116 Fisioterap/e, November 1986, dee/ 42 no 4 A Re-evaluation o f the Im portance o f the Lymphatic System in the Treatm ent o f Post-mastectom y Lymphoedema AILEEN Z. GOODENOUGH LAETITIA A. H. M. SCHEPERS SUMMARY The physiology and pathophysiology of the lym phatic system are d iscu ssed . C om plex decongestive physiotherapy is presented as an alternative approach to the treatment of post-mastectomy lymphoedema. This is seen to be an effective method of treatment, but good patient com pliance (hygienic measures, wearing elastic support while working, com ­ pression bandaging while at rest and remedial exercises), is a prerequisite. T h is may be achieved by intensive patient education. O PSOM M IN G Die fisiologie en patofisiologie van die limfatiese sisteem word bespreek. Saamgestelde dekon- gestiewe fisioterapie word as ’n alternatiewe benadering tot die behandeling van namastek- tomie-limfedeem aanbeveel. Dit word beskou as ’n doeltreffende metode van behandeling, maar die resultate sal alleenlik behoue bly met die noue samewerking (higieniese maatreels, die dra van ’ n rekbare mou gedurende die dag, drukverbande gedurende nagrus aanwend en oefeninge), van die pasient. Intensiewe op- leiding van die pasient is noodsaaklik om goeie samewerking te bewerkstellig. IN T R O D U C T IO N L ike m an y o th e r areas o f m edicine, th e tr e a tm e n t o f b re a s t c a n c e r has ch an g ed co n sid erab ly d u rin g the last decade. A recen t e n q u iry by th e a u th o rs d irected to p h y sio th e ra p ists in N a ta l, th e T ra n sv a a l and Z im b ab w e suggests th a t th e p h y s io th e ra p is t is n o t alw ays called u p o n to p lay a m a jo r role in the p o st-o p e ra tiv e care o f b re a st c a n c e r p a tie n ts. In this regard, it m ay be argued th a t th e early p o st-o p e ra tiv e role o f the p h y sio th e ra p ist rem ain s c o n tro v e rsia l, possibly due to o v e r-e n th u sia stic exercise w ith re s u lta n t co n g estio n o f the tissues in the axilla. S u rp risin g ly these en q u iries also in d ic a te d th a t th e g re a te st p ro b le m c u rre n tly being ex perienced by su ch p a tie n ts relates to ly m p h o e d e m a — th a t is a high p ro te in o e d e m a o f the arm on th e o p e ra te d side. It has been suggested th a t th e reaso n fo r th e a p p a re n t increase in such incidences is th a t in som e centres b re a st c a n c e r p a tie n ts a re selectively being given the Aileen Z. G oodenough, Nat. Dip. Phys. Private Practitioner, P.O. Box 255, Howick 3290 L aetitia A. H. M. Schepers, State Phys. (N etherlands) N o longer practising, 4 Palm C ourt, Sargeant Street, Greytown o p tio n o f lu m p rem oval only. T his is th e n follow ed by high doses o f ra d ia tio n to the axilla. Excessive fibrosis and scarring fro m these high ra d ia tio n doses are th o u g h t p o ssib ly to c o n tr ib u te to the m o re fre q u e n t o ccu rren ce o f ly m p h o e d e m a . F u rth e r stu d ies will be needed to ev alu a te this h y p o th esis m o re fully. R e p o r t s o n th e in c i d e n c e o f p o s t - m a s t e c t o m y ly m p h o e d e m a in the U .S .A . v ary fro m 6,7% to 62,5% ' It h as nev er been e x p la in e d w hy som e m astectom y* p a tie n ts develop ly m p h o e d e m a while o th e rs d o not. S o m e m ay go fo r several y ears w ith o u t ly m p h o e d e m a , o n ly to d e v elo p m assive o e d e m a la te r fo r no a p p a re n t reaso n . It has been suggested th a t m u ltip le fa c to rs such as ra d ia tio n th e ra p y , in fectio n , delay ed w o u n d healing, surgical a b la tio n o f lym phatic nodes and vessels, fibrosis fro m ra d ia tio n o r c h ro n ic o e d e m a , th ro m b o p h le b itis, o r in a d e q u a te reg e n e ra tio n o f ly m p h a tic vessels are possible etiological fa c to rs .2 T h e p u rp o s e o f th is article is, firstly , to ta k e a fresh l o o k a t th e p h y s i o lo g y o f th e ly m p h a ti c s y s te m . S eco n d ly , it h ig h lig h ts th e co n c e p t o f com plex d econ­ gestive physiotherapy, as describ ed by F o ld i, F o ld i & W eissled e r,3 as a w o rth w h ile a lte rn a tiv e m e th o d o f tr e a tm e n t. It is the a u th o r s ’ view th a t this a p p ro a c h deserves co n sid eratio n , in spite o f the fact th a t it requires R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) extensive p a tie n t e d u c a tio n and a high level o f p a tie n t com pliance. p h y s i o l o g y 1. N orm al Lymph D ynam ics G u y to n 4 defines ly m p h as in te rstitia l fluid th a t flows into the lym phatic system . T he lym phatic system consists o f p re -ly m p h a tic c h an n els in the in te rstitiu m , lym ph cap illaries, ly m p h c o llecto rs, lym ph nodes an d lym ph tru n k s. T hey hav e valves alo n g th e ir la rg e r vessels (collectors) up to the p o in t w here th ey e m p ty in to the c irc u la tio n . T h e ly m p h atics also hav e m in u te “fla p ” valves th a t o p e n in to th e in te rio r o f th e ly m p h atic capillaries a t th e ir very tips. T his m eans th a t su b stan ces o f h ig h m o le c u la r w eight, su ch as p ro te in s , can pass alm o st u n im p ed ed in to th e ly m p h a tic cap illaries v ia the flap valves. F u r th e rm o r e ,there is n o o th e r ro u te besides the lym p h a tics th ro u g h w hich excess p r o te in s can return to th e circulatory s y s te m .4 A A n increase in in te rstitia l fluid p ro te in in creases the ^tissue colloid o sm o tic p re ssu re w hich d is tu rb s n o rm a l capillary dynam ics. T h erefo re, th e m o st im p o rta n t fu n c ­ tio n o f th e ly m p h atics, is to c o n tro l th e p ro te in c o n cen ­ tra tio n in th e in te rstitia l fluid (F ig. 1). physiotherapy, November 7986, vol 42 no 4 tissue fluid A R T E R I A L e n d L Y M P H A T I C - v v e n o u s 2 5 M M H g P l a s m a P R O T D N O S M O T I C ♦ P R E S 5 u P > £ - COLLOID OSMOTIC 3 2 M M H g P R e s s u R t B l o o d p r e s s u r e N E T - O U T W A R D 3 2 - 2 . 5 = 7 12 M M H g B L O O D P R E S S U R E N E T - IN W A R D £K£ABSORPTiOn ) 2 . 5 - l Z - 13 M r. Hq l C r r t CT ' VC COLLOID OSMOTIC PACSSUAC P R E C A P t L L A f V * ARTERIOLES A R T E R 'O V E N O U S a n a s t o m o s e s BV-PASSES T"E CAPH-LAfcV NtTWOSK. P O S T O F I U - A H V VEIN'S S T A R L IN G S EXCHANGE. H YPO THESIS T he ra te o f ly m p h flow is d eterm in ed by:4 (i) In te rstitia l fluid pressure If th e in te rs titia l fluid p re ssu re rises ab o v e its n o rm a l level it resu lts in an in crease in th e flow o f in te rstitia l fluid in to th e ly m p h a tic cap illaries and co n se q u e n tly in creases the ra te o f ly m p h flow. F acto rs, besides the o b stru ctio n to th e lym ph system