Patient self-massage for breast cancer-related lymphedema

Patient self-massage for breast cancer-related lymphedema

Anne Williams gives a guide to patient self massage in the management of lymphoedema.
Anne F. Williams RGN, MSc, DN, RNT, Onc Cert, is a Lymphoedema Specialist Practitioner Dalkeith, Scotland.

Article accepted for publication: November 2005

Keywords:

Lymphoedema Lymphatic system; Simple lymphatic drainage (SLD) Manual lymphatic drainage (MLD); Decongestive Lymphatic Therapy (DLT); Lymphedema

The incidence of lymphoedema following breast cancer treatment is around 21 per cent (Clark et al., 2005) with reported prevalence rates as high as 38 per cent (Kissen et al., 1996; Mortimer et al., 1996). In most cases lymphoedema may remain relatively mild but is usually a chronic condition requiring lifelong treatment and care. Self-management practices therefore play a crucial role in maximising long-term independence in people with lymphoedema. This paper will overview the problem of breast cancer-related lymphoedema, discuss the principles and evidence base underlying the use of massage in lymphoedema and describe the practical application of a patient self-massage method for breast cancer- related lymphoedema.
Breast cancer-related lymphoedema Lymphoedema presents as swelling of the arm and/or trunk and may affect the whole limb or be confined to the breast, hand, forearm or upper arm. Surgery and radiotherapy, particularly the level of axillary lymph node intervention, is widely acknowledged as impacting on lymphoedema incidence. Recently, specific risk factors including hospital skin puncture, mastectomy and BMI Ž 26 have been found to be significant (Clark et al., 2005). As the arm and adjacent trunk quadrant share lymph drainage routes via the axilla, trunk oedema may occur, particularly posterior to the axilla. Since the advent of breast conservation surgery, breast oedema is also more common (Mondry & Johnstone, 2002) although this problem is rarely acknowledged in the literature.

The management of breast cancer-related lymphoedema requires a partnership between the patient and practitioner. Intensive treatment by the practitioner including daily manual lymphatic drainage massage and multi-layer bandaging, may be required to reduce limb volume, reshape the limb and improve skin and tissue condition. In the maintenance phase treatment is undertaken by the patient who develops significant expertise in self-care measures including skin care, exercises, wearing of hosiery garments and a type of self-massage often referred to as simple lymphatic drainage (SLD), a modified form of manual lymphatic drainage (MLD).

Manual lymphatic drainage

Manual lymphatic drainage is a specialised type of massage developed in the 1930's by Dr Emil Vodder, a Danish physical therapist who realised that gentle but very specific hand movements on the skin could influence the lymphatic system (Table 1). Several schools of MLD now exist worldwide including the Vodder, Földi, Casley-Smith and Leduc, although all follow similar principles in relation to lymphoedema treatment (Table 2).

Effectively, MLD moves the skin in specific directions to provide variations in tissue pressure that encourage the uptake of fluid and proteins into the initial lymphatics, without increasing capillary filtration. The movements also enhance the natural contraction of pre-collector and collector lymphatics and can be applied to influence drainage through lymph node groups.

MLD is most effective when used in combination with compression therapy, skin care and appropriate exercise and may be applied daily for a course of 2-4 weeks (Table 3). Treatment usually takes 30-60 minutes and begins centrally and proximally, often with clearance of the neck lymphatics and breathing exercises. The healthy, unaffected lymph nodes and trunk are then treated prior to treatment of the affected trunk and limb. MLD is used on the anterior and posterior trunk where possible. In a patient with a right-sided arm lymphoedema, the direction of drainage is usually towards the healthy lymph nodes in the left axilla and right inguinal areas.

Simple lymphatic drainage

Application of self-massage techniques to lymphoedema practice began in the UK in the late 1980's partly due to limited accessibility to MLD at this time (Badger et al., 1988). The British Lymphology Society later described this approach as 'simple lymphatic drainage' (SLD), based on the principles of MLD and designed to be easily accessible to patients and their relatives (British Lymphology Society, 1999). The main focus of SLD is treatment of the trunk, using simple hand movements and breathing exercises.

et al., 1988). The British Lymphology Society later described this approach as 'simple lymphatic drainage' (SLD), based on the principles of MLD and designed to be easily accessible to patients and their relatives (British Lymphology Society, 1999). The main focus of SLD is treatment of the trunk, using simple hand movements and breathing exercises.

