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Pink Ribbon


Treatment in provided in a warm and comfortable atmosphere.

We specialise in the aftercare of:

Breast cancer surgery


  • Gynaecological cancer surgery.
  • Skin cancer surgery.
  • Head and neck cancer surgery.
  • Sarcoma surgery.

Symptoms such as.

  • Shoulder pain and stiffness
  • Muscle tension
  • Fibrosis
  • Cording
  • Adhered scars
  • Swelling and lymphoedema
  • Neck stiffness and pain
  • Back complaints
  • Hip complaints
  • Knee stiffness and swelling


  • Soft Tissue Mobilisations
  • Scar therapy
  • Cording and axillary web therapy
  • Myofascial release therapy
  • Massage
  • Trigger Point Massage
  • Relaxation therapies
  • Breathing exercises
  • Therapeutic exercises.
  • Manual Lymph Drainage. (MLD)
  • Compression therapy (i.e. measuring and fitting compression garments).

Breast Cancer Rehab.

In many cases patients recover full and pain-free mobility after instruction on home exercising by the hospital based Physiotherapists. In some cases, however, significant symptoms occur and it is these symptoms that benefit from specialised treatment.

Siobhan specializes in the treatment of these acute problems. She offers evidenced based treatments that quickly lead to the improvement of these symptoms. Her approach is based on the most recent published studies.


An emerging standard of care in breast-cancer-surgery-after-care, includes screening for changes in limb volume and detecting early stage lymphoedema during the survivorship years.

Screening for early lymphoedema and other sequelae helps avoid serious impairments from developing and includes taking standardised circumferential measures of the treatment-side arm either before treatment starts or soon there-after.

Therapists can use these measures to compare and identify changes in arm girth during scheduled follow-up visits. For example, the arm’s girth may be decreased possibly due to guarding and disuse or it may be increased possibly due to accumulating lymphoedema. In either case these objective measures show changes over months and years during the survivorship years and guide rehab as needed.

Siobhan takes these measures as a standard part of her initial assessment and at subsequent reviews and can recommend therapies as needed.

If you have further questions, please contact us by phone or by sending us an email to siobhan@theoreillycentre.ie

Air Travel and Holiday Tips for People with Lymphoedema

Air Travel and Holiday Tips

Lymphedema Air-travel and Vacation Tips  

There is nothing quite like a wonderful holiday to chase the blues away and we in Ireland are spoiled for choice. This article deals with lymphedema, airline travel and vacation challenges, so you may learn how to reduce your risk of developing lymphedema, or minimise your risk of flare ups. Lymphedema is the accumulation of protein-rich fluid in tissues with inadequate lymphatic drainage. It is a chronic and progressive condition without a cure. As with all chronic conditions successful self-management is the key to you leading a full and active life.

The information in this article is filled with practical information and tips relevant to vacationing with lymphedema to help you may make good decisions quickly.

I have combined recommendations from the National Lymphedema Network (lymphnet.org)  position papers “Lymphedema risk reduction practices” and “Healthy habits for people at risk for lymphedema”, I also reviewed the latest research on flying and finally added in some practical tips shared by my patients.

Individualized risk-reduction practices

No two lymphedema patients are the same. Each person is unique and because lymphedema may be caused by many different factors, each person with lymphedema or each person who is at risk for lymphedema is advised to have their risk-reduction practices individualized. Before you travel, talk with your lymphedema professional to figure out what your risks are and what will work best for you.

First know “the conditions most favourable to lymph flow”.

Lymph flow is facilitated by several key factors including:

  1. An intact and robust lymphatic system.
  2. A well-rested and hydrated body.
  3. Intact meticulously clean and healthy skin and nails.
  4. Lean active pumping muscles.
  5. A normal body mass index (BMI).
  6. Well-functioning unrestricted lungs and breathing movements.

Flying and lymphedema.

Air travel today is safer and more affordable than ever. You may be golfing in sunny Spain in the summer or skiing in Chamonix in the winter. It both cases you will be flying. Airline travel is associated with conditions that challenge our anatomy and physiology and contribute to swelling. For example, your flight may include;

  1. You may arrive tired after a sleepless night getting packed.
  2. You may arrive tired because it was an early take-off time.
  3. There may be crowds at check-in and at security which could mean long slow queues and lots of standing around.
  4. During the flight, you may be sitting inactive for several hours, with seat belts around your middle, in a tight seat.
  5. Flight cabin pressure is similar to altitudes of 6,000 and 8,000 feet. As altitude increases compressive pressure on veins and lymph vessels decreases which may slow the flow of blood in the veins and lymph fluid in the lymph vessels.
  6. At these altitudes air is drier and less dense with oxygen which may cause you to feel dehydrated and drowsy.
  7. The compounding effects of prolonged standing, prolonged inactivity, seats and belts, dehydration, drowsiness plus the cabin pressure may contribute to reduced flow and stasis of the body’s blood and lymphatic fluids and may cause swelling particularly in the lower body, ankles and feet.

Tips for lymphedema and flying. 

Plan ahead and use the help airports offer. 

  • Arrive at the airport well rested and in good time to avoid stress and delays.
  • Book a wheelchair to reduce standing time.
  • Procure a credit card with an airline partnership so you can check in promptly at the business desk
  • Check-in online with carry-on luggage.
  • Ask the flight attendant for assistance to store the luggage in the overhead bin for you and avoid straining any recent chest surgery or radiation.


  • Sip water and plenty of it.
  • Avoid sweet drinks, caffeinated drinks and alcohol during your flight.
  • Buy 2-3 bottles of water in duty free so you do not have to wait for a busy flight attendant during the flight.

Move around.

  • Book an aisle seat.
  • Keep your lymphedema limb on the outside and move it freely.
  • Sleep on the other arm.
  • Relax the limb and encourage flow by opening up the angles at the hip, knee and ankle for the leg or at the shoulder, elbow, wrist and fingers in the arm.
  • Move around the plane.
  • Slip between the section dividers, do ankle pumps and hip extensions to pump the lymph fluid past the hips and knees towards your heart and lungs.
  • Finally, sipping water throughout the flight will also make you need the bathroom more than your fellow passengers and an aisle seat will help you avoid disturbing them.

On holiday with lymphedema 

Bug bites and mosquitos.

  • Bites cause local pain and inflammation, itching and scratching. Bites and scratching can lead to cellulitis as they open skin and let bacteria in. Lymphedema is a high protein oedema which bacteria will consume and rapidly multiply, spreading the infection.


