Annals of Oncology Advance Access originally published online on October 3, 2006
Annals of Oncology 2007 18(4):639-646; doi:10.1093/annonc/mdl182
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© 2006 European Society for Medical Oncology
reviews |
A systematic review of common conservative therapies for arm lymphoedema secondary to breast cancer treatment
1 School of Nursing & Midwifery, University of South Australia, Adelaide
2 Department of Anatomy, School of Medicine, Flinders University, Adelaide
3 Department of Surgery & Lymphoedema Assessment Clinic, Flinders University & Medical Centre, Adelaide, Australia
* Correspondence to: Ms A. L. Moseley, Institute of Women's Health, Department of Gynaecological Oncology, University College London, London, UK; E-mail: amanda.moseley{at}yahoo.com.au
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Abstract |
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Top
Abstract
introductionSecondary arm lymphoedema is a chronic and distressing condition which affects a significant number of women who undergo breast cancer treatment. A number of health professional and patient instigated conservative therapies have been developed to help with this condition, but their comparative benefits are not clearly known. This systematic review undertook a broad investigation of commonly instigated conservative therapies for secondary arm lymphoedema including; complex physical therapy, manual lymphatic drainage, pneumatic pumps, oral pharmaceuticals, low level laser therapy, compression bandaging and garments, limb exercises and limb elevation. It was found that the more intensive and health professional based therapies, such as complex physical therapy, manual lymphatic drainage, pneumatic pump and laser therapy generally yielded the greater volume reductions, whilst self instigated therapies such as compression garment wear, exercises and limb elevation yielded smaller reductions. All conservative therapies produced improvements in subjective arm symptoms and quality of life issues, where these were measured. Despite the identified benefits, there is still the need for large scale, high level clinical trials in this area.
Key words: breast cancer, conservative therapies, lymphoedema
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introduction |
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Currently, secondary arm lymphoedema affects approximately 30% of those who undergo breast cancer treatment [1] and results in excess fluid accumulation in the interstitial space, detrimental tissue changes, limb swelling and quality of life issues. As this condition will generally worsen over time [2], a number of health professionals based and patient instigated conservative therapies that aim to decrease the limb swelling and its associated problems have been developed. Two systematic reviews have investigated some of these therapies in upper and lower limb lymphoedema, including manual lymphatic drainage, compression bandaging and garments [3] and benzopyrones [4], with both studies finding it difficult to make definitive therapy recommendations. Due to the chronicity of secondary arm lymphoedema there is still a need to determine the comparative benefits of the different conservative therapies for this condition. Therefore this review aimed to undertake a broad investigation of commonly instigated conservative therapies for this population, including; complex physical therapy, manual lymphatic drainage, pneumatic pumps, oral pharmaceuticals, low level laser therapy, compression bandaging and garments, limb exercises and limb elevation.
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inclusion and exclusion criteria |
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All study participants had to have a formal diagnosis of secondary arm lymphoedema subsequent to breast cancer surgery (total or partial mastectomy) ± radiotherapy ± chemotherapy. Studies which included participants with recurrent cancer and/or primary lymphoedema were excluded.
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conservative therapies |
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This systematic review focused on therapies that are commonly administered to or undertaken by secondary arm lymphoedema patients, and included the following:
Complex physical therapy (CPT) involves 2–4 weeks of daily manual lymphatic drainage (described below) followed by compression bandaging (administered by a health professional) and skincare plus prescribed limb exercises undertaken by the patient [5]. The patient is then fitted with a compression garment.
Manual lymphatic drainage (MLD) uses various light massage techniques to encourage the removal of excess interstitial fluid, increase lymphatic transport and soften fibrotic induration [6–8]. All methods start by clearing the areas distance or adjacent to the affected limb before moving to the limb root then to it's most distal section and then back to the limb root again.
Self/partner massage: Health professionals often teach patients (or their significant other) a simplified version of manual lymphatic drainage which includes clearing of the adjacent area and limb root followed by sweeping strokes over the limb itself [9].
Pneumatic pumps: These are single or multiple chambered pumps that envelop the limb and inflate and deflate at different cycles and pressures to encourage fluid drainage from the distal to the proximal end of the limb [12].