Evidence base for MLD and SLD

There is a limited evidence base related to the use of manual lymphatic drainage, mainly in breast cancer-related lymphoedema. Various studies have highlighted the efficacy of MLD in reducing limb volume and improving aspects of quality of life (Sitzia et al., 2000; Williams et al., 2002). Johansson et al. (1999) also reported a significant reduction in excess limb volume and pain following MLD and compression bandaging, as compared to compression bandaging alone. Other studies have suggested that MLD does not contribute to limb volume reduction (Anderson et al., 2000) or is more effective in certain groups such as those with mild lymphoedema (McNeeley et al., 2004). However, many studies are limited by small samples, short study periods and unreliable or insufficient outcome measures, such as no measurement of trunk oedema.

Similarly, studies of SLD have failed to provide longitudinal data on the effect of long term self-massage and to date there is no empirical evidence to support the use of SLD despite its wide use in clinical practice. Much of the literature on self-massage is from the UK and Australia, describing a variety of techniques (Gillham, 1994; Bellhouse, 2000). Most information leaflets on lymphoedema also contain a section on SLD and videos from organisations such as the Lymphoedema Support Network provide useful instructions on SLD.

Studies of self-management practices have highlighted the difficulties for patients in adhering to treatment routines (Rose et al., 1991; Bunce et al., 1994). Piller et al. (1994) have described the importance of self-massage in maintaining and improving results of intensive treatments and discuss the use of massage at a focal point of the day, such as during showering, to improve adherence. The use of partners or carers in providing the massage has been described (Casley-Smith & Casley-Smith, 1997; Forchuk et al., 2004) and the fact that patients who have experienced MLD appear to be more confident using SLD has also been identified (Williams et al., 2002).

Practical application of the SLD method

No definitive method of SLD exists and the method taught will depend on the individual needs of the patient and the type of MLD used by the lymphoedema practitioner. Table 4 provides an example of an SLD sequence for treatment of right sided breast cancer-related lymphoedema.

Breathing exercises are important as they enable clearance of the central lymphatics and influence lymph flow up the thoracic duct and into the venous system (Vaqas & Ryan, 2003). Treatment of the neck and shoulder aims to enhance drainage towards the lymph nodes at the neck and supraclavicular fossa, adjacent to the area where the lymphatics drain into the venous circulation. Massage to the unaffected lymph nodes and trunk clears the way ahead, encouraging fluid to drain away from the oedematous areas. The treatment of the midline watershed areas is probably important in opening the collateral pathways that are required in the longer term although the scientific and functional changes produced by MLD or SLD have not been fully established. SLD treatment of the arm and shoulder is useful in some patients, following trunk clearance although not included here.

Teaching SLD to patients

SLD is a specialised technique requiring a very gentle touch, slow pace and many repetitions, as with MLD. This can be difficult to achieve and patients need to be advised to avoid firm pressures, using talc if necessary to prevent friction and skin reddening. A clear description of the lymphatic system along with explanation and rationale for the treatment is important to enable patients to understand why and how it is used. Several other points should be considered when teaching SLD:

- The person teaching SLD should ideally be experienced in MLD.

- Sufficient time should be given to teaching SLD in an appropriate and quiet setting, so the patient feels comfortable and can practice the techniques.

- Written information, drawings or a video should be provided to supplement the teaching.

- Follow up appointments should be made to evaluate technique.

- Patients should be encouraged to fit SLD in with their lifestyle, finding a suitable time of the day with minimal distractions.

- If time is limited they may have to modify the SLD and focus mainly on the trunk rather than the neck or limb.

- Patients should be encouraged to identify a partner to help with the SLD, but only if both feel comfortable with that approach.

- Those who will clearly benefit from SLD, such as patients with breast oedema, should be targeted for teaching.

-SLD should be combined with exercises and the latter used if patients are unable or unwilling to do SLD.

- Compression garments should usually be worn when doing SLD.

Adhering to a prolonged course of SLD may be daunting for some patients and one option is to suggest using SLD for a given period of time such as 6-8 weeks. At this point the frequency of treatment may be reduced, with SLD used at particular times, after a long car journey for example, when the limb has become more swollen.