itself, w hich tend to increase th e in te rstitia l pressure an d th e re fo re the ra te o f ly m p h flow , are elevated c a p illa ry p re s su re , d e c rease in p la s m a c o llo id osm otic pressure, increase in interstitial fluid p rotein an d an increase in the p e rm e a b ility o f th e ca p il­ laries. T h is last p o in t is im p o rta n t in selecting tr e a tm e n t tech n iq u es so as n o t to c o n tr ib u te to fu r th e r tissue congestion. (ii) T h e ly m p h atic p u m p C o m p re s sio n o f a ly m p h vessel o r ca p illa ry fro m any source squeezes lym ph fo rw ard alo n g th e lym ph c h an n els to th e next valve in a p u m p -lik e m an n er. (A sectio n o f ly m p h c h a n n e l fro m o n e valve to the n ex t is called a ly m p h an g io n .) T h is p ressu re can be fro m th e c o n tra c tio n o f th e sm o o th m uscles in the walls o f the ly m p h a tic s, o r fro m e x te rn a l sources. T h ese e x te rn a l p ressu res a re th e c o n tra c tio n of m uscles, m o v em en t o f b o d y p a rts , arte ria l p u ls a ­ tio n s, b re a th in g m o v em en ts an d th e co m p ressio n o f tissu e by o b je c ts o u ts id e th e b o d y ; fo r ex am p le, g en tle m assage. T h e in c re a se in ly m p h flow c a n be as m u ch as 5 to 15-fold d u rin g exercise.4 T his is ob v io u sly an im p o rta n t fa c to r in exercise-induced overloading. 2. Oedem a from A bnorm al Capillary D ynam ics4 T h e cause o f ex tra c e llu la r flu id o e d e m a are: (i) In creased c ap illary p re s su re c au sin g an increase in th e filtra tio n o f fluid th r o u g h capillaries. (ii) A d ecrease in p la s m a p ro te in c a u sin g a d ecrease in th e p la s m a co llo id o sm o tic p re ssu re and th erefo re a failu re to re ta in fluid in the capillaries. (iii) L y m p h a tic o b s tru c tio n resu ltin g in an increase in in te rs titia l p ro te in w hich increases th e o sm osis o f th e fluid o u t o f th e capillaries. (iv) A n increase in cap illary p e rm e a b ility resu ltin g in th e leak a g e o f excess fluid p ro te in in to the tissue spaces. T his is the m ain reaso n fo r avo id in g in flam ­ m a to ry processes in a congested lim b. 117 3. R esp on se o f Tissues to Secondary L ym phoedem a after M astectom y L y m p h a tic d ra in a g e in to th e ax illa is p a rtia lly o r to ta lly d is ru p te d by surgery o r su b seq u en t ra d ia tio n . S o m e w om en h ave cephalic ly m p h ch an n els th a t d ra in in to s u p r a c la v ic u la r n o d es.5 T his can co m p e n s a te fo r the ly m p h a tic e m b a rra ss m e n t an d m ay be one o f the re a s o n s w hy these w om en d o n o t d ev elo p an y o e d e m a o f th e arm . R e g e n e ra tio n is only possible if fibrosis d o es n o t m ech an ically an d n u tritio n a lly lim it new lym ­ p h a tic fo rm a tio n . P re m a tu re d ra s tic exercising, high d o ses o f ra d ia tio n an d in fectio n all p lay a role in e x a c e rb a tin g fib ro -sclero tic changes in th e tissues. F o ld i an d F o ld i5 sta te th a t b efo re severe ly m p h a tic o b s tru c tio n develops certain c o m p e n s a to ry m echanism s ta k e place w ith in th e ly m p h atic system itself. (i) In crease in v o lu m e-tim e ra tio o f c o lla te ra l lym ph vessels. In o th e r w o rd s, th e lym ph tr a n s p o rt c a p a ­ city o f th e n o n -o