Oral pharmaceuticals encompass the alpha (
) Benzopyrones such as the Coumarin derivatives and the gamma (
) Benzopyrones such as the flavones and flavonols [16]. Benzopyrones may help lymphoedema by reducing vascular permeability, protein and extracellular fluid accumulation [16, 17], stimulating lymph contractility and flow [16, 18] and reducing protein concentration and fibrotic induration in the tissues by stimulating proteolysis [19].
Low level laser therapy uses low intensity wave lengths between 650–1000 nm, either in a scanning or spot laser form. Research suggests that laser therapy increases the rate of lymph vessel pumping and promotes lymph vessel regeneration [13], reduces pain [14] and softens both fibrous tissue and surgical scarring [15].
Compression bandaging consists of a gauze sleeve which protects the skin, soft cotton wrap or high density foam and 2–3 layers of short-stretch bandaging. Compression helps to decrease the amount of interstitial fluid formation, prevent lymph back flow and enhance the muscle pump by providing a relatively inelastic barrier for the muscle to work against [10].
Compression garments have a similar mode of action as compression bandaging and are designed to be graduated, with the greatest compression being at the distal end of the limb and the least amount being at the proximal end.
Limb exercises can be progressive, resistive or sequential in nature and are recommended as a way of varying total tissue pressure to encourage lymphatic drainage and for improving limb range of movement and strength [11].
Limb elevation reduces capillary exudation in to the tissues and promotes lymphatic return. It is considered most useful in the earlier (fluid) stage of lymphoedema [5].
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literature search |
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The literature search was limited to English, with the following databases searched; Cumulative Index to Nursing & Allied Health Literature (Cinahl), Medline, Academic Research Periodicals, PubMed Clinical Queries (including Complementary Medicine), CANCERLIT, EBM Reviews – Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews (CDSR), American College of Physicians (ACP) Journal Club, Database of Abstracts of Reviews of Effects (DARE), PREMEDLINE, Australian Medical Index, Physiotherapy Evidence Database (PEDro) and the National Guidelines Clearing House.
The general terms used for all these search engines were as follows:
- Secondary lymphoedema/lymphedema
- Arm swelling/oedema/edema
These were then combined with the following terms:
- Complex/complete, physical/decongestive therapy
- Manual lymphatic drainage/lymphatic massage/lymphatic drainage
- Support hosiery
- Compression garment/sleeve
- Compression bandaging/bandage
- Pneumatic/compression/intermittent pump therapy
- Exercise/physical therapy
- Elevation
- Laser/low level laser/laser therapy
In addition, health institution websites and online lymphatic societies were also searched. The biennial congress proceedings of The International Society of Lymphology (1977–2004) and the Australian Lymphoedema Association (2000–2004) were searched by hand. Primary authors were contacted when publications were difficult to source. The reference section of each article was also checked for relevant articles.
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data extraction and quality assessment |
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Endnote 7® was used as the data extraction tool. Once the data had been extracted and recorded, the quality of each study was assessed and given a rating. The Quality Scale Assessment tools used in this review were based upon a tool developed by Mulrow and Oxman (1996) [20], with one tool being developed and used for the review of randomised trials (scored out of 10) and the other for non-randomised trials (scored out of eight). The data extraction and rating was undertaken by A. Moseley, with the process checked by N. Piller and C. Carati. The quality rating and level of evidence [21] for each reviewed study is presented in Table 1.
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analysis |
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This review included studies performed in the randomized controlled, parallel and cross-over format plus case control and cohort studies. Case studies and anecdotal evidence were not reviewed. Due to treatment and data heterogeneity, a meta-analysis could not be performed. Therefore, only a narrative of the different conservative therapies for secondary arm lymphedema is presented. For ease of comparison, an approximate oedema reduction (%) has been calculated in each case where the limb volume reduction is presented in milliliters (ml).
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results |
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The average percentage volume change at end of trial achieved by each reviewed conservative therapy is displayed in Figure 1. This demonstrates the magnitude of the reduction (average) that can be achieved by the different conservative therapies.
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complex physical therapy (CPT) |
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Five studies reviewed investigated standard CPT over a varying treatment period of 8 days to 3 months [9, 22–25]. Participant numbers ranged from 16–78, with some studies having no stated exclusion criteria [22, 23] and others having a poorly stated criterion [24, 25]. The reductions achieved from the five studies varied from 298–652 ml (18.7–66%), with three studies demonstrating additional volume reductions over 6–12 months follow up [9, 22, 25]. Two studies measured subjective symptoms, with one showing a reduction in pain [24] and the other in tightness, heaviness, pins and needles, cramps and tension [9].
