Compression and Bandaging Information

Types of Compression – Different Standards

Several standards for medical compression stockings exist. Prescribers need to be aware of variance in standards order to treat the patient appropriately for their condition. The most recognised standards are 1-4:

- Germany and others : RAL-GZG standard

- France : AFNOR

- Great Britain : BSI

 

CHHC are experience with a wide range of high quality compression garment manufactures and with extensive variety of styles, so we can help you to find the right garment that is perfect for you.  We take great care to expertly take measurements for the perfect fit and then select garments for each individual. We work closely with your chosen prescription service and GP to ensure the correct garments are ordered and delivered.   Naturally this take may time to get right, but we will help and support you throughout the process and monitor changes on a regular basis. We are proud of our patient care and go the extra mile to make sure your happy with your garments.

The variety of compression garment and the type of material depends on serval diagnostic factors such as stage and severity to accommodate a wide range of patients with Lymphoedema or Lipodema, post-operative and post-trauma odema. Fabrics generally come in Flat Knit or Circular Knit; some garments are “Off the shelf” others are “Custom Made”, many available in various colours and patterns to increase your confidence and compliance.  Self adjustable compression wraps can be used for palliative or less abled patients, and are similar to short-stretch bandages.

 

Multi Layer Lymphatic Bandaging (MLLB) is often recommended initially to reduce swelling where a patient has severe Lymphoedema 5. It forms part of the intensive Complete Decongestive Treatment (CDT) which usually includes a combination of skin care, exercise, MLD and MLLB 5-6. Currently there are no international or European accepted standards relating to the performance of compression bandages 7 .

The concept of multi-layer lymphatic bandaging is that pressure is applied in layers, giving an accumulation of pressure. There are a variety of multi-layer bandaging systems available and include either elastic or inelastic compression bandages, cohesive/adhesive bandages, crepe bandages and/or padding layers 8.

It is rarely used as part of long-term management, only in exceptionally complex patients who cannot wear compression hosiery.

Short stretch is rating on elasticity/extensibility of a bandage to increase in length in response to an applied force 9.  Examples of short-stretch bandages include Actiban and Actico, and Comprilan. Short stretch bandages elastic bandage provides sustained compression on the lymphedema limb with minor variations during functional activity.

Alternatively, 3M Coban 2 and Coban 2 Lite Compression Systems may offer patients mobility during intensive treatment, provided patients do not show signs of allergic reaction.  Inelastic, cohesive and adhesive bandages offers rigidity and enhances the calf muscle pump function against the resistance of the bandage to reduce limb volume.

Inelastic bandages produce a low resting pressure and high pressure on moving (i.e. create peak pressures) cohesive and adhesive can be used to prevent slippage and increase bandage wearing time. Compression remains the most important treatment measure in managing Lymphoedema10.

References:

1          Franks, P.J., Moffatt, C.J., Murray, S., Reddick, M., Tilley, A. and Schreiber, A., 2013. Evaluation of the performance of a new compression system in patients with lymphoedema. International wound journal10(2), pp.203-209.

2             Takanishi, Y., Ogawa, Y., Hamada, Y. and Harris, R., 2018. The hybrid approach to treating severe lower-extremity lymphoedema. Journal of Lymphoedema13(1).

3             Mosti, G. and Cavezzi, A., 2019. Compression therapy in lymphedema: Between past and recent scientific data. Phlebology, p.0268355518824524.

4             Woods E (2008) Lymphoedema Care: The Role of Compression Therapy. Blackwell Publishing: Oxford

5             Cancer Research UK (2019). Compression treatments for lymphoedema. [Online] [Accessed 030120] Available from:  https://www.cancerresearchuk.org/about-cancer/coping/physically/lymphoedema-and-cancer/treating/compression

6            St Georges - Centre of Excellence UK (2020). Lymphoedema Department [Online] [Accessed 14/07/2015] Available from:https://www.stgeorges.nhs.uk/service/lymphoedema/

7             Moffatt CJ, Franks PJ, and Hardy D (2011). A preliminary randomized controlled study to determine the application frequency of a new lymphoedema bandaging system. British Journal of Dermatology . Nov 7. doi: 10.1111/j.1365- 2133.2011.10731

8             Lamprou DA, Damstra RJ, and Partsch H (2011). Prospective randomized controlled trial comparing a new two-component compression system with inelastic multicomponent compression bandages in the treatment of leg lymphedema. Dermatol Surgery 37, 7: (985-981)

9            Damstra R and Partsch H (2012). Prospective, Randomized Controlled Trial Comparing the Effectiveness of adjustable compression Velcro-wraps versus Inelastic Multilayer Compression Bandages in the initial Treatment of Leg Lymphedema. J Vascular Surgery

10          Gordon, K. and Mortimer, P.S., 2018. Decongestive lymphatic therapy. In Lymphedema (pp. 413-429). Springer, Cham.