  • A certain amount of sun is good for us however too much may cause pain, inflammation and swelling over large sections of your body and increase the burden on a compromised lymphedema limb.

Extreme of low or high temperatures

  • Whether it is a sunny or snowy vacation, you may be exposed to extremes of temperatures. High and low temperatures also exist at different times of the day. Extremes of temperatures challenge the circulatory and lymphatic systems and prolonged exposure increases the challenge.
  • Figure out the time of day best for you.
  • Limit Jacuzzis and hot-tubs to less than 15 minutes.


  • Depending on the location, its temperature, its altitude, the amount of activity you are doing and the time of day you are doing it, you may need to drink more a lot water to meet your needs and avoid dehydration and a feeling of heaviness in the limb.
  • A well hydrated body’s urine is a lighter shade of gold and easily observed.

Over-use injuries and lymphedema

  • Golf and tennis players love to play longer and more frequently when on vacation which is often a lot more than at home.
  • Overuse injuries may cause pain and swelling and even cellulitis in a lymphedema limb.

Tips for lymphedema on vacation. 

Pack a location specific first-aid kit.

When you come prepared you may quickly apply the right remedy. Items may include:

  • Light back pack to carry the kit
  • A water bottle
  • A sun hat
  • Long sleeved high collared shirts to keep lymphedema arms cool and sun protected
  • Light loose pants to keep lymphedema legs cool and sun protected
  • Waterproof sandals or flip-flops to wear poolside and on the beach to protect feet from injury and infection.
  • UV and Jelly fish sting protection leggings ecostinger.com
  • Sunscreen cream for sunny and snowy vacations.
  • Sunburn cream for sunny and snowy vacations
  • Wipes and plasters
  • Mosquito repellent spray
  • A tube anti-itch/anti-inflammatory cream
  • Anti-histamine tablets
  • A tube of anti-bacterial cream
  • A filled prescription of antibiotics

Know your numbers.

  • Before you travel know your baseline data points so you can pick up and respond to changes in:
  • Size
  • Sensation
  • Colour
  • Temperature
  • Skin condition.
  • Your lymphedema professional may assist you in getting to know your baselines and how to track and respond to changes.

Cellulitis signs and symptoms

Mosquito bites, painful sunburns, inflammation or injury to your lymphedema limb may result in a flare up or even a cellulitis infection in that limb on vacation. Cellulitis is an urgent medical situation. The signs and symptoms of cellulitis skin infection in an area of impaired lymph drainage may include:

  • A feeling of overall illness or flu-like symptoms
  • Redness, warmth, pain, fever
  • Cellulitis episodes may lead to worsening lymphedema. When addressed early the doctor or emergency room nurse will treat cellulitis with oral antibiotics, when its advanced intravenous antibiotics may be needed and/or a hospital stay

Managing cellulitis on vacation

  • Pack a filled prescription of antibiotics.
  • Know the contact details of a local GP at your vacation place
  • Know the address and directions to the local hospital.
  • Finally, when you return home after a cellulitis infection, see your lymphedema professional to determine if you need a new course of therapy or a new garment as the limb measurements may have changed.

Book a hotel with a pool.

Holidays may offer a variety of exercise options. Fortunately, water based exercise is often accessible. Hydrostatic pressure increases as you go deeper into the pool or ocean. At 1 metre, it is 70mmHg of pressure on the feet, when compression garments exert between 20 and 40mmHg of pressure. Hydrostatic pressure affects our anatomy and physiology in the opposite way to altitude pressure. The increased pressure on the submerged limbs acts like a comfortable compression garment that’s comfortable. This facilitates lymph flow and eases swelling in the extremities. Lymphedema loves water based exercise, when possible book a hotel with a pool or source the local pool.

Air travel, lymphedema and compression garments.

If you have lymphedema, The National Lymphedema Network (lymphnet.org) recommends: 

“That people with a confirmed diagnosis of lymphedema wear properly fitting compression garments for air travel”.

The airline and vacation tips listed above all apply to reduce your risk of a flare-up when on vacation; arrive on-time and rested, ask for assistance when needed, hydrate, book an aisle seat so you may move around as often as you wish.

If you are at risk for lymphedema

If you have had cancer treatment involving the lymphatic system and don’t have lymphedema but are at some risk of developing swelling, please know that the decision to wear a compression garment during air travel is controversial.

The controversy regarding compression garments during air-travel. 

The studies that have been done on compression and prophylaxis are limited and they reached different conclusions that lymphedema is caused or worsened by air travel. One study showed that physically fit women on their way to a competition, who were at risk for breast cancer-related lymphedema had no increase in swelling from air travel. Another study showed that prophylactic compression had the potential to make swelling worse. Because additional research is needed to guide us, The National Lymphedema Network position at this time is:

People at risk for lymphedema who decide to wear prophylactic compression on airplanes should work with an experienced garment fitter and should not self- purchase a garment”.

If, however you choose to go ahead and wear a prophylactic compression garment on an airplane, they advise you wear the garment several times prior to air travel to make sure the garment fits well and has no areas of constriction. If, while wearing a garment on an airplane, the swelling increases or the garment constricts, remove it immediately.

In summary, when you are flying on vacation, plan ahead, know your risks and your data points so you can monitor for changes and quickly manage the common challenges associated with air-travel and holiday destinations. When possible, work with your lymphedema professional to get to know your numbers and your individual risk profile. Prepare well so you are confident and calm and well able to self-manage your lymphedema or risks in the different locations.

10 Tips to better manage Cancer Related Fatigue

10 Tips to Conquer Cancer Related Fatigue

March 2019

#1. Understand Cancer Related Fatigue

Cancer related fatigue (CRF) layers on top of normal tiredness and exhaustion.  Up to 90% of patients treated with radiation and up to 80% of those treated with chemotherapy experience fatigue. (Hoffman M. et al, 2007). 90% of cancer patients rank it more troublesome than pain and anxiety. CRF is different from normal fatigue as it is not relieved by rest or a good night’s sleep. It can persist for months or years after cancer treatment. Being chronically fatigued affects critical aspects of your life including your relationships, job performance and participation in social activities.

#2. Talk to your doctor.

Many different conditions can also cause fatigue such as pain, emotional distress, sleep disturbance, anaemia, and hypothyroidism. (Mock, V et al, 2000) So talk to your doctor who may be able to treat it medically.