One study investigated standard CPT (n = 13) in comparison with CPT plus 30 min of intermittent pump (50 mmHg) therapy (n = 14) [26]. After 10 days CPT alone yielded a 3.1% mean volume reduction whilst the CPT + pneumatic group had a statistically greater reduction of 7.9%. Although a reduction in symptoms was reported, it was not stated what symptoms were actually measured. The follow-up measurements over one and two months demonstrated a continuing decrease in percentage volume in both treatment groups (3.6% and 9.6% at 2 months). Two studies investigated CPT in combination with intermittent pump therapy. The first study [27] involved 1 hour of intermittent pump (40–70 mmHg) therapy incorporated into the CPT regime (n = 188), with this regime yielding statistically significant percentage reductions in all grades of lymphoedemas (grade I–III, 43.4–19.3 %) after 5 weeks of treatment. The second study involved a regime of CPT with a pump of <60 mmHg (n = 25) [28]. After 1 month there was a reduction of 40% in excess limb volume, with this reduction being maintained at 12 months follow up. The last study investigated a combination of treatments incorporated into the CPT regime, including mechanical plus manual massage, hand grip exercises, the wearing of a compression garment and the addition of hot compresses during one treatment phase [29]. All treatment combinations yielded similar actual oedema reductions in the range of 8.5–13%.
All the reviewed studies demonstrated that a reduction in limb volume and/or percentage oedema can be achieved with standard CPT, CPT plus pump therapy and a combination of therapies, with five studies [9, 22, 25, 26, 28] demonstrating a continued volume reduction at follow up (range 1–12 months). The three studies [9, 24, 26] which measured subjective symptoms demonstrated that these improved after the CPT regime, unfortunately none of these studies report whether these improvements were sustained at the follow up periods. The study by Piller et al. (1996) also demonstrated that volume and subjective symptom reductions could be achieved when patients and their partners were taught how to apply a regime of lymphatic massage and compression bandaging themselves [9]. The optimal treatment period for CPT appears to be 1 month, however, two studies [22, 29] achieved a volume reduction at the end of 7–8 days of treatment.
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manual lymphatic drainage (MLD) |
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Two studies investigated the effect of MLD alone. These two studies [30, 31] involved 12–17 participants who received MLD and who experienced a volume reduction of 104–156 ml (8–10%), with one study reporting that the volume reduction was maintained at 6-months follow up [31]. The other study reported reductions in heaviness and tension, but did not state the inclusion/exclusion criteria or the length and frequency of MLD [30]. Two studies investigated MLD in comparison to another treatment modality. The first of these studies used a cross-over design to investigated a phase of MLD and self massage (n = 27), each over a 3-week period [32]. Results showed that MLD produced a statistically significant reduction of 71 ml and improvements in subjective heaviness, fullness and bursting whilst the self massage resulted in a non significant reduction of 30 mls. The second randomized study investigated MLD (n = 20) in comparison to a ‘control’ group who undertook education, wearing a compression sleeve and limb exercises (n = 20) [33]. After 2 weeks the ‘control’ group actually had a greater percentage reduction in absolute oedema (60%) in comparison to the MLD group (48%). Both groups equally experienced a reduction in the symptoms of heaviness and tightness, whilst the ‘control’ group also had a reduction in reported discomfort. The reduction in absolute oedema (66%) was maintained at 12-months follow up (pooled data).
Four studies investigated the effect of MLD in combination with compression (bandaging or garment). All four studies had a clearly stated inclusion/exclusion criterion, with the first two studies investigating MLD plus compression bandaging. These two studies [34, 35] involved 18–24 women who received MLD plus compression bandaging over 1 week to 1 month. After 1 week there was a significant volume reduction of 47 ml (11% in oedema) [34], whilst over 1 month the reduction was 260 ml (46.1%), with significant improvements in tension, heaviness and pain [35]. The third study investigated the effect of a compression (30–40 mmHg) sleeve worn for 2 weeks followed by 2 weeks of additional MLD (n = 12) [36]. Wearing the sleeve alone resulted in a significant volume reduction of 49 ml (7%), with the addition of MLD resulting in a significant reduction of 75 ml (15%). Both phases also significantly improved arm tension and heaviness. The last study investigated MLD in combination with a compression garment or bandaging once a week for 12 weeks [37]. Both treatment groups experienced significant reductions in oedema of 84% and 78% respectively.