CHHC’s Holistic Management of Lymphoedema and Lipoedema

Colchester Holistic Health Clinic fosters a holistic approach to management providing advice and support to enable patients to live a full and active life. In addition to providing Manual Lymphatic Drainage treatment and Compression Garments we strongly support and encourage patients with self management and maintaining the cornerstones of care.   We provide appropriate and effective education about their condition and psychosocial support.  This is a non rushed environment, where patients are listened to and given time to ask as many questions as they need. Benefit from our vast experience and get support with your self management plan which incorporates your cornerstones of care:

■ Skin care

■ Exercise/movement

■ Compression – compression garments application

■ Simple Lymphatic Drainage SLD performed by the patient

 

Holistic management goals can help achieve the following 1-2:

Reduction in size and volume

Improved lymph flow

Improved skin condition

Improved subcutaneous tissue consistency with loosening of hard fibrotic tissue

Improved limb shape

Improved limb function and mobility

Improved symptom control for lipoedema with reduction in pain and haematoma

Improved emotional state

Enhanced patient/family/carer involvement

Increased independence and self-management skills

 

Lymphoedema has a physical and psychosocial impact so we think it is important to have a holistic approach to care.  Education, psychosocial support, pain management are the foundations of care of which Manual Lymphatic Draining (MLD) and Self Lymphatic Drainage (SLD) forms a part.   The objectives of treatment are to reduce excess volume so that compression hosiery can be applied and to support patients/carers in their self-management 3.

 

Lymphoedema treatment generally has three different phases 4-5:

First phase Initial management 1 – 4 weeks intensive phase treatment + education/cornerstones/ psychosocial supportSite, stage, severity andcomplexity
Second phase Transition management 1-3 months Reduced treatment phase/Monitoreducation/cornerstones/ psychosocial support
Third phase Long-term management 6 months then yearly adjust to living with a long-term condition/maximise self mx/empowerment/sense of control

relapse management start back at phase one

 

References

1             Kwan M, Cohn JC, Armer JM, Steward BR and Cormier JN (2011). Exercise in patients with lymphedema: a systematic review of the contemporary literature. Journal of Cancer Survivorship. December 2011, Volume 5, Issue 4, (320-336)

 

2             NHS Choices Information (2019) Lymphoedema – Treatment [Online] [Accessed 030120] Available from: https://www.nhs.uk/conditions/lymphoedema/

 

3             International Lymphoedema Framework (ILF) (2019) Annual Report June 2019 [Online] [Accessed 030120] Available from: https://www.lympho.org/wp-content/uploads/2019/06/National-Lymphoedema-Frameworks_Compilation-of-annual-reports-2018-2019_June-2019_update-26062019.pdf

 

4             International Society of Lymphology Executive Committee (2013). The Diagnosis and Treatment of Peripheral Lymphedema. Consensus Document of the International Society of Lymphology. [Online] [Accessed 030120] Available from:

https://www.stgeorges.nhs.uk/wp-content/uploads/2013/08/Best_practice_20_July_lymphoedema.pdf

 

5             Bjork, R. and Hettrick, H., 2019. Lymphedema: New Concepts in Diagnosis and Treatment. Current Dermatology Reports8(4), pp.190-198.

Manual Lymphatic Drainage Information

MLD (Manual Lymphatic Drainage) is a gentle massage which helps drain lymphatic fluid.  It is often used as a therapeutic, preventative or remedial treatment before and after surgery.  It is also be used as part of Complete Decongestive Treatment (CDT) for Lymphoedema which last approximately 3 weeks 1-3.

There are several well-recognised forms of Medical Lymphatic Drainage  – Vodder (developed in the 1930s), Földi (1960s), Leduc (1960s) Casley-Smith (1970s) and FG (2014) (Foldi 2003). All schools of MLD follow the same principles and are accepted worldwide as key to the treatment and management of Lymphoedema 4-8

Style Country
Vodder Austria
Földi Germany
Casley-Smith Australian
Leduc Belgium
Fill & Flush UK

 

Whilst MLD should not be used as a stand-alone treatment in the management of Lymphoedema it has far reaching benefits which have a holistic effect on patient’s well-being and empowerment 9-12.

