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Casley-Smith International is a worldwide organisation for Certified Casley-Smith Instructors in the field of Lymphology and Oncology. Casley-Smith International is a non-for-profit organisation. Certified Casley-Smith instructors teach the Modern Treatment for Lymphoedema, based on the work of Dr John R. Casley-Smith and Dr Judith R. Casley-Smith.

You can read more on the Casley-Smith method here.

Casley-Smith International is a worldwide organisation of Certified Casley-Smith Instructors.

Where is Casley-Smith International based?

Founding members of Casley-Smith International (CS-I) are based in Australia (C-S Aus), Israel (C-S Israel), the Netherlands (C-S NL), the United Kingdom (C-S UK) and the United States of America (C-S USA). It is anticipated that CS-I will expand over time to incorporate other countries around the world.

Casley-Smith International has representatives across the globe who meet regularly at lymphology conferences and via Zoom.

All Casley-Smith Instructors, therapists and students are involved and encouraged to participate in publishing peer-reviewed articles, reviewing and contributing to books, poster presentations, webinars and Casley-Smith ambassadorship.

Who was Dr John Casley-Smith?

 

Dr John and Dr Judith Casley-Smith

Dr John and Dr Judith Casley-Smith (left). Dr John Casley-Smith (right) working on the electron microscope.

Dr John Casley-Smith was one of the most eminent lymphologists in Australia. He lived at his internationally known Electron Microscope Unit, which was based at the University of Adelaide.

From the late 1960s through to the 1990s he was an active member of the national (Australian) and international lymphology community, a founding member of the International Society of Lymphology (ISL) and was involved in the establishment of basic care and treatment programmes for patients, which were practicable and possible in the South East Asian and Indian regions.

Dr John and Judith Casley-Smith working overseas.

Dr John Casley-Smith published several papers on the lymphatics in peer-reviewed journals. While John (together with his wife Judy) wrote over 400 papers in a range of journals, the ones in Professor Piller’s opinion that made the most difference were, ‘How the lymphatic system works’ in the Journal of Lymphology published in 1968 and a later one in the New England Journal of Medicine, of which he was extremely proud entitled, ‘Treatment of lymphoedema of the arms and legs with benzopyrones’ in 1993. This was perhaps the first time that lymphoedema and its treatment had been acknowledged in such a high level journal.

Another example is this review which starts with a brief description of the pioneering work done by J.R. Casley-Smith when he looked at the pathophysiological changes that occur, and transport from the blood vessels, through the interstitium to the lymphatics and lymphatic uptake, with the electron microscope.

Dr John Casley-Smith sadly passed away in 1997.

You can read this paper written by Professor Neil Piller: Article by Professor Neil Piller on the Lymphoedema Association of Australia in the Journal of Lymphoedema in 2014.
The tribute at the end of this paper reads, “This article is dedicated to Dr John Casley-Smith, one of the founders of modern lymphology, a true gentleman, friend and mentor, without whom many of us would never have embarked on a path of discovery in the world of lymphatics and lymphoedema to learn how we can make a difference.”

A eulogy of Dr John Casley-Smith was published in the Journal of Lymphology (Clodius, L. & O’Morchoe, C., (1997) “IN MEMORIAM: JOHN R. CASLEY-SMITH”, Lymphology 30(4), p.204-207.)

In Memoriam: Dr John Casley-Smith published in the Lymphology in 1997

Who was Dr Judith Casley-Smith?

Dr Judith Casley Smith was able to work with her husband to integrate the theory of the anatomy and physiology of the lymphatics into treatments for patients suffering from lymphoedema.

Dr Judith Casley-Smith sadly passed away in 2022.

In a tribute to Judith Casley-Smith, words from the 2022 President of Casley-Smith International (Physiotherapist Jillian Bracha from Israel) follow, “Judith and her husband Dr. John Casley-Smith dedicated their lives to lymphedema treatment and research and their life’s work has had a major impact on the lives of patients, doctors, therapists and teachers all over the world. Working in a country with vast distances and scarce treatment resources, Judith was the forerunner in the concept of patient centered treatment including tools for self-treatment.