b s tru c te d vessels increases. (ii) T h e fo r m a tio n o f an a sto m o se s w ith n earb y lym ph vessels a p p ro x im a te ly th re e days afte r the lym ph sy stem is o v e rlo a d e d (ly m p h o -ly m p h a tic a n a s ­ tom oses). R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 118 Fisioterapie, November 1986, deel 42 no 4 (iii) T h e c re a tio n o f ly m p h o -v en o u s a n asto m o ses w ith a d ja c e n t vessels. (iv) T h e fo r m a tio n o f lo n g e r p re-ly m p h a tic channels. (v) E x tr a ly m p h -v a sc u la r p la s m a p ro te in m astering. M o n o cy tes m ig rate fro m the c ap illaries in to the ly m p h o ed em ato u s area. H ere the m onocytes change to b eco m e m a c ro p h a g e s w hich a tta c k th e a c c u m u ­ la tin g p ro te in s th e re b y d ecreasin g th e ly m p h atic load. T h e m a c ro p h a g e s release p ro te o ly tic enzym es w hich divide th e p ro te in s in to a m in o -acid s w hich are so lu b le and th u s ta k e n u p by th e b lo o d circ u la ­ tio n . T h is, h ow ever, o n ly p ro d u ces a m a rg in a l re d u c tio n o f the oedem a. W hen these c o m p e n s a to ry m echanism s fail m ore p ro ­ te in will ste a d ily co llect in th e tissue spaces, increasing th e co llo id o sm o tic pressu re. A p ro te in -ric h o e d e m a th u s fo rm s, w hich is described as th e first stage o f ly m p h o ed em a. T h re e stages o f th is c o n d itio n have been classified.3 Stage 1: reversible ly m p h atic o ed em a w hich is a soft, p ittin g oedem a. Stage 2: s p o n ta n e o u sly irreversible ly m p h atic oedem a: w h en th is stag e is re a c h e d , th e o e d e m a can no lo n g e r be in d e n te d , fib ro sis an d sclerosis have ta k e n place. T he c o n d itio n o f the tissue d e te ri­ o ra te s if left u n tre a te d . C h ro n ic in fectio n of th e a rm tissue c o m p o u n d s th is p ro b le m , th u s c re a tin g a vicious cycle lead in g to th e th ird stage. Stage 3: L y m p h o static E lephantiasis — swelling o f lim b in gross p ro p o rtio n s . A possible c o m p lic a tio n o f th is stage is ly m p h an g io sarco m a. It is o b v io u s th a t in the light o f tissue p h ysiology no sw elling is m eaningless an d e v ery th in g possible m u st be d o n e to tre a t even the m ildest degree o f oedem a. C O M P L E X D E C O N G E ST IV E P H Y S IO T H E R A P Y 3 T h e aim o f tre a tm e n t is to restore the b alan ce betw een ly m p h a tic p ro te in lo ad an d ly m p h v a sc u la r tr a n s p o rt capacity, i.e. to resto re the p ro te in c o n te n t o f in te rstitia l fluid to n o rm a l. T his g o al is achieved by helping the ly m p h a tic system to rem ove th e excess p la s m a p ro tein s fr o m th e tissues u sin g its ow n m echanics. T re a tm e n t consists o f fo u r c o m p o n en ts, all considered to be o f e q u a l im p o rta n c e . 1. Personal Hygiene S tr ic t m e a s u re s to lim it in f la m m a to ry p ro cesses cau sin g increased b lo o d c ap illary p erm eab ility are vital. I f c o n tra c te d , an y fu n g a l o r in fla m m a to ry c o n d itio n m u st be v ig o ro u sly c o m b a tte d by th e d o c to r co n cern ed . T h is p rev en ts o v e rlo a d in g o f th e a lre a d y d is ru p te d ly m p h atic system . 