Colchester Holistic Health Clinic tailors your treatment to suit your individual needs and requirements. As a Specialist Physiotherapist and Clinical Lymphoedema Therapist with a wealth of experience in primary and secondary Lymphoedema, as well as Lipodema and post-surgical oedema from plastic or orthopaedic surgery treatments and complex post-trauma odema. You are in safe professional hands that care about your health and comfort.

MLD is very gentle technique that subtly moves and stretches the skin which influences the underlying initial lymphatics and stimulates movement of lymphatic fluid through a network of vessels and nodes in your lymphatic system. This improves the free flow and removal of waste products from your body, and increases delivery of substances vital to your immunity; promoting healthy fluid balance and healing with the natural defence mechanisms.

MLD can be safely used for patients who have Lymphoedema secondary cancer treatment such as surgery or radiotherapy, and hosts many potential benefits both physically helping compromised immune and lymphatic system and psychologically to optimise positive outcomes 13-14.  Most reputable surgeons and doctors recommend soothing MLD following surgery to optimise healing and recovery. Whatever your reason for requiring MLD you can feel reassured and confident that your best interest is our central focus at Colchester Holistic Health Clinic.

MLD may also be beneficial and promote proper functioning of your body’s immunological response helping auto-immune diseases and other disorders such as 15:

Rheumatoid Arthritis

Psoriasis

Asthma &Eczema

Chronic Fatigue/ME

Menstrual Problems

Sinus Problems

Migraines and Headaches

 

References

1             Macmillian (2016). Lymphatic Drainage. [Online] [Accessed 030120] Available from: https://www.macmillan.org.uk/information-and-support/coping/side-effects-and-symptoms/lymphoedema/lymphatic-drainage.html

2             Macmillan (2018) Lymphoedema. [Online] [Accessed 030120] Available from:https://www.macmillan.org.uk/information-and-support/coping/side-effects-and-symptoms/lymphoedema/what-is-lymphoedema.html

3             Cancer Research (2019) MLD [Online] [Accessed 030120] Available from: https://www.cancerresearchuk.org/about-cancer/coping/physically/lymphoedema-and-cancer/treating/massage-manual-lymphatic-drainage/fluoroscopy-guided

4             Badger C, Preston N, and Seers K (2004). Physical therapies for reducing and controlling lymphoedema of the limbs. Cochrane Database Systematic Review. 18(4): CD003141. Review

5             Giacalone G, Belgrado JP, Bourgeois P, Bracale P, Roh N and Moraine JJ (2011). A New Dynamic Imaging Tool to Study Lymphoedema and Associated Treatments. The European Journal of Lymphology. Vol XXII – Nr 62

6            De Vrieze, T., Vos, L., Gebruers, N., Tjalma, W.A., Thomis, S., Neven, P., Nevelsteen, I., De Groef, A., Vandermeeren, L., Belgrado, J.P. and Devoogdt, N., 2018. Protocol of a randomised controlled trial regarding the effectiveness of fluoroscopy-guided manual lymph drainage for the treatment of breast cancer-related lymphoedema (EFforT-BCRL trial). European Journal of Obstetrics & Gynecology and Reproductive Biology221, pp.177-188.

7             Royal Marsden (2015) Manual Lymphatic Drainage [Online] [Accessed 030120] Available from: https://www.royalmarsden.nhs.uk/your-care/living-and-beyond-cancer/lymphoedema/lymphatic-drainage

8             Lee, N., Wigg, J., Pugh, S., Barclay, J. and Moore, H., 2016. Lymphoedema management with the LymphFlow Advance pneumatic compression pump. British journal of community nursing21(Sup10), pp.S13-S19.

9            St Georges – Centre of Excellence UK (2020). Lymphoedema Department [Online] [Accessed 14/07/2015] Available from:https://www.stgeorges.nhs.uk/service/lymphoedema/

10          Gordon, K. and Mortimer, P.S., 2018. Decongestive lymphatic therapy. In Lymphedema (pp. 413-429). Springer, Cham.