Her concept was based on rehabilitation with strong emphasis on providing technique for self-bandaging, self-massage and special exercise for lymphedema, thus enabling and encouraging patient engagement, empowerment and improved quality of life. Judith provided therapists with an essential assessment tool consisting of circumference measurement and volume calculation to discern lymphedema stage, severity and treatment progress. This tool has become invaluable for patient education, clinical decision making and as support for treatment coverage by insurance providers. Judith trained therapists in Australia, the UK, USA, Canada, Holland and Israel some of whom she later trained as Casley-Smith Instructors. Sadly, Judith had to retire in 2003 due to health reasons but the foundation was laid and today there are 18 teachers, 4 trainee teachers, hundreds of therapists and an international organization called the Casley-Smith International offering lymphedema treatment and information based on the Casley-Smith Method of Lymphedema Treatment.” You can read Jill’s tribute here: Tribute to Dr Judith Casley-Smith by Jill Bracha

A tribute to Judith Casley Smith was published in the July 2022 Australasian Lymphology Association newsletter. You can read the article: Vale_Judith Casley-Smith

Vale article that acknowledged Dr Judith Casley-Smith

It is with hope and pride that the work of Casley-Smith International continues.  May the lives of those living with lymphoedema continue to to benefit from the work of Dr John and Dr Judith Casley-Smith.

Has Casley-Smith International published any research?

Yes, Casley-Smith International is a global team of Certified Casley-Smith Instructors whom strive to continually update teachings. The group has many publications. This ensures that training materials are in line with the latest in evidence-based practice.

Several Certified Casley-Smith instructors work or are studying at renowned Universities. In Australia, or example, Andrea Mangion is completing her PhD with Flinders University.

Examples of two original publications which started global research into the Casley-Smith method are below:

Casley-Smith JR, Casley-Smith JR. Complex physical therapy; the first 200 Australian limbs. Australian Journal of Dermatology. 1992;33:61-8.

Casley‐Smith JR, Boris M, Weindorf S, Lasinski B. Treatment for lymphedema of the arm‐The Casley‐Smith method: A noninvasive method produces continued reduction. Cancer: Interdisciplinary International Journal of the American Cancer Society. 1998 Dec 15;83(S12B):2843-60.

Recent publications from Casley-Smith International in order of most recent to least recent are below:

Borman P, Noble-Jones R, Thomas MJ, Bragg T, Gordon K. (2021) Conservative and integrated management of genital lymphoedema: case reports for men. In: Genital Oedema. Journal of Wound Care (special edition Nov. 2021) pp.5-16

Noble-Jones, R., Thomas, MJ., Quéré, I., Morgan, K., Moffatt, C. (2021) An international investigation of the education needs of health professionals conservatively managing genital lymphoedema: survey findings. In: Genital Oedema.  Journal of Wound Care (special edition Nov. 2021) pp17-26

Noble-Jones, R., Thomas, MJ., DiCecco, S., Gabe-Walters, M., Moffatt, C. (2021) Contextual factors affecting the education needs of lymphoedema health professionals regarding genital oedema. In: Genital Oedema. Journal of Wound Care (special edition Nov.2021) pp27-37

Jacob T, Bracha J, Peleg R. Epstein A, Yosha I. Risk Reduction Recommendations for Upper Quadrant Side Effects After Breast Cancer Surgery and Treatments: A Delphi Survey to Evaluate Consensus Among Expert Physical Therapists and Alignment With Current Evidence. Reh Oncol (2021), 39, 4, pp. E106-E118(13) https://doi.org/10.1097/01.REO.0000000000000274

Deutscher D,  Hayes D, , Cook K F, Werneke M W,  Tucker C A, PT, Mioduski J E, Levenhagen K, PT, Tidhar D, Pfarr M, Kallen M A. Upper Quadrant Edema Patient-Reported Outcome Measure Was Reliable, Valid, and Efficient for Patients with Lymphatic and Venous Disorders. Physical Therapy (2021), pzab219, https://doi.org/10.1093/ptj/pzab219 27 September

Gabe-Walters, M. and Thomas M. Development of the Lymphoedema Patient Reported Outcome Measure (LYMPROM). British Journal of Nursing (2021) 30.10: 592-598.‏

Thomas, M. Breast cancer-related upper limb lymphoedema: an overview. British Journal of Community Nursing(2021)  26.Sup4: S30-S35.‏