Conclusion

Simple lymphatic drainage is used to supplement and complement MLD treatments. Further research is however required to inform practice in this area and evaluate the role and use of SLD over the longer term. Consideration should be given to how and when SLD is taught to exploring the use of information and teaching resources for this patient group.

Table 1: The lymphatic system

The lymphatic system consists of a complex network of lymph vessels and approximately 700 lymph nodes, many of which are situated in groups in the neck, axilla, inguinal area and deep in the abdomen. Variation in tissue pressures encourages interstitical fluid to move into the plexus of thin walled lymph capillaries in the dermis and through a series of pre-collector and collector lymphatics that gradually increase in size. It is then filtered through the lymph nodes before being returned to the blood circulation. One of the largest lymph vessels, the thoracic duct runs alongside the aorta and drains the lymph from the legs and left side of the body. The right lymphatic duct drains the right upper body. These large vessels drain into the venous blood circulation near the subclavian vein.

The lymphatic system has various functions:

- maintaining tissue fluid balance

- transporting fats and proteins

- providing immunity (lymphocytes are produced in the lymph nodes)

The superficial lymph drainage routes of the skin are divided into skin territories or lymphotomes according to the direction of flow into regional lymph node groups. The division between these territories is often referred to as the 'watershed'.

Table 2: Principles of MLD and SLD in lymphoedema

Table 3: Indications and contraindications for MLD and SLD in lymphoedema

MLD

- Component of the Decongestive Lymphatic Therapy (DLT) programme to reduce lymphoedema; often applied daily over a 2-4 week course.

- Used periodically (eg weekly) during the maintenance phase if trunk oedema is persistent.

- Used specifically for trunk, breast, genital and head/neck oedema.

- Treatment of tissue fibrosis and scarring.

SLD

Useful in the maintenance phase when patients are undertaking self treatment (daily use).

- Used following DLT.

- Used if MLD is not available.

- Particularly useful for patients with trunk oedema.

Contraindications

MLD

- Acute cellulitis.

- Recent thrombosis

- Untreated cardiac disease/failure.

- Active tuberculosis.

- Untreated malignancy.

SLD

- Similar to MLD.

Table 4: Simple lymphatic drainage for right sided lymphoedema following breast cancer treatment

- Sit or lie down with shoulders relaxed and hands resting below ribs.
- Breathe in and feel your abdomen rising (imagine a balloon inflating under your hands).
- Slowly breathe out and press gently inwards with your hands. - Repeat 5 times.

- Place your relaxed hands on your neck below your ears.
- Gently stretch or stroke the skin down towards your shoulders and release.
- Repeat this 5 times.

- Place your relaxed hands on your shoulders and stroke inwards to the hollow behind your collarbone.
- Use your finger pads to make gentle pressures into the hollow behind your collarbone.
- Repeat this 5-10 times.

- Place your right hand in your left armpit.
- Massage upwards into your armpit and release (10 times).
- Ensure the direction is always upwards.

- Place relaxed hand on your chest.
- Stroke the skin across towards your left armpit.
- Repeat from position 1 x 10 times.
- Repeat from position 2 x 10.
- Repeat from position 3 x 10.
- Always stroke in the direction towards the left armpit

- Place relaxed hand below your waist on the right side.
- Stroke the skin downwards over the hip.
- Repeat from position 1 x 10 times.
- Repeat from position 2 x 10.
- Repeat from position 3 x 10.
- Always stroke down away from the affected area.

- Sitting or lying.
- Massage upwards into the left armpit and release (10 times).
- Ensure the direction is always up.

- Place relaxed hand/s on the back.
- Stroke the skin across towards the left armpit.
- Repeat from position 1 x 10 times.
- Repeat from position 2 x 10.
- Repeat from position 3 x 10.
- Always stroke in the direction towards the left armpit.

Article with charts and graphs: JCN Online

Secondary Leg Lymphedema

Related terms: leg swelling, leg edema, leg lymphoedema

Introduction

If you ask most people that are familiar with lymphedema the question, "Are you aware of secondary lymphedema," most would reply that "yes, it is where the arm swells after the lymph system has been damaged by breast cancer biopsy and treatment."

Even if they are aware that such a condition as secondary lyg lymphedema exists, their response might well be that it is a small group of afflicted men who have prostate cancer.