#3. Do a CRF Self-efficacy Program ….. they work.

Research shows that self-efficacy focused programs result in less fatigue, improved quality of life, exercise compliance and general self-efficacy. Reif, K. et al (2007). Self-Efficacy is the belief that you yourself have the knowledge, attitude and skills to reduce your CRF. These types of programs, typically include 6, 90 minute sessions. Groups of similarly affected people learn about their CRF and identify ways to improve their self-care by problem-solving, setting realistic goals and reflecting on and tracking their progress.

#4. Score your CRF.

Doctors don’t have a blood test for pain nor for CRF. Both are scored by the patient using the VAS scale of 0 to 10, when 0 is no fatigue and 10 is the worst fatigue you can imagine. When scores are 4/10 or higher it is highly recommended that you talk to your doctor.

#5. Exercise daily.

Being active is one of the top two practices of people who manage their CRF well. Reif, K. et al (2012). Research shows that people with CRF who exercise feel less tired. The American Cancer Society recommends that cancer survivors take part in regular physical activity and aim to exercise at least 150 minutes per week and include strength training exercises at least 2 days per week. ACS (2014).

#6. Ask your Cancer Rehab Physio to make you a exercise plan.

The Cancer Rehab Physio will work with you to establish your baseline and to develop a progress plan. For example a person with severe CRF might start with a 2 minute walk each day for week 1, 4 minute walks for week 2, progress to 6 minute walks for week 3 and so on until by week 15 they are walking for 30 minutes.  Vallance, J. et al, (2006)

#7. Get good at energy conservation.

Practicing energy conservation is the other top practice of people who manage their CRF well. Research on energy conservation programs shows that patients feel less tired when they can effectively prioritise, plan and pace their life’s activities. Packer, T et al (1995) and Reif, K et al (2007).  Contact your local Cancer support centres or National Cancer Society for information about Energy Conservation Programs. Topics covered include:

(a) the value of rest;

(b) budgeting and banking energy;

(c) incorporating rest periods throughout the day;

(d) learning to communicate personal needs to others;

(e) using good body mechanics and posture;

(f ) using energy-efficient appliances and organizing stations of activity;

(g) separating fatiguing tasks into components;

(h) prioritizing and setting standards for activities;

(i) planning rest periods with self-care, productivity, and leisure activities so that a balance can be maintained; and

(j) reviewing course principles and setting short-term and long-term goals.

#8. Make priorities.

Take the time to list your priorities and decide which priority is first second, third etc. then design your week around these priorities. A simple example of a priority would be, you would like to reconnect with your friends. On that day you could conserve energy by doing less work and having a rest before going out so you are alert and comfortable throughout the evening.

#9. Pace yourself.

Pacing takes practice and can be a major adjustment for those who were very busy people before cancer treatment. Pacing is linked to your priorities. The more adaptive and flexible you are the better. In the group classes people are given time to process how well they are pacing and class mates share their experiences and wisdom with each other.

#10. Stay positive.

Research shows that these self-care skills are much improved with a positive attitude. So stay positive, believe in yourself and give yourself the best chance to conquer your cancer related fatigue.


  1. Reif, K et al, 2012. A patient education program is effective in reducing cancer-related fatigue: A multi-centre randomised two-group waiting-list controlled intervention trial. European Journal of Oncology Nursing. Vol 17, Issue 2. April 2013. Pages 204-213
  2. Hofman, M et al (2007) Cancer-Related Fatigue: The Scale of the Problem. doi: 10.1634/theoncologist.12-S1-4The OncologistMay 2007 vo 12 Supplement 1 4-10
  3. Mock, V et al, NCCN Practice Guidelines for Cancer-Related Fatigue (PMID:11195408). Oncology (Williston Park, N.Y.)[01 Nov 2000, 14(11A):151-161]
  4. Vallance, J.et al, (2007) Randomized Control Trial of the Effects of Print Materials and Step Pedometers on Physical Activity and Quality Of Life in Breast Cancer Survivors. Journal Clinical Oncology, 25, 17 (June 10), 2352-2359.

Exercise Styles

Exercise Styles

Exercise Styles

There are so many wonderful styles of exercising all with there own special gifts. The following is a brief description of the styles I am familiar with. If you wish me to highlight another style, that you think our readers would enjoy learning more about please email me and I will post it on this page.

  • Yoga
  • Pilates
  • Dance classes
  • Tai Chi
  • Circuits
  • Body sculpt
  • Spinning
  • Kickboxing
  • Kettle bells
  • Jogging
  • Running
  • Swimming
  • Hydro-aerobics



My Thoughts About Exercise and Lifestyle..

We know exercise is good for us, but making it part of our daily lives is not that simple. Like you I struggle to keep it a non-negotiable part of my lifestyle.  What motivates me, particularly on those stressed out and exhausted days, is how happy and energized I feel afterwards and how proud I feel for doing the right thing for myself. My goal is to make exercise an established habit for myself.

Exercise makes my children and I feel good!

If the promise of long life is not working for you, maybe the promise of happiness will? As a Mom with two awesome teenagers I can feel guilty going off to exercise class. What’s interesting is, they encourage me to go. We are better together afterwards and laugh a lot more. They know that I have been seriously ill and some of our dear friends have died, so they worry. But maybe they see exercise as an insurance policy?  They both exercise too, one is in an athletic club and trains 4 days a week and the other plays for two field hockey teams and also trains 4 days a week. On vacation they like to ski and surf and to relax deeply as they take time to recharge. Suits me just fine!

Exercise an established habit.

I’m delighted my children love sports and training 4 days a week. I can safely say exercise is now an established habit for both of them. They love it and again that suits me just fine, I don’t have to stress discipline or time-management.

You gotta wanna.

Making the decision to integrate exercise into your day is the hardest part and being indecisive can be stressful. But please remember it is never too late and today is the first day of the rest of your life. Daily exercise is for every stage of our lives, as children, in college, at work, marriage, parenting, retirement and all during old age, to help each one of us enjoy a happier healthier life. Of course like everything, you can over do it, show up unprepared and even injure yourself as some of my patients can attest to.

Preparation is king.

No matter your style of exercising I recommend you work with experienced coaches or trainers who are all about your safety and earning your trust. It’s not just about showing up and jumping into a weight training class or running a 5km. So many people get injured and end up in physiotherapy clinics just like mine because they make the decision but then go straight from a sitting job to intense bouts of exercise. Ouch!