One study compared MLD and pneumatic pump therapy [38], with one group receiving 1 hour of MLD over 43 sessions (n = 27) and the other receiving 0.5 h of pump therapy (40 mmHg) followed by 0.5 h of MLD over 25 sessions (n = 62). Results showed that the MLD alone and when combined with pneumatic pump therapy yielded similar reductions in oedema volume (40% and 45% respectively), however, there were no accompanying statistical values so significance is not known. The follow up period in this study (14–24 months) demonstrated an oedema volume increase of 33% in those who underwent no further treatment, whilst those who underwent regular treatment (type not stated) experienced a slight reduction (1%) in oedema volume.
The volume reductions achieved by MLD alone varied from 104–156 ml, with the greatest percentage reduction being 48% [33]. Larger reductions were achieved from MLD in combination with compression, which varied from 47–260 ml (7–84%), with these studies demonstrating that either form of compression (garment or bandaging) could be effectively used in combination with MLD. MLD in combination with pneumatic pump therapy was also shown to be effective [38]. The majority of volume reductions were achieved after a 4 week treatment period, although volume reductions were also seen to occur over 2 weeks of treatment [31, 33, 36]. Only three of the reviewed studies included a follow up period which demonstrated that the initial volume reductions were maintained [31, 33, 38]. The overall lack of follow up in these studies makes it difficult to formulate strong conclusions on the long term benefits of MLD (± bandaging).
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pneumatic pump therapy |
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Five studies were reviewed which investigated the effect of pneumatic pump therapy. The first was a poorly reported study which involved a group that received a combination of MLD (0.5 h) and pump therapy (0.5 h) over 25 sessions (n = 62) and another that received 6 hours of sequential (40 mmHg) pump therapy (only) over 5 days (n = 14) [38]. Both groups experienced identical oedema volume reductions (45%), with this reduction being achieved over a shorter treatment duration (5 days) in the pump only group. However, considering this group had a sample size of 14, it is hard to determine whether this volume reduction is a true reflection of what can be achieved with this form of sequential (40 mmHg) pump. Szuba et al. (2002) performed two randomised studies which investigated the use of a four-chambered, sequential pump as an adjunct therapy [39]. The first study compared 10 days of complex physical therapy (CPT) alone (n = 11) and in combination with 30 min of 30–40 mmHg pump therapy (n = 12). Results showed that the CPT plus pump therapy resulted in a greater and significant limb volume reduction in comparison to CPT alone (45.3% versus 26% respectively). Interestingly, the CPT plus pump therapy reduction was not maintained at 1 month follow up (increase of 15%), whilst the CPT alone reduction was maintained. The second study investigated a 1 month phase of arm self maintenance including self massage and compression garment wear, followed by a phase of applying 1 hour of pump therapy for a further 1 month period (n = 25). The self maintenance phase resulted in an arm volume increase of 32.7 ml (
3.3%), with the addition of the 1 h of pump therapy resulting in a statistically significant reduction of 89.5 ml (9.0%). Some participants continued using the pump an average of four times a week for 6 months, with 19 participants having an additional reduction in limb volume of 29.1 ml (3.0%) and five having an increase of 35 ml (3.5%). Why this sub-group of participants had a worsening in limb volume was not explored. One study investigated 2 h of pump therapy (40–60 mmHg) 5 days a week for 2 weeks [36]. After this time there was a non significant reduction in arm volume (28 ml; 7%) and reported tension and heaviness. One study investigated the wearing of a compression (30–40 mmHg) garment for 6 months then 6 h of pump therapy (35–60 mmHg) over 10 sessions followed by the continued wear of the compression garment (n = 54) [40]. Results showed a significant 8% reduction after wearing the compression garment and an additional 9% significant reduction after the pump therapy (with the assumption that the total edema reduction at this time point was 17%). A 6-month follow up demonstrated a 19.8% reduction in those who continued to wear the compression garment. The last study investigated 2–3 h of sequential (100–150 mmHg) pump therapy, three times a day for 3 days (n = 25) [41]. After 3 days the percentage reduction ranged from 12–44% (statistical values not stated). After trial cessation, 2 h of maintenance therapy was applied one–four times a week over the following 6 months. Follow up at this time showed that the initial treatment reductions had been maintained. However, it was not reported whether the maintenance of limb volume was the result of one or four sessions of treatment per week.