2. M anual lym ph drainage T h is c o n sists o f a gentle m assage tec h n iq u e w hereby ly m p h is rem oved fro m th e congested tissue. T h e b o d y has fo u r ly m p h a tic d ra in a g e q u a d ra n ts , tw o a x illa ry a n d tw o in th e g ro in . T h e fo u r tr u n k q u a d ra n ts 7 I. C e p h a l i c c h a n n e l w h e n p r e s e n t Z S U P R A C L A V IC U L A R NODE 3 V E N T R A L IN T E R A X IL L A R Y A N A S T O M O S E S t_ .T R A N S V E R S E LYM PH ATIC W ATERSHED 5 . A X IL L A R Y - IN G U IN A L ANASTO M O SES 6 .J N T E R IN G U IN A L ANASTOMOSES 7. S A G lT A L WATE.R5HED 8 . DORSAL INTER AXILLARY ANASTOMOSES Fio.2. S t K u b ik ■ Po s s ib l e w a y s of d r a i n a & e v i a s k i m T E R R ITO R IES ftFTE-ft L W P H A D E N E K T Q M ie are se p a ra te d by “ly m p h atic w a te r-sh e d s” (F ig u re 2). T h ere are som e o v e rb rid g in g ly m p h atics in th e u p p er q u a d r a n ts w hich d ra in ly m p h in to th e a x illary nodes on th e op p o site side. T h ere are also co n n ectio n s betw een th e lo w er q u a d r a n ts an d betw een the u p p e r an d low er q u a d ra n ts o n th e sam e side. In m o st p a tie n ts , p o s t­ m a s te c to m y ly m p h o e d e m a in clu d es th e a rm an d the u p p e r tr u n k a c c o rd in g to th e ly m p h a tic d ra in a g e q u a d ­ ra n t o n th e sam e side. T h e first step in m a n u a l d rain ag e is to stim u la te ly m p h o k in e tic activ ity in th e n o rm a l ly m p h atics o f the health y s u rro u n d in g q u a d ra n ts . T his p re p a re s th em to co p e w ith th e in creased lo ad . I t has been sh o w n th a t ly m p h ag io n s increase th eir o u tp u t if su b jected to m ildi m ech a n ical s tim u li.6 T h ese d ilated ly m p h atics will now s ta r t to d ra in th e congested q u a d r a n t acro ss the lym ­ p h a tic w atersh ed . T his m ay ta k e several tre a tm e n ts to establish. T h e seco n d step consists o f gently p u sh in g o ed em a flu id fro m the ly m p h o sta tic side acro ss th e w atersh ed to th e d ila te d h e a lth y ch an n els o n th e n o rm a l side. T he u p p e r a rm can be e m p tied once the congested p ro x im a l p a rt o f the u p p e r q u a d ra n t is free o f oedem a. T re a tm e n t o f the fo re a rm com es la te r an d e v e n tu a lly includes the han d . 3. Bandaging F ro m th e s ta r t o f tre a tm e n t b an d ag es are ap p lied to th e ly m p h o e d e m a to u s lim b im m ed iately afte r m assage. O ne o f th e first p a th o lo g ic a l con seq u en ces o f ly m p h ­ o e d e m a is th e d e stru c tio n o f elastic fibres. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) physiotherapy, November 1986, vol 42 no 4 119 T he red u ctio n o f skin connective tissue elasticity co m ­ p o u n d s the d ro p in tissue p ressu re b ro u g h t a b o u t by the fluid red u c in g m assage. C o n se q u e n tly , the o ed em a fluid w ould sim p ly re-a c c u m u la te unless su p p lem en ted by b a n d a g in g . B an d ag es also assist ly m p h flow by increasing tissue pressure. 