There is so much to learn about being healthy.

Its not all about exercise, there are several other things you may wish to learn that will compliment your efforts and improve your results. For example;

  • getting 7 to 8 hours of sleep every night,
  • why aerobics in the morning before breakfast burn more fat,
  • which diets best support your lean muscle development, 
  • what is so important about hydration and flexibility,
  • when core strength and posture are your first step,
  • how warm ups protect and prepare your body,
  • how pacing allows you to progress and succeed without injury,
  • how cool downs speed up your recovery,
  • how mental preparation and breathing connect your mind and body and builds your inner strength.

So my advice is to find a highly trained professional trainer or coach in your area of interest who will answer your questions and learn everything you can from them. You may also read more about these topics here on this website in the very near future.

Find your exercise style!

Take a pause and assess your lifestyle! Are you on track for health and happiness? Are you feeling your best and looking even better? If you already love exercise and are comfortable in your body, then you may just need to revisit your beliefs and practices and make sure you have sound and current information. Exercise and Health is big business with many stakeholders. Its important to be critical and to check the evidence and its source.

If you exercise regularly but have aches and pain in your joints or spine you may benefit from an assessment by your doctor or physiotherapist to check for muscle tightness, biomechanical stress or pathology. You may wish to reconsider changing from high impact exercise like road running, to lower impact cycling. Switching is hard to do, but remember who the beneficiary is and why pro-action and prevention is smarter than the cure.

If you are just starting out with regular exercise and are painfree, then its important to start wherever you are at and to progress patiently under the guidance of professionals who can help you with weight lifting technique, aerobic progression and lean muscle dietary support to reduce your risk of injury and so you proceed with a winning mix.

If you are just starting out with regular exercise and uncomfortable in your spine or joints I advise you first see your medical professionals such as your Chartered Physiotherapist to assess your readiness and to treat any existing issues.

Exercise and Seasonal Fun and Games.

My social life is geared around seasonal activities such as skiing and snowshoeing in the mountains in winter and playing tennis and golf all through the long summer days. This is good time spent with friends and family. So when I exercise I match the specifics of these activities with my exercise choices. For example to prepare for ski season I work on legs and balance and for golf and tennis I work on spinal flexibility, arm strength and explosive speed. For me nothing beats snowshoeing with friends and family in Vermont or a game of golf on the links courses on Donegal’s coast!

If you would like to share how you have integrated exercise into your lifestyle and how it has benefitted you, please do! Or if you have a comment or question please do not hesitate to contact me directly here via email.

Thank you and I look forward to hearing from you.


Shoulder Pain

Shoulder Pain and Injury

Shoulder Pain

A comfortable shoulder is essential for everyday life and sports.

The shoulder region includes the collarbones, chest muscles, glenohumeral joint, shoulder blades and back muscles. It is a ball and socket joint. Unlike the deep socket of the hip joint, it is shallow and so able to move in all directions. Experts describe it as being like a seal balancing a ball on its nose. It achieves this with an intricate combination of static ligaments, dynamic stabilizing muscles (the rotator cuff muscles) and scapular stabilizing muscles.

During your physiotherapy exam I will accurately identify which of these structures is responsible for your shoulder pain and which treatment combination will be most effective in reducing it.

 The 5 common causes of shoulder pain.

 Shoulder tendonopathies:

  • Rotator cuff injuries (acute, chronic or acute on chronic).
  • Shoulder impingement pain.
  • Overuse tendonopathy.
  • Complete rotator cuff tear.

Shoulder instability:

  • Shoulder instability.
  • Glenoid labral lesions.
  • Repetitive injuries.
  • Dislocation and recurrent dislocations.
  • Subluxations and recurrent subluxations.
  • Scapular dyskinesis.

Acromioclavicular  Joint Sprain

  • Localized acromio-clavicular joint pain.

Frozen shoulder

  • Shoulder stiffness.
  • Shoulder stiffness secondary to surgery, injury to a neck nerve or brachial plexus.
  • Idiopathic adhesive capsulitis.
  • Frozen shoulder.

Referred pain into the shoulder

  • Shoulder pain referred from problems in the cervical or thoracic spine.
  • Shoulder pain referred from tension in the trapezius, levator scapula and rotator cuff muscles.
  • Shoulder pain referred from tight muscles, trigger points and muscle fatigue.

 Less common causes of shoulder pain.

  • Nerve entrapment (e.g. the scapular or long thoracic nerves).
  • Biceps tendonitis.
  • Fracture and stress fractures.
  • “Burner” neuropraxia.
  • Tumor (e.g. bone tumors in the young)
  • Referred pain from: the diaphragm, gall bladder, perforated duodenal ulcer, the heart, the spleen (left shoulder pain), apex of the lungs.
  • Thoracic outlet syndrome.
  • Axillary vein syndrome

 Treatment techniques.

 The treatment techniques we select will depend on your diagnosis and how irritable the condition is. Examples of the different treatment techniques we may use include:

  • Rest and ice to sooth pain and reduce inflammation.
  • Glyceryl trinitrate {GTN} and single corticosteroid injection (from your GP or Sports Medicine Physician).
  • Manual therapy to the joints. (e.g. mobilization and manipulation)
  • Manual therapy for muscles (e.g. hold-relax, soft tissue therapy including trigger point massage, muscle massage and myofascial release).
  • Manual therapy for neural structures (e.g. neural tissue mobilization).
  • Therapeutic exercise to increase shoulder flexibility:
  • Early therapeutic exercises to correct underlying muscle weakness and/or instability. E.g. starting with closed chain rotator cuff exercises with hands on a wall, a table or tilt board practicing scapular retraction and protraction in a single plane, progressing to scapular elevation and depression of the entire scapula and then selective elevation of the acromion.
  • Early kinetic chain exercises to relink the legs, hips, the back and shoulder together to restore the force-dependent motor activation patterns and normal biomechanical positions. E.g. reaching over head with two hand weights while doing a chair stand to integrate the hip extensors and shoulder retractors.
  • Later conditioning exercises with isolated strengthening of the external rotators for correct balance between the internal and external shoulder rotators to prepare for sports and physical activity using theraband and dumbbells.
  • Plyometrics and closed chain exercises to develop momentum and force while maintaining perfect ball and socket kinematics. (e.g. low rows, lawn mover actions, push-up progressions, scaption exercises and many others).