Gabe-Walters, M, Thomas M, and Noble-Jones, R. Lymphoedema care in the mobile unit: a service evaluation of patient experience and attendance rates. British Journal of Healthcare Management (2021) 27.6: 1-8.‏ https://doi.org/10.12968/bjhc.2020.0167

Noble‐Jones, R, and Thomas MJ. Recognizing genital lymphoedema after penile cancer. International Journal of Urological Nursing (2021) http://doi.org/10.1111/ijun.12272

Noble-Jones R., Thomas, M.J., Lawrence, P., Pike, C. (2021) Guidelines for managing people with lymphoedema remotely: a post-Covid-19 response document. BJN. Vol 30, No 4 pp218-225. https://doi.org/10.12968/bjon.2021.30.4.218

Gabe-Walters, M., and Noble-Jones, R. Challenges and opportunities identified for lymphoedema services in Wales during the COVID-19 pandemic. British Journal of Nursing (2021) 30.4: 210-217.‏ https://doi.org/10.12968/bjon.2021.30.4.210

Noble-Jones, R., Thomas M J., and Gabe-Walters M. The education needs of health professionals conservatively managing genital oedema: UK survey findings. British Journal of Nursing (2021) 30.9: S18-S26 https://pubmed.ncbi.nlm.nih.gov/33983806/

Van der Gucht E, Dams L, Meeus M, Devoogdt N, Beintema A, Penen F, Hoelen W, De Vrieze T, De Groef A. Kinesiophobia contributes to pain-related disability in breast cancer survivors: a cross-sectional study. Support Care Cancer. 2020 Sep;28(9):4501-4508. doi: 10.1007/s00520-020-05304-4. Epub 2020 Jan 17. PMID: 31953624.

Armer, Jane M., et al. “ONS Guidelines™ for Cancer Treatment-Related Lymphedema.” Oncology nursing forum. (2020) 47.5‏

Tidhar D, Deutscher D, Armer JM. Lymphoedema, a significant health problem in Israel: A descriptive community-based study. Int Wound J. 2020 Nov 25. doi: 10.1111/iwj.13523. Epub ahead of print. PMID: 33236836.

Thomas M, Coveney E, Pike C, Morgan K, Noble-Jones R. Exploring the impact of lymphoedema on individuals and if lymphatic venous anastomosis surgery effects perceptions on quality of life: A qualitative study. Eur J Oncol Nurs. 2020 Feb;44:101720. https://doi.org/10.1016/j.ejon.2019.101720

Hague, A., Bragg, T., Thomas, M., Pike, C., Morgan, K., & Ghattaura, A.. Severe lower limb lymphoedema successfully treated with a two-stage debulking procedure: a case report. Case Reports in Plastic Surgery and Hand Surgery (2020) 7(1), 38-42.‏

Jacob T, Silman-Cohen H, Bracha J, Peleg R. Importance of standardized and on-line instructions for women after breast cancer surgery was emphasized by the lockdown during the Covid-19 crisis- A clinical letter. Int J Physiother (2020) 7(5)

Klein I, Tidhar D,  Kalichman L. Lymphatic treatments after orthopedic surgery or injury: A systematic review. Journal of Bodywork and Movement Therapies  (2020)  24, 4, 109-117  ISSN 1360-8592, https://doi.org/10.1016/j.jbmt.2020.06.034

Herbst, Karen L., Karen L. Herbst, Linda Anne Kahn, Emily Iker, Rachelle Crescenzi, Chuck Ehrlich, Tami Faris, Thomas Wright, Lindy McHutchison, Jaime Schwartz, Erik Lontok, Michael S. Schwartz, Molly Sleigh, Steven M. Dean, John R. Bartholomew, Polly Armour, Margarita Correa-Perez, Kathleen H. Lisson, Ingrid A. Harten, Nicholas Pennings, Ethan Larson, Andrea Brennan, Joachim Zuther. Letter to the Editor regarding Lipoedema–myths and facts, Part 1 and Part 5. European Best Practice of Lipoedema–Summary of the European Lipoedema Forum consensus. Phlebologie (2020) 49: 31–49. Phlebologie 50.01 (2021): e5-e6.