Two studies [38, 41] demonstrated that volume reductions could be achieved from pump therapy alone, although the high pressures (100–150 mmHg) used by Zelikovski et al. (1980) [41] are above the 60 mmHg of pressure normally recommended for the treatment of lymphoedematous limbs [42]. Three of the reviewed studies [36, 38, 40] demonstrated that better results in volume reduction were achieved when the pneumatic pump was combined with other therapies, including; manual lymphatic drainage, compression garments and self massage. Three studies [38, 40, 41] also demonstrated that continuing the pump therapy or wearing a compression garment were beneficial in maintaining the initial volume reductions.
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oral pharmaceuticals |
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Five studies were reviewed that investigated the effect of oral pharmaceuticals. Two studies investigated Coumarin [43, 44], with the first study investigating two dosages; 90 mg (n = 23) and 135 mg (n = 30) over 12 months [43]. At trial end, both groups experienced a similar reduction in percentage limb volume (14.9% and 13.2% respectively) and reductions in heaviness, pain and cramps. The second study used a cross over design to investigate a 6-month phase of Coumarin (400 mg) and a 6 month phase of a placebo (n = 138) [44]. Results demonstrated a volume increase (and therefore worsening) of 58 ml (
6%) in the treatment phase and 21 ml (2.1%) in the placebo phase. Despite this, participants reported improvements in arm swelling, pressure, tightness, heaviness and mobility. The third study investigated Daflon (Diosmin plus Hesperidin 1g, n = 46) or placebo (n = 48) over 6 months [45]. After this period the treatment group experienced a 7% volume reduction whilst the placebo group experienced a volume increase of 10%. Both groups experienced a significant reduction in reported discomfort, with the treatment group also having a significant reduction in heaviness.
The fourth study investigated three capsules of Cyclo-Fort (Ruscus Aculeatus and Hesperidin Methyl Chalcone) three times a day (n = 27) compared to placebo (n = 30) over 3 months, with the addition of MLD (2 x week) in the first month of the trial [46]. After the first month both the treatment and placebo groups experienced volume reductions of 1.2% and 0.5% respectively. By 3 months the treatment (Cyclo-Fort) group had an overall volume reduction of 12.9% whilst the placebo group had an increase of 2.5%. Both groups experienced improvements in heaviness and limb mobility, with these being significant in the Cyclo-Fort group. The last study used a cross over design to investigate a 6 month phase of 5–6 Benzo--pyrone (200 mg) and placebo (n = 31) [47]. Results demonstrated a volume reduction of 840 ml (35.6%) in the treatment phase, with this reduction being significant in comparison to the control phase in which the limb increased in volume by 490 ml (41.6%). A 1-month follow up demonstrated an additional decrease of 3.3% in oedema (treatment phase) and an additional increase of 1.2% (placebo phase).
The two studies which investigated Coumarin had conflicting results, with one showing a decrease in arm volume (dosage 90 mg, 135 mg) [43] and the other showing an increase in volume (dosage 400 mg) [44]. As neither study had a follow up period it is not known whether the initial volume reduction or increase would have continued. The other reviewed studies [45–47] demonstrated that varying volume reductions and subjective improvements could be obtained from oral pharmaceuticals such as Daflon (1000 mg) and Cyclo-fort, with the greatest limb reduction (840 ml, 35.6%) being obtained from the 5–6 Benzo--pyrone (200 mg) [47]. It is also important to note that two studies [43, 47] reported gastrointestinal upsets in 13.7% and 22.6% of participants.