Thus shows how little awareness there is about this particular form of lymphedema. Even in the lymphedema world it is a poor step-child. However, if the membership of Lymphedema People and the posts in the online lymphedema support groups are an indication, this condition is increasing dramatically.

The reasons for this increase are multiple. They include:

1. increased survival rates of cancer
2. improved treatment of trauma injuries that previously would have been terminal
3. increase in antibiotics for infections and treatment for other conditions that previously might have resulted in death.

It is also important to note that secondary leg lymphedema does not necessarily start immediately after the injury/trauma. It may not start for years.

What is secondary leg lymphedema?

Secondary lymphedema is a condition where the lymphatic system has been damaged. The main job of this system is to move excess through and out of our bodies. When it becomes damaged or impaired, it is no longer able to accomplish this function and these fluids (lymph fluids) collect in the interstitial tissues of our legs. This causes leg swelling.

Another important function of the lymph system is to help our bodies fight infections. With lymphedema, this ability is also weakened and the patient becomes more susceptible to infections.

What causes secondary leg lymphedema?

Secondary leg lymphedema (also referred to as acquired lymphedema) is caused by or can develop as a results of:

1.) Surgeries involving the abdomen or legs where the lymph system has been damaged. This includes any intrusive surgery. Examples are vein stripping surgery for peripheral vascular disease hip replacement knee replaement insertion of bolts, screws and other devices in orthopaedic repair lipectomy

2.) Removal of lymph nodes for cancer biopsy. These cancers include, but are not limited to prostate cancer testicular cancer ovarian cancer uteran cancer vulva cancer bladder lymphoma - both hodgkins and non hodgkins melanoma colon Kaposi Sarcoma

3.) Radiation treatment of these cancers that scars the lymph system and lymph nodes

4. Some types of chemo therapy. For example, tamoxifen has been linked to secondary lymphedema and blood clots.

5.) Severe infections/sepsis. Generally referred to as lymphangitis, this is a serious life-threatening infection of the lymph system/nodes.

6.) Trauma injuries such as those experienced in an automobile accident that severly injures the leg and the lymph system.

7.) Burns - this even includes severe sunburn. We have a member that acquired secondary leg lymphedema from this.

8.) Bone breaks and fractures.

9.) Morbid obesity - the lymphatics are eventually crushed by the excessive weight. When that occurs, the damage is permanent and chronic secondary leg lymphedema begins.

10.)Insect bites

11.)Parasitic infections

What are some of the symptoms of secondary leg lymphedema?

These symptoms may include:

1.) Unexplained swelling of either part of or the entire leg. In early stage lymphedema, this swelling will actually do down during the night and/or periods of rest, causing the patient to think it is just a passing thing and ignore it.

2.) A feeling of heaviness or tightness in the leg

3.) Increaseing restriction on the range of motion for the leg.

4.) Unsual or unexplained aching or discomfort in the leg.

Treatment

The preferred treatment today is decongestive therapy. The forms of therapy are complete decongestive therapy (CDT) or manual decongestive therapy (MDT), there are variances, but most involve these two type of treatment.

With these massage treatments, swelling is reduced and then the patient is fitted with a pre-measured custom pressure garment to keep the swelling down.

Manual Lymphatic Drainage (MLD): is a unique, therapeutic method of stimulating the movement of fluids in the tissues. The gentle, rhythmic, pumping, massage movements follow the direction of lymph flow and produce rapid results. It assistes the cutaneous lymphatics in picking up and removing not just fluids, but all the waste products, protein partical and debris from our system. It also is successful in breaking fibrosis and fibrotic areas of a lymphodemous limb.

This treatment was created and developed Danish therapists Dr. Emil Vodder and his wife, Estrid, in the 1930's and was introduced in Paris in 1936. They are also credit with creating a specialty of medicine called Lymphology.

First brought to North America in 1982, the school is located in Victoria, British Columbia, Canada. Before it was introduced the standard treatment course in North American was either a surgery called debulking or the use of compression machines wherein the limb was literally squeezed by pneumatic air pressure.

Comprehensive Decongestive Therapy (CDT): is used primarily in the treatment of lymphedema and venous insufficiency edema. It is a combination of MLD, bandaging exercises and skin care. CDT may also involve breathing exercises, compressive garments and dietary measures. A frequent indication for CDT is lymphedema caused by irradiation or surgery due to cancer. It can relieve edema, fibrosis and the accompanying pain and discomfort.