Hague, A., Bragg, T., Thomas, M., Pike, C., Morgan, K., & Ghattaura, A. Severe lower limb lymphoedema successfully treated with a two-stage debulking procedure: a case report. Case Reports in Plastic Surgery and Hand Surgery (2020)  7(1), 38-42.‏

Noble‐Jones, R., Thomas, M. J., and Bose, P. “The Lymphoedema Genitourinary Cancer Questionnaire in urology follow‐up clinics.” International Journal of Urological Nursing (2019) 13.1: 5-12.‏

Jacob T, Bracha J. Lymphedema treatment certified physical therapists’ awareness of and practice patterns for side effect risk reduction after breast cancer treatments. Int J Physiother. (2019) 6(5):224-230.

Tamar Jacob, Jillian Bracha, Identification of Signs and Symptoms of Axillary Web Syndrome and Breast Seroma During a Course of Physical Therapy 7 Months After Lumpectomy: A Case Report, Physical Therapy (2019) 99, 2 : 229–239, https://doi.org/10.1093/ptj/pzy110

Tidhar D, Deutscher D, Horn S, Armer J. Treatment Documentation in Practice-Based Evidence Research for Patients Receiving Physical Therapy Because of Lymphedema. Archives of Physical Medicine and Rehabilitation (2019) 100, 8 :1467-1474 ISSN 0003-9993, https://doi.org/10.1016/j.apmr

Nijs J, Wijma AJ, Leysen L, Pas R, Willaert W, Hoelen W, Ickmans K, Wilgen CPV, Explaining pain following cancer: a practical guide for clinicians. Braz J Phys Ther. (2019),  23-5 Sept-Oct: 367-377.

Karakashian, K, Pike C., and van Loon, R. “Computational investigation of the Laplace law in compression therapy.” Journal of biomechanics  (2019) 85: 6-17.‏

Morgan, K, and Thomas M. “The development of a ‘wet leg’ pathway for chronic oedema.” International journal of palliative nursing (2018) 24.1: 40-46.‏

Karakashian, K., Shaban, L., Pike, C., & van Loon, R. Investigation of shape with patients suffering from unilateral lymphoedema. Annals of biomedical engineering (2018) 46(1), 108-121

Lee, T. S., Morris, C. M., Czerniec, S. A., & Mangion, A. J. Does lymphedema severity affect quality of life? Simple question. challenging answers. Lymphatic research and biology (2018) 16(1), 85-91.‏

Gott, F. H., Ly, K., Piller, N., & Mangion, A. Negative pressure therapy in the management of lymphoedema. Journal of Lymphoedema (2018) 13 , 1.‏

Tidhar D. Armer J. The meaning of success in lymphoedema management. Journal of Lymphoedema, (2018) 13, 1: 37-42

Tidhar D, Deutscher D, Armer JM. Construct Validity of functional status scores of patients with lymphedema. Lymphology (2018) 51, 4 : 160-173

Morris, C. M., Lee, T. S., Czerniec, S. A., & Mangion, A. J.  A patient-based self-examination survey for staging the severity of lymphoedema. Journal of Lymphoedema (2017) 12(1).‏

Humphreys, I., & Thomas, M. J. Evaluation of the economic impact of a national lymphoedema service in Wales. British Journal of Nursing, (2017)  26, 20 :1093-1100.‏

Thomas, M. J., & Morgan, K. The development of Lymphoedema Network Wales to improve care. British Journal of Nursing, (2017)  26, 13: 740-750.‏

Lister, L. and Noble-Jones, R. “Case study: Obesity, genital oedema and lower limb compression bandaging.” British journal of community nursing (2017)  22, Sup10: S21-S25.‏

Peleg, Ruthi MScPT1; Katz-Leurer, Michal PhD2 Effect of Arm Position on Circumference Measurement of Upper Arms in Healthy and in Women With Breast Cancer–Related Lymphedema, Rehabilitation Oncology( 2017) 35, 2 : 72-80 doi: 10.1097/01.REO.0000000000000054

Noble-Jones, R., Rowley, L. and Rowley C. “Clinical innovation: wider collaboration on lymphoedema research is needed—footwear and gait analysis.” Wounds International (2017) 8,1 : 21-24.‏

Thomas, M. J., & Morgan, K. The development of Lymphoedema Network Wales to improve care. British Journal of Nursing (2017)  26,13: 740-750.‏

Thomas, M., et al. “Managing chronic oedema and wet legs in the community: a service evaluation.” Nurs Stand (2017) 32.11 :39-50.‏