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low level laser therapy |
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Three studies were reviewed which investigated concentrated or scanning laser therapy. The first study was a double-blinded, randomised controlled trial involving one group which received two cycles of active laser to the axilla three times a week for 3 weeks (n = 37) and another group who received one cycle of placebo laser and one cycle of active laser (n = 27) over the same time periods [48]. At trial end there were volume reductions in all phases: placebo; 35 ml (
3.5%), one cycle; 15 ml (1.5%), two cycles; 25 ml (2.5%). A 3-month follow up demonstrated a volume increase of 30 ml (3.0%) in those who received placebo and volume reductions in the one cycle (10 ml 1.0%) and two cycle (90 ml 9.0%) phases. The two cycle phase also resulted in a significant reduction in the mean perceptual score and improvements in quality of life parameters. The second study investigated 30 min of scanning laser, twice a week for 6 weeks and then once a week for a further 4 weeks (n = 10) [49]. This resulted in a volume reduction of 19.3% and progressive improvements in subjective symptoms. A follow up study of these participants (n = 8) [50] demonstrated that there were continued volume reductions of 397 ml (40%) at 6 months and 288 ml (29%) at 36 months, with subjective symptoms returning to pre-treatment levels by the 36-month mark. These three studies demonstrate that benefits including volume reduction, improved subjective symptoms and quality of life can be derived from either concentrated or scanning laser therapy. The best results in the Carati et al. (2003) study [48] were seen at 3 months post treatment, which suggests that there maybe ongoing benefits from laser therapy. This is supported by the Piller and Thelander (1998) study [50] (albeit with a much smaller sample size), which found that there were continued reductions in arm volume and reported arm tightness 6 months after treatment cessation.
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compression |
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Four studies investigated the effect of compression (garment or bandaging) alone. Two studies [30, 35] which involved 35–55 participants investigated compression bandaging. These studies demonstrated a volume reduction of 38 ml (7%) [30] and 20 ml (4% oedema) [35] respectively and significant improvements in arm heaviness and tension. Two studies investigated the effect of a 30–40 mmHg compression garment. The first study involved 12 participants who wore the garment over a 2-week period [36], after which time there was a significant volume reduction of 49 ml (
5.0%) and improvements in tension and heaviness. The second study involved participants (n = 26) wearing the compression garment over a 6-month period [40]. Results showed an 8% reduction in actual oedema, however, at the 6-month point only 12 women remained in the study. Two studies investigated the effect of wearing a compression garment in combination with other activities. One study [33] demonstrated that after 3 months of limb exercise and compression wear (n = 22) there was a 60% reduction in absolute oedema, with the other study showing a 243 ml (24.4%) volume reduction after 4 weeks of self massage combined with compression wear [51]. Neither study reported statistical values, so the significance of these volume reductions are not known. Four of the reviewed studies [30, 35, 36, 40] demonstrated that modest volume reductions of 20–49 ml (4–8%) and significant improvements in heaviness and tension could be achieved when wearing compression (bandaging or garment) alone. However, none of these studies included a follow up period, so the ongoing effects of compression cannot be determined. Two studies [33, 51] demonstrated that greater volume reductions of 243 ml (24.4%) and 60% could be achieved when the wearing of a compression garment was combined with limb exercise or self massage.
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exercise |
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Five studies were reviewed which investigated a variety of exercise regimes. The first study investigated a 10-minute arm exercise and deep breathing regime (n = 38) [52] which resulted in an arm volume reduction of 52 ml (5.8%) and improvements in heaviness and tension, with some reductions maintained over 24 h and 1 week follow up. After 1 month of performing this regime (n = 24) there was a volume reduction of 101 ml (9%) and significant improvements in heaviness and perceived limb size. Two studies investigated the effects of 40–45 min of hydrotherapy [11, 53], with neither study stating the exclusion criteria. The first was a randomised study which involved a control group (n = 8) and a hydrotherapy exercise group (n = 8) [53]. After 4 weeks there was a volume reduction of 48 ml (
