Complex Physical (Lymphatic / Lymphedema) Therapy (C.P.T. / C.L.T.) This is called Complex Physical Therapy (C.P.T.) because a number of physical therapeutic approaches are combined to produce the results. (It is also called 'Complex Lymphatic (or) Lymphedema Therapy' - C.L.T. - or 'Complex Decongestive Physical Therapy' - C.D.P.T.) It achieves the fastest reduction of lymphoedema; even better results are obtained if C.P.T. is used in conjunction with dietary change and other vitamins where dietary intake is insufficient and it become possible to stimulate beneficial effect. A full course of this treatment normally lasts from 2 to 6 weeks, depending on the severity of the condition and the number of limbs involved. C.P.T. consists of four main parts:  skin care to prevent any infection adding to the lymphatic load and to improve the skin condition; a special form of massage each day, which removes the excess fluid and protein and opens collateral lymphatics so that unaffected regions can drain the affected one in the future;  compression bandages applied during the course, followed by compression garments after it, to stop the reduced limb from rapidly resuming its former size;  special exercises to supplement the massage The special lymphatic massage first empties the lymphatics of the trunk (even of quite distant regions) and the normal areas adjacent to the lymphoedematous one are further cleared. Then the limb is massaged. This is always in the direction of lymph flow, i.e. towards the body. It starts on the part of the limb adjacent to the trunk. Gradually more and more of the limb is involved, until the hand or foot is reached. Reduction will only continue to improve after treatment if the drainage from the blocked area to the normal adjacent areas has been improved by enlarging the size and number of the lymphatics which join one drainage area to the next (the collateral lymphatics). C.P.T. gives by far the most rapid reductions. The first 618 limbs treated in Australia using the C.P.T method advocated by the Casley-Smiths had average reductions of 50 percent of the oedema, with three-quarters of the patients achieving reductions of better than 20 percent. Of course, these are only the average results. Extremes range from 25 to 110 percent reduction. The average results can only give an indication of the results one can expect; everyone is different! With a longer-term lymphoedema, when the reduction does return the limb to 'normal', sometimes it is less than normal - because of muscle wastage. A year later, the reductions still averaged 45 percent. More information about these results is published in the book Modern Treatment for Lymphoedema ISBN (fifth edition) ISBN 0 646 31664 8 Maintaining these reductions depends on the patient being willing to wear gradient compression garments at all times, looking after their limb and treating any infection promptly, and persevering with their exercises. (The specially-designed exercises make a great difference both during the C.P.T. and after it.) Oral and topical molecules of the benzo-pyrone family may help greatly with maintaining the reductions. With these precautions, after a year in many cases a limb may stay at the reduced size, or even somewhat smaller, and have softened further. Now another course of the therapy, which can commence six months to a year after the first, can result in a further removal of about half of what swelling remains. The cost of a course of treatment varies from one therapist to another, and also depends on the time necessary for treatment, the number of bandages required and the type of garment necessary afterwards. Some hospitals are now providing lymphoedema bandaging services.  With all bandaging applications it is important that a space is cleared for fluid to drain into prior to evacuation of fluid from a lymphoedematous area. Lymphatic drainage massage and /or combination laser therapy may be used to effect this clearance. Without this prerequisite being met there is a possibility of overloading an adjacent area to swelling and lymphatic overload in a previously unaffected part of the body. To achieve good results, C.P.T. consists of two to four weeks of treatment (longer in severe cases), of at least one hour per limb per day. Is should be given at least 5 days per week for best results. With a full course of C.P.T., correctly done, most of the reduction will usually occur in the first 7-10 days. The rest of the (usually) four weeks is spent maintaining this, opening-up collateral lymphatic drainage, increasing pumping by the deep drainage pathways, breaking down excess fibrotic tissue and sometimes performing special work on skin conditions. When choosing a therapist it is important they understand the principles of C.P.T and its practical application. Every therapist must have a staring point and where the principles of complex physical lymphatic therapy are applied I have seen cases where an elderly gentleman with no prior experience and a next door neighbor of a patient without  the financial means for professional therapy, who after minimal instruction was able to achieve a 45% reduction of oedema over a four week period. in this case the patient performed self massage as the clearance technique to clear room for fluid form the affected limb prior to the bandaging. As you can see from this scenario, treatment options are relative to levels of understanding and application, not necessarily from the length of time someone has been trained. From this scenario it  can be seen, it is understanding and application of C.P.T that can provide good results, not just the length of time someone has trained. Prior to concluding a condition is lymphoedema it is best if all other possible causative reasons for chronic oedema have been investigated and dealt with. It is strongly suggested that your own doctor ensures that your limb is free of any infection before you go for treatment, since it places much more of a load on your lymphatic system and interferes with treatment. (However chronic ulcers and fungal infections can be treated satisfactorily during C.P.T.) It is also strongly believed that your diet should include foods high in vitamins of the benzo-pyrone family  while waiting for an appointment for the C.P.T.; these will improve the results considerably where dietary intake strengthens blood and lymphatic structure - continuing in this manner has potential for easier maintenance of reductions afterwards. The treatment also reduces chronic venous insufficiency (which has a component of lymphoedema), including intractable ulcers caused by this disease. After C.P.T. you MUST wear a good compression sleeve or stocking, look after it properly, and change it when necessary. It is a waste of time and money to have this course of treatment but to let all the oedema come back just because you do not wear the compression garment properly! You must also continue with the exercises and eat foods that will assist control rather than be detrimental. If you can bandage your limb as it was done during treatment, you will probably find this more comfortable to sleep with than a garment. You may wish to come back in six months to a year and repeat the course, and possibly do the same after another year. These return visits are because after this time the body has remodeled itself and it is possible to reduce the oedema still more. Some patients benefit from more frequent but possibly shorter courses. The sooner lymphoedema is treated, the better. A recent, soft one can often be reduced to almost normal size, but good reductions occur even with very long-standing ones. Elderly patients often have very good reductions and cope well with the firm bandaging.

Explaining the causes of lymphoedema