The key to success…

Adherence or following through with your home shoulder exercises between sessions is the key to your complete recovery. To help you succeed at home we will provide you with tailored written instructions and / or video of the exercise progressions. Throughout treatment you are encouraged to email me directly with questions. For more information click here to contact me now via email.

Neck Pain

Neck Pain

A comfortable neck is essential for everyday life and sports.

The anatomy of the neck includes the muscles, bones and nerves between your skull and collarbones. A physiotherapy examination can accurately identify which segment is responsible for your neck pain and which treatment combination will be most effective in reducing the pain and correcting any abnormality, so you may safely return to your normal level of activity.

Common neck syndromes include:

  • The acute wry neck
  • Whiplash injury
  • Slow onset pinched nerve.
  • Arthritis pain and inflammation
  • Cervical posture syndrome
  • Osteoarthritis
  • Chronic headaches
  • Neck shoulder arm pain and tingling.
  • Muscle spasms, tightness, trigger points and weakness.

Treatment techniques include:

The treatment technique will depend on the diagnosis and how irritable the condition is.

Different treatment techniques include:

  • Manual therapy to the joints. (E.g. mobilization and manipulation)
  • Manual therapy for muscles (E.g. hold-relax, soft tissue therapy including trigger point massage, muscle massage and myofascial release).
  • Manual therapy for neural structures (E.g. neural tissue mobilization).
  • Therapeutic exercise to increase neck flexibility.
  • Neck muscles endurance training using pressure biofeedback.
  • Neck posture re-education.
  • Advice regarding body mechanics when using computers or driving for long periods.
  • Stress management (e.g. breathing exercises, yoga, meditation and relaxation massage).

As each person’s presentation is unique and there is often more than one structure involved (e.g. a joint and muscle) we commonly use a combination of treatment methods to achieve lasting results.

The key to success….

Adherence or following through with your home neck exercises between sessions is the key to your complete recovery. To help you succeed at home we will provide you with tailored, written instructions and / or video of the exercise progressions. Throughout treatment you are encouraged to email me directly with questions. For more information please click here to contact me now via email.

Back Pain

Back Pain

A comfortable low back is essential for everyday life and sports.

Back pain is a very common symptom in the general population and among athletes. Its affects 85% of us at some point in our lives. most of us get better after a few months, however 50% of us will have at least one recurrent episode.

Risk factors for Back Pain

Risk factors are the same for men and women up until the age of 50 and after 50 women are more at risk, as are women who have given birth.

There is a strong association between smoking and back pain.

Those of us who suffer from stress, anxiety and depression associated with work are also at increased risk.

Driving a car, sitting and jobs that involve bending, twisting and heavy physical labor are also risk factors.

The Surface Anatomy of The Low Back.

The surface anatomy of the lower back is composed of muscles and bones ( the vertebrae and joints ). The muscles include the erector spinae, lumbar multifidus and longissimus and the quadratus lumborum. The bones are five lumbar vertebrae denoted by the letter L and numbers 1 through 5. We describe the lumbar segments as the L1-2, L2-3, L4-5 or L5-S1 intervertebral joints. The other bones you can feel from the surface are the sacroiliac joints (sacrum/tailbone and ilium) and the bony rims of the pelvis the iliac crests.

Signs and Symptoms of Low Back Pain.

You may be complaining of acute low back pain, chronic low back pain or acute chronic pain.

The pain may be confined to the lower lumbar area (L4-5), be radiated into both buttocks or be on one side unilateral. It may be radiating to the buttock(s), hamstring(s) or lower leg(s).

The pain may be sharp piercing pain, radiating in a narrow band and associated with nerve root irritation as a result of lumbar disc bulge or herniation. More common is a deep-seated ache into the buttock and hamstring.

A physiotherapy examination can accurately identify which segment is responsible for your low back pain and which treatment combination will be most effective in reducing the pain and correcting any abnormality, so you may safely return to everyday life and sport. Occasionally the physiotherapy exam may not be able to identify the pain source and may refer you for review by your General Physician.

Common Sources of Low Back Pain.

  • Disc (bulging)
  • Spinal (apophyseal) joint
  • SI or sacroiliac joint injury/inflammation
  • Muscle trigger points (along the spine and in the buttocks).

Less Common Sources of Low Back Pain

  • Disc – herniated.
  • Spondylolisthesis
  • Lumbar instability
  • Spinal canal stenosis
  • Crush fracture vertebral body
  • Fibromyalgia.

Physiotherapy Treatment Techniques.

The treatment technique we select will depend on the diagnosis and how irritable your condition is.

Physiotherapy Treatment for Acute Low Back Pain

  • Bed rest in the position of most comfort for 48 hours.
  • Taping.
  • Pain medication may reduce muscle spasms and NSAIDS may reduce inflammation.
  • TENS, interferential stimulation, magnetic field therapy and only if travelling to physiotherapy is not aggravating.
  • Therapeutic exercise.
  • Education on the contributing postures.
  • Gentle massage.

Physiotherapy Treatment for Mild to Moderate Low Back Pain.

We can intensify the physiotherapy once the acute phase has passed and pain and inflammation have reduced.

Correcting the root causes of the mechanical strain for example:

  • Poor posture while sitting, standing or driving.
  • Poor lifting technique
  • Sleeping in a bed with poor support.

Pain Management and Medication:

  • In the short term NSAIDS (Non Steroidal Anti Inflammatory Drugs)
  • Or simple pain medications.

Mobilization and manipulation: To reduce pain and stiffness by:

  • Mobilizing.
  • Or manipulating the affected segments.

Soft tissue therapy.

  • Massage.
  • Trigger point massage.

Trigger Points.

The longer your low back pain has been present the more likely we are to find tight thickened muscles and fascia and multiple active trigger points. Common sites for low back trigger points are the muscles that run down the thoracic spine to the tailbone, the quadratus lumborum which runs between the lower ribs and the iliac crest and the gluteal muscles of the buttock area especially the gluteus medius which is accessible lateral to L4-5 and below the iliac crest.

Neural mobilization.

Tension in the nerves is common in patients with low back pain and tests positive if the slump test and/or straight leg raise test aggravate the low back pain. Careful mobilization of these neural tissues will improve the low back pain and gently recover normal neural movement.

Exercise therapy.