11           NHS Choices Information (2019) Lymphoedema – Treatment [Online] [Accessed 030120] Available from: https://www.nhs.uk/conditions/lymphoedema/

12          International Lymphoedema Framework (ILF) (2019) Annual Report June 2019 [Online] [Accessed 030120] Available from: https://www.lympho.org/wp-content/uploads/2019/06/National-Lymphoedema-Frameworks_Compilation-of-annual-reports-2018-2019_June-2019_update-26062019.pdf

13           Deng, J., Sinard, R.J. and Murphy, B., 2019. Patient experience of head and neck Lymphedema therapy: a qualitative study. Supportive Care in Cancer27(5), pp.1811-1823.

14          Achen, M., YUAN, Y., Arcucci, V. and Levy, S., 2019. Modulation of Immunity by Lymphatic Dysfunction in Lymphedema. Frontiers in immunology10, p.76.

15          Soos, J.M., Schiffenbauer, J. and Johnson, H.M., University of Florida, 2000. Method for treatment of autoimmune diseases. U.S. Patent 6,060,450.

Lipoedema

What is it?

Lipoedema is a chronic progressive condition that predominately affects women; it involves disproportionate deposits of an inflammatory fatty tissue that is painful and often misdiagnosed as simply “Fat” [1-2].  Typically women develop increased fatty deposits in the calves, thighs and buttocks following puberty, causing a pear shape appearance, sometimes it can occur in the arms [3-4]. Often described as Lipoderm or Lipoedema it causes symptoms of:

 

  • sensitivity to touch and tenderness in areas of increased fatty tissue
  • increased bruising
  • painful joints and reduced mobility
  • smooth skin but “bean bag” appearance below surface
  • heaviness of legs (or areas affected)

 

Hypermobility and cold temperature on the legs compared to the rest of the body is also reported [5-6]. Having Lipoedema is not due to over eating, weight loss will not affect the disproportionately large legs and hips, however a healthy diet and exercise promotes healthy mental attitude and targets psychological effects.

 

Having Lipoedema  can cause problems with day to day living.  The physical effects may cause difficulty with mobility, standing and other medical complications, such as varicose veins and joint pain [7-8]. Often Lipoedema can have a negative effect of on body image, low self-esteem and lack of confidence, which has an impact work and life relationships and emotional well-being [9-10].

 

Lymphatic drainage can be used:

Proper diagnosis and treatment can prevent progression, retain mobility and reduce pain. Lipoedema can result in poor mental health, body image, and self-confidence [11-12]. Lymphatic drainage can help as part of the treatment and management of Lipoedema [13-14].  The gentle action of MLD can help reduce pain, sensitivity and inflammation by stimulation of the body’s lymphatic system to reduce swelling and toxins, and promote relaxation of the sympathetic nervous system to improve well-being.

 

Treatment Time + Approach:

Following a complete assessment and detailed history, patients will be physically examined and measurements taken. Patients will be asked to remove their outer garments, and comfortably position themselves on the couch. The gentle and rhythmic massage treatment makes direct contact with the skin, working from the trunk outwards (proximal to distal) and lasts between 30 minutes to 2 hours, depending on the areas being covered. MLD may be repeated every 4-6 weeks, then reviewed 6 monthly, after which patients should be reviewed yearly.

 

History: 

Lipoedema has been described by doctors since the 1940’s, and although research is taking place at St Georges Hospital and Royal Derby Hospital to discover the hormonal and genetic link, some families may notice the hereditary occurrence skips a generation, this is not fully understood and there is no cure as yet. Lipoedema is potentially physically disabling and needs to be managed regularly to reduce the severity and progression of the symptoms and debilitating impacts of this condition.

 

Recognised Body & References:

 

1             Williams, A.F., (2018) Lipoedema—a fat disorder: Considerations for GPNs. Journal of General Practice Nursing.

2             Fetzer, A. and Fetzer, S., (2015) Early lipoedema diagnosis and the RCGP e-learning course. British journal of community nursing20(Sup4), pp.S22-S28

3             Todd M (2010) Lipoedema: presentation and management. Br J Community Nurs 15(4 Suppl): S10–16.

4             Fetzer, A. and Wise, C., (2015) Living with lipoedema: reviewing different self-management techniques. British journal of community nursing20(Sup10), pp.S14-S19.

5             Tyszczak, P. and Szuba, A., (2018) Lipedema: a clinical entity. Acta Angiologica24(4), pp.141-148.

6             https://www.lipoedema.co.uk/wp-content/uploads/2016/04/UK-Big-Surey-version-web.pdf

7             https://www.lipoedema.co.uk/wp-5content/uploads/2012/10/Frambach_Yvonne_3005648.pdf

8             https://www.lipoedema.co.uk/wp-content/uploads/2012/10/Schmeller-8-year-study.pdf

9             Langendoen, S.I., Habbema, L., Nijsten, T.E.C. and Neumann, H.A.M., 2009. Lipoedema: from clinical presentation to therapy. A review of the literature. British Journal of Dermatology161(5), pp.980-986.