Also known as Complete Decongestive Physiotherapy (CDP), this treatment therapy was pionered in the United States by Dr. Robert Lerner.

Preventative Steps from the National Lymphedema Network

18 Preventive Steps For LOWER Extremities For the patient who is at risk of developing lymphedema, and for the patient who has developed lymphedema.

WHO IS AT RISK?

At risk is anyone who has had gynecological, melanoma, prostate or kidney cancer in combination with inguinal node dissection and/or radiation therapy. Lymphedema can occur immediately postoperatively, within a few months, a couple of years, or 20 years or more after cancer therapy. With proper education and care, lymphedema can be avoided or, if it develops, kept under control. (For information regarding other causes of lower extremity lymphedema, see What is Lymphedema?)

The following instructions should be reviewed carefully pre-operatively and discussed with your physician or therapist.

Absolutely do not ignore any slight increase of swelling in the toes, foot, ankle, leg, abdomen, genitals (consult with your doctor immediately).

Never allow an injection or a blood drawing in the affected leg(s).

Wear a LYMPHEDEMA ALERT Necklace.

Keep the edemic or at-risk leg spotlessly clean. Use lotion (Eucerin, Lymphoderm, Curel, whatever works best for you) after bathing. When drying it, be gentle, but thorough. Make sure it is dry in any creases and between the toes.

Avoid vigorous, repetitive movements against resistance with the affected legs.

Do not wear socks, stockings or undergarments with tight elastic bands. Avoid extreme temperature changes when bathing or sunbathing (no saunas or hottubs). Keep the leg(s) protected from the sun.

Try to avoid any type of trauma, such as bruising, cuts, sunburn or other burns, sports injuries, insect bites, cat scratches. (Watch for subsequent signs of infection.)

When manicuring your toenails, avoid cutting your cuticles (inform your pedicurist).

Exercise is important, but consult with your therapist. Do not overtire a leg at risk; if it starts to ache, lie down and elevate it.

Recommended exercises: walking, swimming, light aerobics, bike riding, and yoga.

When travelling by air, patients with lymphedema and those at-risk should wear a well-fitted compression stocking. For those with lymphedema, additional bandages may be required to maintain compression on a long flight. Increase fluid intake while in the air.

Use an electric razor to remove hair from legs. Maintain electric razor, properly replacing heads as needed.

Patients who have lymphedema should wear a well-fitted compression stocking during all waking hours. At least every 4-6 months, see your therapist for follow-up. If the stocking is too loose, most likely the leg circumference has reduced or the stocking is worn.

Warning: If you notice a rash, itching, redness, pain, increase of temperature or fever, see your physician immediately. An inflammation or infection in the affected leg could be the beginning or a worsening of lymphedema.

Maintain your ideal weight through a well-balanced, low sodium, high-fiber diet. Avoid smoking and alcohol. Lymphedema is a high protein edema, but eating too little protein will not reduce the protein element in the lymph fluid; rather, this may weaken the connective tissue and worsen the condition. The diet should contain easily-digested protein such as chicken, fish or tofu.

Always wear closed shoes (high tops or well-fitted boots are highly recommended). No sandals, slippers or going barefoot.

Dry feet carefully after swimming. See a podiatrist once a year as prophylaxis (to check for and treat fungi, ingrown toenails, calluses, pressure areas, athelete's foot).

Wear clean socks & hosiery at all times. Use talcum powder on feet, especially if you perspire a great deal; talcum will make it easier to pull on compression stockings. Be sure to wear rubber gloves, as well, when pulling on stockings.

Powder behind the knee often helps, preventing rubbing and irritation.

Unfortunately, prevention is not a cure. But, as a cancer and/or lymphedema patient, you are in control of your ongoing cancer checkups and the continued maintenance of your lymphedema.

Revised (c) January 2003 National Lymphedema Network. Permission to print out and duplicate this page in its entirety for educational purposes only, not for sale. All other rights reserved. For more information, contact the NLN: 1-800-541-3259

See Also:

Leg Lymphedema

NEW LYMPHEDEMA PEOPLE FORUMS

Remember, this was the week with the date 06/06/06??With only an hours notice GoDaddy, our fee-paid host of LymphedemaPeople abruptly decided our forums were gobbling up too much space,so they shut them down.