4.8%) in the hydrotherapy group, with continued reductions at 3 and 6 weeks follow up (30 ml 2.9% and 86 ml 8.6% respectively). This in comparison to the control group, which increased in limb volume. The exercise group also had reductions in reported aching, heaviness, tightness, limb swelling, stiffness and heat intolerance. The second study investigated hydrotherapy performed by seven participants in two different pool temperatures (28° C; 82° F and 34° C; 93° F) [11]. After the first session (28° C) there was a decrease in arm volume of 32 ml (12% oedema change), whilst after the second session (34° C) there was a slight increase in volume of 2 ml (0.7% change). Subjective symptoms remained unchanged after both pool sessions. One study investigated a 30 min regime of instructed deep breathing, self massage and sequential limb exercises (n = 7) [54]. Directly after performing the regime there was a slight increase in arm volume (12 ml, P = n.s.), with a net decrease (12 ml, P = n.s.) experienced 20 minutes post regime. Despite the minimal volume reduction, the group reported improvements in arm range of movement, subjective limb temperature difference, heaviness and tightness. Two studies investigated the effect of resistive arm exercises. The first of these studies involved a regime of shoulder flexion and abduction and elbow extension and flexion using 0.5 kg hand weights, performed firstly with no compression garment and secondly when wearing a compression garment (n = 23) [11]. Results showed an initial increase in arm volume after performing the regime, plus or minus garment wear (12 ml, 0.5% and 10 ml, 0.3% respectively). However, at the 24 h follow up the volume increases had been reversed, with both phases demonstrating a volume reduction of 15 ml (0.7–1.0%) at this time point. Reported tension and heaviness remained unchanged in both phases, however, when the regime was performed without a compression garment there was a significant increase in reported physical exertion. The second study investigated latissimus dorsi, bicep and tricep exercises with weights and the wearing of a compression garment undertaken three times a week for 8 weeks (n = 7) [55]. This resulted in a limb volume reduction of 2% plus significant improvements in physical functioning, general health and vitality.
The five studies reviewed demonstrated that exercise regimes can have a varying impact upon limb volume, ranging from 12–101 ml (0.4–9%), with three studies demonstrating improvements in subjective symptoms [52–54]. Sustained volume reductions were also seen to occur 24 h to 6 weeks after exercise program cessation [11, 52, 53]. The hydrotherapy study [11] suggests that this form of exercise is best undertaken in a pool temperature of 28° C (82° F).
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elevation |
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Only one study was reviewed that investigated the effects of limb elevation [56]. It involved 33 women who elevated their arm at 80° angle over a 5-h period. At the end of this time there was a significant 3.1% reduction in arm volume. Subjective symptoms and adverse effects were not recorded, so it is not known how well this regime was tolerated.
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discussion |
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In recent times, sentinel lymph node biopsy (SLNB) has become a more common procedure in breast cancer surgery, resulting in less arm morbidity [57], including lymphoedema [58]. However, there is still the possibility of developing arm lymphoedema after SLNB, especially if the sentinel node is located at the level of the axillary vein and lymphatic collectors [59] and if SLNB is combined with axillary radiotherapy [60]. Although the number of women developing arm lymphoedema maybe reduced as a consequence of SLNB, it is still important to know the benefits of conservative therapies for the proportion of women who do go on to develop this condition after breast cancer treatment.
The current review investigated conservative therapies for arm lymphoedema that can essentially be divided into intensive treatments administered by trained health professionals and limb maintenance therapies undertaken by the patient. As demonstrated by Figure 1, treatments that are predominantly administered by health professionals, such as complex physical therapy, manual lymphatic drainage (with and without compression), laser therapy and pneumatic pump therapy generally yielded the larger percentage volume reductions. Maintenance therapies (normally undertaken by the patient), such as wearing a compression garment, limb exercises, elevation and self massage generally yielded smaller percentage reductions. There is some research to suggest that undertaking therapies such as arm rehabilitation and exercise may prevent the onset of lymphoedema [61], but further research is required to determine the true benefits of such programs.
Although those therapies which would be categorised as ‘self maintenance’ yielded smaller volume reductions, this review has demonstrated that they are more beneficial than doing nothing at all for the lymphoedematous limb. This indicates that such therapies maybe useful when health professional based therapies are not accessible or economically viable for the patient. The review also demonstrated the positive impact upon subjective limb complaints and quality of life issues, indicating that these conservative therapies can be initiated by the health professional or patient with the anticipation of some benefit. Follow up periods (when incorporated) indicated that some form of continuing therapy (intensive or patient based) needed to be undertaken to maintain the initial volume reductions, which demonstrates the chronic nature of this condition. Despite the range of positive outcomes identified in this review, the evidence to support them is, in some instances, poor. Therefore, there is still a need for large scale, high level clinical trials in this area.
Received for publication April 10, 2006. Revision received June 13, 2006. Accepted for publication June 23, 2006.
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