4. Exercises E xercises e n a b le th e m uscle and jo i n t p u m p s to e x ert their lym pho-kinetic effect. T h ere are im p o rta n t c rite ria 5 to c o n sid e r w h en w o rk in g o u t a re m e d ia l exercise p ro g ram m e . T he b an d ag es m u st be w o rn d u rin g e x e r­ cise. T h e exercises them selves m u st n o t be v igorous, cause excessive m uscle fatig u e o r d em an d to o m u ch energy. T h ese fa c to rs w ill increase th e level o f w aste p ro d u c ts a n d th e re fo re th e ly m p h a tic lo ad . H y d ro ­ th e ra p y is id eal b ecau se th e h y d ro s ta tic p ressu re assists the tissue p ressure. H ow ever, th e w ater te m p e ra tu re m u st be c a re fu lly m o n ito re d to avoid v a so d ila tio n . E xercises m u st be c o m fo rta b le an d pain free an d should n o t include su d d e n o r rip p in g m o v em en ts th a t could dam age fragile, recovering tissue. A t th e end o f th e tre a tm e n t, w hen sw elling is elim i­ n a te d , an elastic s u p p o r t m u st be p rescrib ed an d m ade to m e a su re . It m u s t be as s tro n g as can be to le ra te d by th e p atien t. I t is o f in te re st to n o te th a t F o ld i an d his w o rk e rs 3 do n o t ad v o cate the use o f diuretics. T his m eth o d leaves th e s ta g n a tin g p la s m a p ro te in s in the tissue and will accelerate tissue h ard en in g . T hey also have reserv a­ tions a b o u t using p n eu m atic p u m p devices via inflatable cuffs (J o b s t, L y m p h ap re ss etc). T h eir reaso n in g is based on the fa c t th a t it has been sh o w n th a t th e volum e re d u c tio n is b ro u g h t a b o u t by th e re - a b s o rp tio n o f w ater only. T h is m ean s th a t the c o n c e n tra tio n o f sta g ­ n a tin g p ro te in s in th e in te rstitiu m increases. O nce again th is accelerates th e fib ro -s c le ro tic h a rd e n in g o f the tissues. O nly a p p ro x im a te ly 20 per cen t o f th e ir p atien ts have p n e u m a tic devices in te g ra te d in to th e ir co m p lex decongestive tre a tm e n t. T h is is d o n e in o rd e r to replace som e o f th e m a s s e u r’s w o rk . T h ey also fo u n d th a t d ru g -in d u ced stim u la tio n o f e x tra -ly m p h -v a s c u la r p r o ­ tein m a s te rin g (tissue p ro teo ly sis) is effective, b u t m u ch slow er th a n p h y sio th e ra p y .3 P A T IE N T E D U C A T IO N A clear u n d e rs ta n d in g by th e p a tie n t o f w h at is expected o f her is critical to the success o f this ap p ro ach . T h e overall c o n c e p t is to avo id excessive use o f the arm , co n strictiv e c lo th in g , local o r generalised h eatin g and tra u m a . H o u se h o ld ad v ice5 sh o u ld include ta k in g e x tr a care w ith s h a r p k itch en uten sils o r sew ing pins to avoid p iercin g th e sk in . S h e sh o u ld av o id w ash in g dishes in w a te r th a t is to o h o t o r use gloves, an d sh o u ld alw ays use p o th o ld e rs to ta k e dishes fro m th e oven o r stove. It is b e tte r to av o id w ash in g w indow s o r c a rry in g heavy parcels o r bags w ith th e affected arm . E x tra care is necessary w h en ir o n in g to avoid b u rn s a n d fo r this re a s o n c ig arettes are best held by th e u n affected hand. A tig h t w rist w a tc h sh o u ld n o t be w o rn on th e affected a rm an d all h o u se w o rk sh o u ld be d o n e w hilst w earing th e prescribed glove stocking. T h e p a tie n t’s b ra stra p s sh o u ld never c u t in to her sh o u ld e rs n o r sh o u ld the b ra itself be to o tig h t a ro u n d th e th o r a x . A lightw eight p ro th e sis also assists w ith this fa c to r. D ress sleeves sh o u ld be k e p t loose. S k in care in c o rp o ra te s careful m a n ic u re s to avoid p u