Peleg Ruthi, Sofrin-Politi Dafna “Raising doubts concerning doubts the guidelines for the prevention of lymphedema after breast cancer surgery – A storm in a glass of water? Journal of the Israeli Oncology Nursing Society, May 2017, Vol 29, No 1: 20-25

Wanchai, A., Armer, J. M., Stewart, B. R., & Lasinski, B. B. Breast cancer-related lymphedema: A literature review for clinical practice. International Journal of Nursing Sciences (2016) 3,2: 202-207.‏

Nijs J, Leysen L, Pas R, Adriaenssens N, Meeus M, Hoelen W, Ickmans K, Moloney N, Treatment of pain following cancer: applying neuro-immunology in rehabilitation practice. Disabil Rehabil. (2016) Dec 15:1-8.

Nijs J, Leysen L, Adriaenssens N, Aguilar Ferrándiz ME, Devoogdt N, Tassenoy A, Ickmans K, Goubert D, van Wilgen CP, Wijma AJ, Kuppens K, Hoelen W, Hoelen A, Moloney N, Meeus M, Pain following cancer treatment: Guidelines for the clinical classification of predominant neuropathic, nociceptive and central sensitization pain, Acta Oncol. (2016) Jun;55(6):659-63

Hugenholtz-Wamsteker W, Robbeson C, Nijs J, Hoelen W, Meeus M, The effect of docetaxel on developing oedema in patients with breast cancer: a systematic review, Eur J Cancer Care (Engl). (2016) Mar;25(2):269-79

Noble-Jones, R. “Using new research to improve treatment and management of lymphoedema.” British Journal of Nursing (2016) 25,13: 726-726.‏

Noble Jones, R. “Compression moves on: advances in care are changing practice.” British Journal of Nursing 25.4 (2016): 204-206.‏

Armer, J. M., Feldman, J. L., Ostby, P. L., Thrift, K. M., Lasinski, B. B., Beck, M. S., … & Stewart, B. R. Simplifying evidence-based management of breast cancer-related lymphedema. Expert Review of Quality of Life in Cancer Care (2016) 1,5 : 389-402.‏

Shaitelman, S. F., Cromwell, K. D., Rasmussen, J. C., Stout, N. L., Armer, J. M., Lasinski, B. B., & Cormier, J. N. Recent progress in the treatment and prevention of cancer‐related lymphedema. CA: a cancer journal for clinicians (2015) 65, 1: 55-81.‏

Geraets, J. J. X. R., Calders, P., Nijs, J., & van Wilgen, C. P. (2014). Oncologie–interview met Wouter Hoelen. In Jaarboek Fysiotherapie Kinesitherapie (2015) 55-61. Bohn Stafleu van Loghum, Houten.‏

Viehoff, P. B., Heerkens, Y. F., Van Ravensberg, C. D., Hidding, J., Damstra, R. J., Ten Napel, H., & Neumann, H. A. M. Development of consensus International Classification of Functioning, Disability and Health (ICF) core sets for lymphedema. Lymphology (2015)  48,1 : 38-50.‏

Tidhar, D.; Armer, J.M.; Deutscher, D.; Shyu, C.-R.; Azuri, J.; Madsen, R. Measurement Issues in Anthropometric Measures of Limb Volume Change in Persons at Risk for and Living with Lymphedema: A Reliability Study. J. Pers. Med. (2015) 5, 341-353. https://doi.org/10.3390/jpm5040341

Tidhar D, Deutscher D,Armer JM. Lymphoedema, a significant healthproblem in Israel: A descriptive community-based study. Int Wound J. 2020;1–18.https://doi.org/10.1111/iwj.13523

Tidhar D, Hodgson P, Shay C, Towers A. A Lymphedema Self-Management Programme: Report on 30 Cases. Physiotherapy Canada (2014) 4, 66  404-412  DOI: 10.3138/ptc.2013-46

Letellier, Marie-Eve MSc; Towers, Anna MD; Shimony, Avi MD; Tidhar, Dorit MScPT Breast Cancer-Related Lymphedema, American Journal of Physical Medicine & Rehabilitation: September (2014) 93, 9 : 751-763 doi: 10.1097/PHM.000000000000008

Noble-Jones, R., et al. “Development of the lymphoedema genito-urinary cancer questionnaire.” British Journal of Nursing (2014) 23 ,Sup18 : S14-S19.‏

Borthwick Y et al “Reliability and validity of the figure-of-eight method of measuring hand size in patients with breast cancer-related lymphoedema” European Journal of Cancer Care (2013) Mar;22(2):196-201.