As a result, we had to put in completely new ones.

But, it takes more then lymphedema, lymphoma or GoDaddy to slow usdown and...

THE NEW FORUMS ARE UP AND RUNNING!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Our new forums represent a significant upgrade with many newfeatures, upgraded security and abilities. There are a number ofnew forums that we have added (including one for cancer) and many familiar ones like our children's forum, advocacy and more.

If you were a member of our old forums, we would love to have youcontinue with our family.

Please go ahead and reregister. We were hoping to automaticallytransfer membership, but that may be more problematic then werealized.

If you have never joined us there, come, share the excitement as wemove forward with the most comprehensive website on the internet forlymphedema and lymphatic conditions.

I will be working feverishly this weekend to see that all thearticles of the old forums are in place again.

In the meantime look forward to seeing everyone there!!!

Lymphedema People

My Best to All!!!!

Pat

Can manual treatment of lymphedema promote metastasis?

J Soc Integr Oncol. 2006 Winter;4(1):8-12.

Godette K, Mondry TE, Johnstone PA.

Complete decongestive therapy (CDT; alternatively known as complete decongestive physiotherapy) is a treatment program for patients diagnosed with primary or secondary lymphedema. CDT incorporates manual lymphatic drainage (MLD), a technique involving therapeutic manipulation of the affected limb. There are several contraindications to performing CDT. Relative contraindications include hypertension, paralysis, diabetes, and bronchial asthma. General contraindications include acute infections of any kind and congestive heart failure. Malignant disease is also widely considered a general contraindication; a current vogue concept is that MLD will lead to dissemination and acceleration of cancer. However, cancer research supports the contention that this therapy does not contribute to spread of disease and should not be withheld from patients with metastasis. The intent of this article is to review these data.

PMID: 16737666 [PubMed - in process]

Related Articles

Decongestive lymphatic therapy for patients with cancer-related or primary lymphedema.

Szuba A, Cooke JP, Yousuf S, Rockson SG.Stanford Lymphedema Center, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA.

PURPOSE:

A prospective evaluation was undertaken to assess the efficacy of intensive, short-term decongestive lymphatic therapy coupled with focused patient instruction in long-term self-care for the management of lymphedema.

METHODS:

The therapeutic responses of 79 patients with lymphedema were analyzed prospectively. Each patient received intensive, short-term decongestive lymphatic therapy, with quantification of the extent and durability of the clinical response. Decongestive lymphatic therapy was performed by therapists trained in these techniques. The mean (+/-SD) duration of therapy was 8+/-3 days. Instruction in self-management techniques was incorporated into the therapeutic regimen by day 3 of the patient's treatment. The mean period of follow-up was 38+/-52 days. Changes in the volume of the affected limb were assessed with a geometric approximation derived from serial measurements of circumference along the axis of the limb.

RESULTS:

The mean short-term reduction in limb volume was 44%+/-62% of the excess volume in the upper extremities and 42%+/-40% in the lower extremities. At follow-up, these results were adequately sustained: mean long-term excess volume reductions of 38%+/-56% (upper extremities) and 41%+/-27% (lower extremities) were observed. CONCLUSION: Decongestive lymphatic therapy, combined with long-term self-management, is efficacious in treating patients with lymphedema of the extremity.

Publication Types:
Evaluation Studies

PMID: 10996580 [PubMed - indexed for MEDLINE]

* * * *
Spread of melanoma after lymphatic drainage: relaunching the debate.

Vereecken P, Mathieu A, Laporte M, Petein M, Heenen M.Department of Dermatology, Erasme Hospital, Free University of Brussels, Brussels, Belgium.

Secondary lymphoedema of the leg can result in disruption of lymphatic vessels following lymph node surgery. Evidence supports the use of complex decongestive physiotherapy (CDP) in such cases, despite the possibility of tumour recurrence due to this therapy in cancer patients. We present the case of a 52-year-old woman who developed in-transit metastases and systemic evaluable disease one month after starting CDP for secondary lymphoedema of the leg.

Publication Types:
Case ReportsPMID: 12846356 [PubMed - indexed for MEDLINE]