  • Stretching the muscles that are tight and contributing to the low back pain, for example; the erector spinae. psoas, iliotibial band, hip external rotators, hamstrings, rectus femoris and calf muscles.
  • Stabilizing ( the core spinal stabilizing muscles transversus abdominus and lumbar multifidus often need to be activated as a first step ).
  • Strengthening (often starts with posterior chain muscles in particular the gluteal and hamstring muscles).

Risk reduction going forward.

As 50% of us will have at least one recurrent episode of low back pain, treatment is not complete until we address reducing your risk. Patients who do lifting daily for example, will be shown how to prepare by gently warming-up their bodies, using a low-intensity muscle stretching program to practice twice weekly  x 10-15mins.

The key to success….?

Adherence or sticking with your home exercise program (HEP) between sessions is the key to your recovery. To help you succeed at home we will provide you with clear, written instructions and / or video of your specific exercise progressions. Throughout treatment you are encouraged to email me directly with questions. For more information please click here to contact me now via email. Thank you and I look forward to hearing from you.  Siobhan.

Cancer Rehabilitation

A brief history….


Cancer rehabilitation is highly valued by people who have cancer diagnoses and the evidence is mounting that patients who receive the services they need, do very well.

In 2006 The American Cancer Society estimated that 1.4 million Americans were newly diagnosed with cancer and predict that as we live longer and our populations age the incidence and prevalence will only increase. The probability of a man getting cancer (not counting skin cancer) is now 1 in 2, while for women it is 1 in 3. Unfortunately experts predict that women’s incidence will increase as will the incidence of our young people, today’s “obese generation”.

Thanks to increased awareness, screening, early diagnosis and treatment, Gerber et al (2001) and many others have reported that the five year survival rate is now more than 50%. In fact many of today’s cancer patients are living long lives and this is why cancer is now viewed as a chronic rather than a deadly illness. As a busy cancer rehabilitation Physical Therapist / cancer survivor myself, I am learning, relearning and sharing with my clinic patients and now you my readers what our cancer thought leaders and researchers are saying about prevention and cancer rehabilitation and what we can do every day to help ourselves. I want to do the best I can for myself and my wish for you, is that you can too.

Mastery in the self-management of your chronic disorder is the goal. 

With this view in mind, I have organized this website so you can read and learn about cancer rehabilitation. If you have a comment, wish to share your self-management tips or have a question please email me . I encourage you to make this site work for you and our readers and to ask questions. I will do the research and respond with the best evidence available. This back and fourth will help us develop in writing to specific issues and develop more relevant content for our readers. If you would like to sign up for our Newsletter please sign up here.

Topics I have selected to include on this website are designed to address the practical steps patients can take to address the common issues they may face. This includes, before, during and after treatment, the first three months post treatment and then beyond as you return to sports and recreational activities. I am a Physical Therapist,  other members of the team can provide you with psychological support, pain management, dietary support, weight management etc. As a Physical Therapist my focus is your physical well being and quality of movement through education, mobility, strength and independence. This site is about you being educated about the practical things you can do at each stage of your treatment so you feel well informed, relaxed, proactive, confident and safe in your exercise and rehabilitation decisions.

Topics included thus far are:

  • A brief history of cancer rehabilitation.
  • Cancer treatment and exercise.
  • Cancer survivorship and exercise.
  • Cancer prevention – new directions.
  • Mindfullness and exercise.
  • Posture and core stability and exercise.
  • Unrestraining the breath and breathing exercises
  • Leg liposarcoma surgery and radiation fibrosis and exercise
  • Leg liposarcoma surgery and lymphoedema and exercise.
  • Leg liposarcoma treatment and low back pain
  • Lung cancer treatment and exercise.
  • Breast cancer treatment – the first three months post – breast cancer surgery and breast reconstruction.
  • Breast cancer treatment and shoulder pain and exercise.
  • Breast cancer treatment and lymphoedema and exercise.
  • Breast cancer treatment and cording or axillary web syndrome and exercise.
  • Chemotherapy and aerobic exercise.
  • Chemotherapy induced peripheral neuropathy (CIPN) and exercise.
  • Cancer Related Fatigue (CRF) and exercise.
  • Radiation Fibrosis Syndrome (RFS) and exercise.
  • Cancer treatment and osteoporosis and joint pain and exercise.
  • Eye cancer treatment and exercise – “Gymnastics for the Eye and the Brain”
  • Head and neck cancer treatment and exercises – “Jaw Stiffness and Trismus.
  • Gynaecological cancer treatment and exercise.
  • Gynaecological cancer treatment and lymphoedema and exercise.

Cancer Rehabilitation

Starting in 1965, much of the credit for the development of rehabilitation for cancer patients can be traced back to Dr Howard Rusk the founder of The Rusk Institute of Rehabilitation Medicine in New York who spoke about the multiple needs of cancer patients at the first Cancer Conference on Rehabilitation in that year. Cancer Rehabilitation he said has three priorities (1) continuity of care (2) a team approach and (3) making quality of life the desired outcome of the team’s treatment.

In 1978 Lehmann et al, published Cancer Rehabilitation: assessment of need; development and evaluation of a model of care. In 1981 Dr Herbert Dietz, Jr developed the Dietz Scale for patient evaluation and published the first text on rehabilitation for cancer patients, Rehabilitation Oncology clarifying which services were most needed and that treatment be goal orientated and vocational.

In 1989, 1994, and 1998 Winningham et al, MacVicar et al and Dimeo et al, published works showing that cancer treatment symptoms, patients stamina and their physical performance of bone marrow transplant patients improved with aerobic exercise. Two groups of bone marrow transplant patients were compared. One group exercised in their rooms with stationary bike ergometers while the others did not. The exercise group showed improved haemoglobin and white cell counts as compared to the non-exercising patients. These results led to aerobic exercise prescription becoming a standard component of cancer care.

In October 1996, Lance Armstrong shared with the public that he had testicular cancer that had spread to his brain, lungs and abdomen. It was the same year I had been diagnosed and I appreciated his disclosure and pragmatic approach. His cancer treatments included brain and testicular surgery and extensive chemotherapy. In February 1997, he was declared cancer free and returned to his professional cycling career. In the same year he founded the Lance Armstrong Foundation. The website wwwlivestrong.org provides a wealth of modules about the deeply sensitive emotional issues common to cancer survivors and is an excellent resource.