Lasinski, Bonnie B. “Complete decongestive therapy for treatment of lymphedema.” Seminars in oncology nursing (2013)  29, 1. ‏

Lasinski, Bonnie B., et al. “A systematic review of the evidence for complete decongestive therapy in the treatment of lymphedema from 2004 to 2011.” PM&R (2012) 4,8: 580-601.‏

Anne L. Newman, Leonard Rosenthall, Anna Towers, Pamela Hodgson, Carol A Shay, Dorit Tidhar, Antonio Vigano, and Robert D. Kilgour.Lymphatic Research and Biology (2013) 104-109.http://doi.org/10.1089/lrb.2012.0020

DiCecco, Shelley Smith. Incorporating pelvic floor exercises in complete decongestive therapy for females with lower extremity lymphedema, with and without genital involvement, to improve volumetric and quality of life outcomes. Diss. 2012.‏

Bracha J;1; Katz-Leurer M. The Immediate Effect of Upper Arm Exercise Compared With Lower or Combined Upper and Lower Arm Exercise on Arm Volume Reduction in Women With Breast Cancer Related Lymphedema: A Randomized Preliminary Study, Rehabilitation Oncology (2012) 30, 3: 3-8

Katz-Leurer, Bracha J. Test-Re-test reliability of arm volume measurement in women with breast cancer-related lymphoedema. Journal of Lymphoedema  (2012) 7, 2 :8-13

Tidhar, D., Katz-Leurer, M. Aqua lymphatic therapy in women who suffer from breast cancer treatment-related lymphedema: a randomized controlled study. Support Care Cancer ( 2010) 18, 383–392 https://doi.org/10.1007/s00520-009-0669-4

Bracha J, Jacob T. Using exercise classes to reduce arm lymphoedema. Journal of Lymphoedema, (2010) 5.1: 46-55.‏

Guterman, C., Jacob T., and Tidhar D.. “Incidence of first and recurrent cellulitis and its relationships to physical therapy: An observational study.” Lymphology 3 (2009): 15

Armer, J., Feldman, J., Fu, M., Stout, N., Lasinski, B., Tuppo, C., … & Cormier, J. (2009). ALFP: identifying issues in lymphoedema in the US. J Lymphoedema, 4(2), 85-91.‏

Mitchell, Katy, Peggy B. Gleeson, and Shelley Smith. “Assessing quality of life for females with upper extremity lymphedema.” Journal of Women’s Health Physical Therapy (2009) 33.2 : 7-13.‏

Shimony A, Tidhar D, Geffen DB. [Cancer-related lymphedema in Israel]. Harefuah (2008) 147,7 :624-7, 661.

Shimony A, Tidhar Dorit. Lymphedema: A Comprehensive Review, Annals of Plastic Surgery (2008)  60, 2, 228- doi: 10.1097/SAP.0b013e318165f1f5

Peleg Ruthi, Bracha Jillian ” Israeli Lymphedema Association”, Journal of Lymphoedema, 2007, Vol 2, No 2: 76-78

Tidhar D, Drouin J, Shimony A. Aqua Lymphatic Therapy in Managing Lower Extremity Lymphedema. Supportive Oncology (2007)  5, 4 : 179-183

Tidhar D, Shimony A, Drouin J. Oncology Aqua Lymphatic Therapy for Postsurgical Breast Cancer Lymphedema. Rehabilitation (2004)  22, 3,: 6-14

Oppenheimer R, Finkel R, Brennan A. Treatment of Radiation-Induced Fibrosis of the Face with Manual Compression Therapy. Ear, Nose & Throat Journal (2004) 83(7):478-480. doi:10.1177/014556130408300714

Casley‐Smith, Judith R., et al. “Treatment for lymphedema of the arm‐The Casley‐Smith method: A noninvasive method produces continued reduction.” Cancer: Interdisciplinary International Journal of the American Cancer Society 83.S12B (1998): 2843-2860.‏

Boris, M., Weindorf, S., Lasinski, B., & Boris, G. Lymphedema reduction by noninvasive complex lymphedema therapy. Oncology (1994) 8, 9 : 95-106.