10           DudekJA, Białaszek W, Ostaszewski P and Smidt T (2018) Depression and appearance-related distress in functioning with lipedema, Psychology, Health & Medicine, 23:7, 846-853, DOI: 10.1080/13548506.2018.1459750

11           Dudek, J.E., Białaszek, W. and Ostaszewski, P., 2016. Quality of life in women with lipoedema: a contextual behavioral approach. Quality of Life Research25(2), pp.401-408.

12           https://www.healtheuropa.eu/a-lesson-on-lipoedema/82966/

13           Fetzer, A., (2016) Specialist approaches to managing lipoedema. British journal of community nursing21(Sup4), pp.S30-S35.

14           Reich‐Schupke, S., Schmeller, W., Brauer, W.J., Cornely, M.E., Faerber, G., Ludwig, M., Lulay, G., Miller, A., Rapprich, S., Richter, D.F. and Schacht, V., 2017. S1 guidelines: Lipedema. JDDG: Journal der Deutschen Dermatologischen Gesellschaft15(7), pp.758-767.

Why is it important to have Lymphatic Drainage treatment post-surgery?

Manual Lymphatic Drainage (MLD) treatment gives your body the crucial support it needs for a full recovery after surgery.  Research shows that MLD accelerates your healing process, decreases recovery time and combats infection by improving your circulation, increasing your metabolic rate and improving immunity.

                                 

Most reputable surgeon’s will advise their patients to get MLD post-surgery as without it there is a high risk that the inflammation will last longer and the swelling could turn into fibrosis, which is a permanent hardening of the area treated.  MLD will ensure you achieve the best results possible by promoting skin elasticity and elimination of waste products, while stimulating the movement of lymphatic and other tissue fluids.

 

MLD is important no matter what surgery is completed, whether it is plastic surgery, vaser liposuction or orthopaedic procedures such as arthroscopic knee surgery.  After surgery the body’s lymphatic system is temporarily overloaded by the cascade of events and brings on the body’s inflammatory response to trauma. MLD treatment is designed to optimise the lymphatic system by clearing lymphatic pathways and collection ducts, which is critical to allow transportation of fluid.

 

Many people confuse Lymphatic Drainage with deep tissue massage when in fact it is very different.  Evidence based MLD is a treatment that specifically targets the lymphatic networks gently and carefully.   It should only be performed by specialist trained health professionals who have crucial knowledge of the anatomy and physiology of the lymphatic system.  MLD is not a painful technique which includes extremely gentle and light hand movements by highly skilled therapists who monitor results closely.

 

It would also be worth considering MLD treatment Pre Operation as it will boost your lymphatic system and positively influence healing, which can reduce the amount of post-surgical treatments required.

 

Most patients will require 4-12 treatments following surgical procedure, over a 2-3 week period but this will vary depending on your general health, area of treatment and adherence to self-management advice. We can schedule appointments that fit in with your life-style and commitments.

 

In summary:

MLD speeds up the healing process, reduces bruising, swelling and removes cellular waste

MLD improves the immune response, reducing inflammation and infection risks

MLD decreases build-up of fibrotic nodules and scarring while also improving skin texture and tone

MLD reduces pain, discomfort and sensitivity – helping to restore your equilibrium

 

References:

Bellini E, Grieco MP, Raposio E. A journey through liposuction and liposculture: Review. Ann Med Surg (Lond). 2017 Nov 6;24:53-60

Lopera C, Worsley PR, Bader DL, Fenlon D. Investigating the Short-Term Effects of Manual Lymphatic Drainage and Compression Garment Therapies on Lymphatic Function Using Near-Infrared Imaging. Lymphat Res Biol. 2017 Sep;15(3):235-240.

Ezzo J, Manheimer E, McNeely ML, Howell DM, et al. Manual lymphatic drainage for lymphedema following breast cancer treatment. Cochrane Database Syst Rev. 2015 May 21;(5).

Masson IF, de Oliveira BD, Machado AF, Farcic TS, et al. Manual lymphatic drainage and therapeutic ultrasound in liposuction and lipoabdominoplasty post-operative period. Indian J Plast Surg. 2014 Jan;47(1):70-6.