In 2001 Dr Lynn Gerber from George Mason University wrote in Cancer Rehabilitation Into The Future, that “rehabilitation professionals are essential for the comprehensive care of cancer patients throughout the phases of their disease and must be trained to manage problems associated with cancer and its treatments”. Dr Gerber suggested that

“cancer is best thought of as a complex, chronic and common disorder” and calls for “collaboration and coordination between the oncology and rehabilitation communities”.

In this way any of the common problems such as post traumatic stress syndrome, frozen shoulder, severe lymphoedema, pain, swallowing difficulties, weight loss and fatigue are identified and treated early allowing patients to avoid pain, disability and depression. Today cancer rehabilitation is being offered at top University Health Programs training Doctors, Pathologists, Radiation Oncologists, Oncologists, Nurses, Physical and Occupational Therapists, Speech Language Pathology, Social Work and Psychotherapy, Diet and Nutrition.

In 2003 and 2006 The US Institute of Medicine (IOM) released two seminal reports on cancer survivorship. The first report Childhood Cancer Survivorship: Improving Care and Quality of Life, recommended lifelong follow-up healthcare for all childhood cancer survivors. The second report “From Cancer Patient to Cancer Survivor: Lost in Transition” focused on adult survivors. The latter acknowledges that,

…each cancer survivor has a unique health risk profile following chemotherapy, surgery and radiation and would benefit from an individualized and systematic plan for lifelong surveillance for recurrence, screening for treatment side-effects…

(e.g. shoulder pain, lymphoedema) and promotion of risk reducing lifestyles with targeted counseling and education. Cancer survivorship as a topic is a separate topic from Cancer Rehabilitation, I will be posting a page on survivorship in the near future so please check back.

In the general population, Physical InActivity (PIA) is linked with an increased risk of heart disease, diabetes, osteoporosis and all cause mortality. In 2005 Ganz and colleagues highlighted how young breast cancer survivors face an increased risk of these conditions. Fortunately Holmes and colleagues also in 2005 reported that…

…Physical Activity (PA) appears to reduce the risk of death from cancer treatment and improves weight maintenance and loss, cancer related fatigue, osteoporosis and bone metabolism.

Demark and colleagues also in 2005 surveyed prostate and breast cancer survivors and reported that 58% reported doing regular exercise but 42% did not.

In studies about the emotional effects of a cancer diagnosis and its treatment surgery, chemotherapy and radiation, researchers including Hegel et al, 2003, and Mehnert et al in 2007 found that…

…post-traumatic stress symptoms and disorder are common among adults diagnosed with cancer.

These studies recommended clinicians being sensitive to the concerns expressed by survivors and referring patients appropriately for treatment and support. In fact, Kevin C Oeffinger contributing author to the excellent book Cancer Rehabilitation Principals and Practice by Stubblefield and O ‘Dell (2009) advocates for routine screening by the team for psychosocial problems. He advises that “addressing fears and concern, providing counseling, and managing psychological  morbidity are some of the most important ways to maximise the health of a cancer survivor”. Dr. Kevin Oeffinger works in Memorial Sloan-Kettering Cancer Center and is Chair-Elect of ASCO’s Cancer Survivorship Committee.

There is a growing number of high quality online resources some more suited to the public. I will be posting a separate page about online resources so please check back for that information.

In 2009 MSKCC Doctors

…Stubblefield and O’ Dell published CANCER Rehabilitation – Principles and Practice (2009 Demos Medical Publishing),

a rich resource for Oncology/Rehabilitation teams. Experts in oncology, surgery, radiation and rehabilitation convened to share their knowledge and opinions on a wide variety of topics. This included pain management, therapeutic modalities, therapeutic exercise, complementary therapies, cancer related fatigue, swallowing and communication dysfunction, lymphoedema, osteoporosis, graft versus host disease, chemotherapy induced peripheral neuropathy, radiation fibrosis, sexuality issues, nutritional care, cognitive dysfunction, bowel and bladder dysfunction, balance and gait problems, metastatic cancer, computer adaptive testing (CAT) of patients function and levels of independence and much much more.

In 2012 Physical Therapist Jill Brinkley and colleagues published…

A Prospective Surveillance Model (PSM) for Rehabilitation for Women with Breast Cancer in the Journal CANCER (Vol 118/ Issue 8 April 2012).

This work contributed to the National Institute of Health (NIH) and The American College of Surgeons Committee on Cancer considering including Cancer Survivorship Care Plans and Cancer Rehabilitation in the emerging accreditation process of cancer centers throughout the United States.

In 2013 the Rehabilitation Team at Memorial Sloan Kettering Cancer Center (MSKCC) in New York many of whom had also co-authored CANCER Rehabilitation – Principles and Practice, held their first Annual Cancer Rehabilitation conference and in 2014 their second. Contact the rehabilitation department at MSKCC.org in New York for details of this year’s conference

In 2004 Jill Brinkley Physical Therapist in Atlanta, and the co-authors of the Breast Cancer Prospective Surveillance Model hosted a Breast Cancer Rehabilitation conference. Contact  http://myturningpoint.org/ for details of this years conference. These conferences were well attended by team members of the oncology / rehabilitation community and indicative if I may suggest, of both the wealth of knowledge our experts have to share and the growing demand from such conferences.

Sharing what we learn….

Since the beginning cancer survivors and their loved ones have been active and organized and are clearly communicating what they need. The number and volume of these voices is increasing every year and gaining momentum. In small towns and villages all around the world active cancer support groups are raising awareness and money for research. Celebrities like Lance Armstrong and Angelina Jolie have generously disclosed their personal experiences to raise the profile of cancer and the standards of care. Now thanks to the Internet, Facebook, Twitter, Social Media, Google Translate, You-Tube captions, websites such as this one here and online forums etc etc, we are now able to share across economic and language barriers to give and feel support for each other. Pretty exciting times indeed!

If you have a question, wish to share your self management tips or wish to comment, please email me hereand I look forward to hearing from you!

Kind regards





Lymphoedema is an abnormal accumulation of protein-rich fluid (oedema ) in the interstitium most often in the arm(s) and/or leg(s), and occasionally in other parts of the body. This causes chronic inflammation and reactive fibrosis of the affected tissues. Lymphoedema can develop when lymphatic vessels are missing or impaired (primary), or when lymph vessels are damaged or lymph nodes removed with cancer surgery (secondary).

