  Physiologically a bruise is a sign that tissue damage has occurred, whether it be from getting a bang off a piece of furniture or from a 'healing treatment'.  If your impaired lymphatic system cannot cope with the demand that the increased circulatory and inflammatory response to this 'therapy' will place on it then you could run into trouble.
After having cancer treatment you may find your skin a little more sensitive than it was before.  You might need to avoid the use of perfumed creams and lotions.  If getting an aromatherapy massage, be sure to tell the therapist that you have had/having treatment and they can select the most appropriate oil for you.
Ask around - word of mouth is often the best way of finding the best people.  There are some very good massage therapists around who I would happily refer any of my clients to and if anyone wants their details then let me know.
There are immense benefits of receiving massage therapy by a trained competent therapist who can work with you tissues to bring about relaxation and release of tension throughout the whole body, and this can be very healing in itself, both physically and psychologically.  It is so important if you have/are at risk of getting lymphoedema to make sure you take all precautions that you need to take.  It is YOUR body, and you have to give permission to someone to place their hands on your body - only do that if you are completely happy they know what they are doing because at the end of the day, if something does go wrong, it is you that has to then deal with it.  You need to do your own risk assessment.  Unfortunately I have seen many clients who have received 'massage' and then end up coming to me because lymphoedema symptoms have been exacerbated. On questioning all these clients have said that they didn't feel totally convinced or comfortable that the therapist knew about lymphoedema, despite the fact that they might have said they did.
In the Autumn I will be running a course aimed specifically at body work in clients that have had breast cancer.  This will be open to any touch therapist (massage, physio etc) who might encounter breast cancer survivors in their work. We will be exploding some of the myths and exploring the many possibilities and benefits available from working on the body tissues through therapeutic touch.  More details will be posted soon, or contact me for more info.