Manual lymphatic drainage and medically-correct compression, monitoring and useful tools as adjuncts to primary treatment.
What is CDT?
Combined Decongestive Therapy is a highly skilled and essential tool for lymphoedema care. CDT comprises of both Manual Lymphatic Drainge (MLD) and medically-correct compression (multi-layer lymphoedema bandaging or MLLB) with an additional focus on carefully monitoring the results, along with multiple “add on” skills such as kinesiotaping.
Unfortunately over the years it has become apparent that MLD is not particularly helpful for sufferers of CPL. The trouble being the severity of the disease’s effect on the lymphatic retraction of the legs. In many cases, as soon as the MLD sessions are complete, the legs simply refill. In advanced cases even compression can’t help unless the horse lives in it, in which case their quality of life is seriously compromised.
Equine CDT (and indeed MLD in it’s own right) requires practitioners to have qualified first in human lymphoedema care. Technically, it is not possible to teach someone MLD via video or similar on a short (“intensive”) course – it needs to be done in the flesh, so to speak. This is because qualified MLD practitioners undergo assessment to ensure they are applying the proper levels of pressure, something that is not possible to do without physical instruction. It is much more than just massaging the legs (something that is strictly contraindicated) and requires the knowledge to monitor the quality of the skin and tissue and level of oedema.
The Press and Stretch Test for Diagnosing and Monitoring CPL.
CPL is surprisingly easy to diagnose once you know what to look for. For veterinary and therapeutic professionals with an interest in equine lymphatics, this is very useful. Always monitor your clients the proper way, checking tissue quality as well as limb circumference as described below…
Affolter and Powell study into CDT for CPL treatment.
Verena K. Affolter who has researched and written extensively on the subject of CPL in draft horses teamed up with Heather Powell (formerly Equine MLD in Worcestershire, UK) to look into the use of CDT when treating CPL horses. Please see the summary below, followed by the PDF link to the whole study. As you will see, the use of CDT is often complicated by the horse’s level of pain tolerance and additional problems like secondary infections.
“This pilot study documents evidence that CDT assists management of CPL. Current CPL management is limited to palliative treatments of secondary infections. Whilst not a permanent treatment, CDT offers a promising tool to manage horses with CPL, improving their quality of life and potential usefulness. More extensive and prolonged studies with a larger number of horses are warranted to evaluate the full potential of CDT.”V. K. Affolter, H. Powell; Combined decongestive therapy including equine manual lymph drainage to assist management of chronic progressive lymphoedema in draught horses.
Medically correct compression
There is an endemic misunderstanding of the term “medically correct compression” in the equine therapies and services industry. The most common issue is the assumption that garments for circulation and lymphatic support are suitable for horses with chronic lymphoedema. The second problem is not realising the importance of including the hoof in the bandaging process. Lets look at what is required, then we can see what is unsuitable about the majority of compression garments on the market.
This is medically correct compression on a CPL cob. Using short stretch bandages (absolutely no more than 10% stretch = 10cm per meter) and specific materials to pad out the indurations of the leg to make a cylinder. This shape allows for safe pressure and reduces the risk of bandages creeping into skin folds.
The bandaging must cover the top 50% of the hoof and tuck under the heel bulbs. Garments that stop at the pastern can cause the lymph to pool below or prevent it from draining upwards from the hoof.
There must always be a gradient of pressure from tightest over the hoof to looser towards the top. There should be a 50% bandage overlap which sometimes means two bandages need to be sewn together if the legs are fairly large in size due to the advanced stage of the CPL.
You can now apply for the Approved Stable Bandage Method remote learning course which is held on the first Tuesday of every month with your vet’s consent, by emailing email@example.com (put “ASBM Course” as the email subject).
How to check whether a garment provides medically correct compression for the treatment of lymphoedema and CPL.
- Is it non-elastic (ie no more than 10% stretch, or 1m10cms on a 1 meter roll)?
- Is it graduated pressure? (ie slightly more pressure distally and lessening up the leg)
- Does it start on the hoof and end at a point above the pitting oedema?
- Does it creep, or move down the leg/into the CPL folds, creating pressure bands? If so, its no good.
- Are there any baggy bits, or bits that don’t connect to the limb? If so, no good
- Can it be over tensioned? It takes very little pressure to over-compress the leg so compare it to a human sock – if it’s tight enough to leave indentations at the top, it’s too tight.
- Does the pressure given correspond to the degree of tissue induration? So, very mild and soft oedema will need less pressure.
- If the tissue quality improves, is the garment able to be adapted to give less pressure?
It is important to realise that lymphoedema is a dynamic disease, therefore will always be changing. There is no “pop it in this compression garment for life” type situation. The affected limbs need constant monitoring and adapting.
Hivamat Deep Oscillation® Therapy
Bodo Wisst, Physiotherapist in Peru was the first to utilise DEEP OSCILLATION in equine with effective results. Rebecka Blenntoft writes:
“The Deep Oscillation machine creates an electrostatic field which “pulls” the tissue layers by attracting and releasing them within the selected frequency ranges between 5Hz and 250Hz. This “shuffling” effect speeds up the healing processes with regard to wounds or injuries, but also reduces oedema and softens protein fibrosis. It is very well tolerated by horses, who often will visibly relax during treatment, and what is especially helpful is that owners can feel the difference themselves within one treatment session”.
See here for the full article published on PhysioPod.