Conditions treated here at The O’ Reilly Centre:

Secondary arm, breast and trunk lymphoedema
Secondary leg lymphoedema
Primary leg lymphoedema
Genital and lower abdominal lymphoedema
Lipo-lymphoedema and lympho-lipoedema
Venous-lymphatic insufficiencies
Head and neck lymphoedema

Services and Treatment provided:

Assessment of swelling and discussion of treatment options
Manual Lymph Drainage (MLD)
Complete Decongestive Therapy (CDT)
Custom made compression garments (Measurement and fitting)
Training in Self Manual Lymph Drainage
Training in Self Multilayer Bandaging
Exercise prescription and preparation for return to sports/recreation
Follow up support
Referral to multidisciplinary team as needed

The benefits of treatment.

The % change in limb volume can be measured before and after treatment (CDT). Table 1 shows % reductions by some of the world’s leading clinical lymphoedema experts. However, as each and every patient is unique, these results serve as estimates of results, some patients may do better while others will reduce less dramatically. It is simply not possible to guarantee results. The Physiotherapist will carefully assess each patient’s stage of lymphoedema and/or post surgical healing and taking into consideration the persons general health and ambitions, will recommend what treatment the treatment options are, give an estimate of expected results and benefits, and together we proceed from there.

Author(s) % Reduction in limb volume with complete decongestive therapy (CDT) treatment Year of study
Foldi >50% 1989
Casley-Smith >60% 1991
Boris et al 65.6% 1997
Leduc 50% 1998
Ko et al 63.4% 1998
Lerner 68% 1998

The stages of lymphoedema.

Stage 0: subclinical state swelling not evident despite impaired system
Stage 1: early onset swelling, that reduces with elevation, pitting, no fibrosis (feels soft, spongy)
Stage 2: swelling, limb elevation may not change it, pitting more difficult.
Late Stage 2: swelling is fibrosing (feels harder)
Stage 3: swelling is fibrosing and sclerosing (severe induration) no pitting, Skin changes (papillomas, hyperkeratosis, etc.)
Late stage 3: Elephantiasis

The characteristics of lymphoedema.

  • Slow onset, progressive
  • Pitting (early stages)
  • In the leg it starts distally and in the arm more proximally
  • The leg
  • Squaring of toes, Stemmer’s sign positive
  • Dorsum of foot “buffalo hump”
  • Loss of ankle contour
  • Asymmetric (affects legs asymmetrically)
  • In the arm
  • Fullness under the armpit, lateral chest, below the elbow
  • Clothes feel tighter in upper arm
  • Watches and jewelry not fitting
  • Squaring of fingers, Stemmer’s sign positive
  • Cellulitis is common
  • It is rarely painful
  • Discomfort is common
  • Heaviness, achiness
  • Skin changes
  • Hyperkeratosis, Papillomas, Peau d’orange
  • Ulcerations unusual
  • In contrast with venous disease the skin maintains hydration and elasticity for longer in the disease process

Diagnostic Tests

Physical Exam and History is the most important.
Lymphoscintography – a lymphatic function test
Doppler/Duplex Ultrasound to rule out a deep venous thrombosis (DVT)
CT scan, MRI to rule out cancer.


Penicillin (Antibiotics) to treat infections e.g. Erysipelas, Cellulitis, Lymphangitis.
Diuretics are useful for certain oedemas, but unfortunately are not useful for lymphoedema, as they drain the fluid but not the proteins and this is a protein rich oedema.

Treatment for Lymphoedema.

Complete Decongestive Therapy.

If you and your Physiotherapist agree that CDT is the indicated treatment for your condition, she will explain what is involved and carefully guide you through the process. This is a time consuming treatment but proven and safe. In some cases treatment can fail to yield the desired results but this is usually due to inaccurate diagnoses or poor compliance. So it is important to be well assessed and well prepared.

CDT treatment consists of two phases. The first phase is completed at the centre and the second at home with follow up support as needed. The objective of the first phase is to reduce the volume of the limb andthe second phase is to maintain that reduction so you may participate in regular activities of daily living including sports and recreation.

As with the successful treatment of all chronic conditions education and early intervention yields the most benefits. But it is never too late for treatment and 100% pf people with lymphoedema will enjoy some benefit from an accurate assessment of their condition and education on how they can help themselves.
The 4 Components of the two phases of CDT include: MLD, MLLB, Skin Care and Exercise

Manual lymph drainage (MLD).

An MLD massage, focuses on the lymphatic system. Benefits include: increases in lymph vessel activity, increases in re-absorption of protein-rich fluid (lymph), it promotes healing and relaxation, has an analgesic (soothing) effect and boosts the immune system.
MLD to divert accumulated lymph fluid. When patients have an accumulation of fluid they benefit from a particular sequence of MLD to divert the fluid to a healthy part of the lymphatic system. After treatment patients are trained to do self MLD (SMLD) at home for long term benefit.

Multi-layer bandaging (MLLB).

During phase 1 short stretch bandages are applied daily until circumferential measurements of the limb reduces significantly. This takes between 2 to 4 weeks. Once the limb is reduced, the reduction is maintained by a custom made ELVAREX compression garment. Each patient benefits from a particular approach to MLLB and is trained to do self MLLB at home for long term benefit.

Meticulous skin care.

Oedema dries out the skin and cuticles which may be easily broken and so increases a patients risk for cellulitis or other infections. Treatment includes meticulous skin care using low pH soaps to gently clean skin and moisturizers with 10% urea to strengthen the skin and the lymphatic system which is under the skin. Supple clean skin and nail cuticles decrease risk of infection (cellulitis). After treatment, patients are trained in meticulous skin and nail care and cellulitis risk reduction practices. This includes avoiding breaking the skin and inflammation from injury, nicks, bites, burns, sunburns, gardening and overuse or sports related injuries. Patients are advised how to clean and treat all injuries immediately and to call their GP at first sign of infection to avoid cellulitis. Finally patients are recommended to use low pH products (e.g. low pH soaps and moisturizers with urea) as part of their regular personal hygiene program for clean supple skin and long term benefit.


Exercise with lymphoedema follows a sequence that starts with the central muscle pumps to clear the way for lymph from the swollen limbs that can be mobilized by arm or leg muscles pumps. Each patient will benefit from a specific sequence of exercises and after treatment is trained to do a daily exercise sequence for long term benefits.


Exercise for general fitness is the ultimate objective of treatment so patients can enjoy general health benefits including: Normal blood pressure, aerobic fitness, bone density, balance, body weight and the ability to participate in activities of daily living, sports and recreational activities with family and friends.

If you have a question or a comment please contact me directly now via email.