n c tu rin g the sk in ; ca re fu l selectio n o f co sm etics th a t are n o t too h a rs h fo r th e skin; n o su n ta n n in g o r sau n as an d no “ k n e a d in g ” m assage to the arm . O th e r p recau tio n s include: suitable protective clothing w hile g a rd e n in g , a v o id in g scratch es an d bites fro m p ets, n o t lettin g th e affected a rea be exposed to the h e a t o f a h a ir d ry e r and preventive m easures ag ain st in sect bites. S p o rt sh o u ld be o f such a n a tu re as to av o id o v e r-e x e rtio n o r p o te n tia l injuries. G entle c o n ­ tro lled sw im m ing is best. M edical c are sh o u ld include: never using th e B.P. c u ff o n th e affected side o r giving in tra v e n o u s or in tra m u sc u la r injections on th a t side; never tak in g blood fro m th a t a rm or give a c u p u n c tu re to it. G o o d w eig h t c o n tro l w ith s a lt re s tric tio n , daily e x e r­ cises in th e p rescrib ed sleeves an d elev a tio n o f th e lim b a t rest, all a ssist in m a in ta in in g th e effect o f the tr e a t­ m ent. E x ten siv e p a tie n t e d u c a tio n , as a p ro p h y la c tic m ea­ su re, sh o u ld be given to all p o st m a s te c to m y /p o s t ra d ia tio n p atien ts. E m p h asis sho u ld be placed on the need to c o n s u lt a d o c to r fo r an y in fectio n o r visible c h a n g e in th e affected a rm . E a rly tr e a tm e n t o f sw elling will prevent a ch ro n ic co n d itio n fro m form ing. H ow ever, c h ro n ic c o n d itio n s also resp o n d well to tre a tm e n t, even in Stage 3. C O N C L U SIO N By m a x im u m u tilisatio n o f h ealth y an d new ly form ed ly m p h atics, ly m p h o ed em a c a n be tre a te d successfully. C o m p le x decongestive p h y sio th e ra p y no rm alises in te r­ s titia l p ro te in lo ad s by in creasin g the tr a n s p o rt cap acity o f th e ly m p h v a sc u la r system . T his volum e red u ctio n c a n be c o n serv ed by g ood p a tie n t c o m p lia n c e , th a t is by s tric t hygiene c o n tro l, w earin g o f elastic sleeves and co m p reh en siv e b an d a g in g d u rin g bed rest. T h e im p o rta n c e o f th e ly m p h a tic system in tre a tin g tissu e c o n g e stio n has, in th e a u th o r s ’ view been a neglected a re a in p h y sio th erap y . F o o tn o te V ideo re c o rd in g s on th e su b ject are available in E nglish fro m B eiersdorf A G , H a m b u rg , G erm any. T hese are: 1. ‘L y m p h o e d e m a ’, o rd e r n u m b e r LY101, 25 m inutes, V .H .S . o r B eta-U -m atic. 2. ‘C o m p l e x D e c o n g e s t i v e P h y s i o t h e r a p y f o r L y m p h o e d e m a ’, o rd e r n u m b e r LY102, 20 m in u tes, V .H .S . o r B eta-U -m atic. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) References 120 F isioterapie, N ovem ber 1986, d e e l 42 no 4 BO O K REVIEW S 1. B ritton RC, N elson PA . Causes and treatm ent of p ost­ m astectom y lym ph-oedem a of the arm: R eport of 114 cases. J A M A 1962; 180: 95-102. 2. De Vita J J n r , H eilm an S a nd R osenberg SA. Breast C ancer. In: Principles a n d Practice o f Oncology. Philadel­ phia: L ippincott, 1982: 1741-1742. 3. Foldi E, Foldi M and W eissledger H. C onservative tre a t­ m ent of lym phoedem a of the limbs. A ngiology. J n l o f Vascular Diseases M arch 1985; 171-180. 