 

Water is Wonderful

Water is good for physical fitness and wellbeing, maintaining healthy body and mind. Our body is 70% water!  CHHC feels everyone should be aware of the importance of drinking adequate fluids.  WATER is vital for general good health and optimum performance whatever your age, size, fitness or ability.

Water effects all our bodily functions; our blood is 80 % water delivering oxygen,  nutrients and speeding antioxidant defence mechanisms, water helps to maintain healthy blood pressure and reduce dizziness.

Water is vital to hydration and drinking water increases performance, improves muscle strength and thickness after exercise. WATER helps eliminate cramps and keep joints lubricated, reduces fatigability and muscle weakness, supports gains in exercise endurance and stimulates mental responses.

Concentration and cognitive status improves with water intake; our brain is 85% water,  stimulating responses and cognition, improving vision fields and activating our senses. Additionally it prevents constipation, helps flush out toxins, cleans your kidneys and refreshes the condition of your skin.

Psychological and emotional wellbeing can be helped by WATER too.   Emotional stress, depression and anger can result in tears, headaches, digestive problems and skin irritation, tiredness and lathergy, poor health and low immunity. Proper hydration with balance diet and exercise stimulates your Parasympathetic Nervous System leading to Peace and Calm.

What the experts say …

The ingestion of COLD WATER improved performance for 49% and 51% of the participants” (LaFata 2013)

“There is good evidence that drinking appropriate amounts of water, especially cold water, can enhance exercise performance in many situations”  (Maughan 2012)

importance of educating individuals about their own fluid needs for safety and improved performance” (Lopez 2013)

Fluid replacement is important for sport performance, recovery, and safety” (Roberts 2013)

Also take a look at:

http://www.symptomfind.com/health/warning-signs-of-dehydration/

 

References:

Cohadon F. (1997) Advances and Technical Standards in Neurosurgery. Austria: Springer

Lopez R (2012) Exercise and Hydration: Individualizing Fluid Replacement Guidelines. Strength & Conditioning Journal (Lippincott Williams & Wilkins) [serial online]. August 2012;34(4):49-54. Available from: SPORTDiscus, Ipswich, MA. (Accessed12/01/13).

Maughan R (2012) Investigating the associations between hydration and exercise performance: methodology and limitations. Nutrition Reviews [serial online]. November 2, 2012;70:S128-S131. Available from: SPORTDiscus, Ipswich, MA. (Accessed12/01/13).

LaFata D, Carlson-Phillips A, Sims S, Russell E (2012) The effect of a cold beverage during an exercise session combining both strength and energy systems development training on core temperature and markers of performance. Journal Of The International Society Of Sports Nutrition [serial online]. January 2012;9(1):44-51. (Accessed12/01/13).

McCarthy S and  Manning D (2012) Water for wellbeing: promoting oral hydration in the elderly. Australian & New Zealand Continence Journal [serial online]. June 2012;18(2):52-56. (Accessed12/01/13).

Roberts W. FIMS Position Statement (2012) Fluid replacement for sports safety and performance. International Sportmed Journal [serial online]. June 2012;13(2):39-42. (Accessed12/01/13).

Kavouras S, Arnaoutis G, Sidossis L, et al (2012) Educational intervention on water intake improves hydration status and enhances exercise performance in athletic youth. Scandinavian Journal Of Medicine & Science In Sports [serial online]. October 2012;22(5):684-689. (Accessed12/01/13).

Laitano O, Kalsi K, Pearson J, Lotlikar M, Reischak-Oliveira A, González-Alonso J (2012) Effects of graded exercise-induced dehydration and rehydration on circulatory markers of oxidative stress across the resting and exercising human leg. European Journal Of Applied Physiology [serial online]. May 2012;112(5):1937-1944. (Accessed 12/10/13)

Chan L and  Braddom R (2011). Physical Medicine And Rehabilitation [e-book]. Elsevier/Saunders; 2011.

Jiménez-Pavón D, Romeo J, Castillo M, et al. (2011) Effects of Running in the heat on cognitive performance . Journal Of Exercise Science & Fitness [serial online]. April 2011;9(1):58-64. (Accessed 22/08/13)

Kenefick  and  Cheuvront   (2012) Hydration for recreational sport and physical activity. Nutrition Reviews [serial online]. November 2, 2012;70:S137-42. (Accessed 12/10/13)