4. G uyton AC. T he lym phatic system. In: H um an Physiology a n d M echanics o f Disease. Philadelphia: W.B. Saunders C om pany, 1982: 237-241. 5. Foldi M and Foldi E. ‘Das L y m p h o d e m ’ Ein Leitfaden f u r Palienten. New York: G ustav Fisher V erlad-Stuttgart, 1983: 31-125. 6. M islin H. The lym phagion. In: L ym phangiology, Ed by Foldi M , C asley-Sm ith J R , S c h a tta u er FK . New York, S tuttgart: 1983: 165. Research Guidelines: A H and book for Therapists by C ecily J . P a rtrid g e and R o se m a ry E. B a rn itt L o n d o n : W illiam H e in e m a n n M edical B ooks, 1986 T h is review er has been w aitin g a lo n g tim e fo r a boo k like this. R e se a rc h G u id elin es is w ritte n by a p h y sio ­ th e r a p is t a n d an o c c u p a tio n a l th e ra p is t fo r th e ra p ists w ho w ish to b eco m e involved in research , b u t d o n o t kn o w how to begin. In a clea r, logical fas h io n the w hole process o f o rg a n isin g a research p ro je c t is set ou t. T h e first c h a p te r describ es th e co m p lete research pro cess, w hile th e c h a p te rs fo llo w in g e la b o ra te on the in d iv id u a l a re a s viz. d ev elo p in g ideas, lite ra tu re search , research d esign, o rg a n is a tio n o f th e p ro je c t, ethics, m e th o d s o f d a ta co llectio n , etc. T h ro u g h o u t th e b o o k e x a m p le s o f research p ro je c ts in p h y s io th e ra p y a n d I o c c u p a tio n a l th e ra p y are used to illu strate th e v ario u s facets o f th e process. T h e fin al c h a p te rs d escrib e how to w rite the research re p o rt an d how to ev alu a te p u b ­ lished rep o rts. S o m e o f th e c h a p te rs in clu d e sh o rt reference lists. T h e re is an ex c e lle n t g lo s sa ry o f th e m o s t co m m o n term s used in research p ro je c ts. A very useful bib lio ­ g ra p h y is also included. R e se a rc h G u id elin es is a sm all b o o k w ith a g re a t deal o f p e rtin e n t in fo rm a tio n . It reads very easily. It is e n lig h te n in g w ith o u t b ein g co n d escen d in g . T h is b o o k sh o u ld be fo u n d o n th e lib ra ry shelves o f all p h y sio ­ th e ra p y schools as well as on the shelves o f any th erap ist rem o tely in terested in “ re s e a rc h ”. L. D avids Better Breathing by Z. H en ry k H reh o ro w W inslow : W inslow Press, 1984 T h is s h o rt b o o k is w ritte n p rim a rily fo r th e p a tie n t who ex p e rie n c e s b re a th in g d ifficulties as a resu lt o f chronic airw ay o b s tru c tio n . T h e first e d itio n w as pub lish ed in 1968. T h e new e d itio n has been co n sid erab ly revised. T h e te x t h as b een very clearly set o u t w ith excellent p h o to g r a p h s an d d ia g ra m s. T h e lan g u ag e is sim ple and will be easily u n d e rs to o d by th e lay m an . T h e m ain c o n c e n tra tio n is on d ia p h ra g m a tic b re a th in g . T h e c h ap ­ te rs c o v e r — how an d w hy we b re a th e , how to p ractice d ia p h r a g m a t ic b r e a th in g , r e l a x a ti o n , p o s tu re , o v e r­ c o m in g b re a th le s sn e ss, c o u g h an d e x p e c to ra tio n and exercises. It w ould be useful to keep a co p y o f th is b o o k in the p h y s io th e ra p y d e p a rtm e n t fo r p e ru s a l by th e chronic chest p a tie n t. M . F a rq u h a rso n F o r O rth o p a e d ic A p p lia n c e s , S u rg ic a l corsets, C e rv ic a l c o lla rs , C h ild re n 's s h o e s