Manual lymphatic drainage for lymphedema in patients after breast cancer surgery: A systematic review and meta-analysis of randomized controlled trials

Management of lymphedema is really a matter in patients with breast cancer

Lymphedema is a prevalent complication affecting patients with breast cancer, greatly impacting their quality of life. This editorial describes diagnostic methods and therapeutic interventions for managing lymphedema in patients with breast cancer. Diagnosis relies on clinical evaluation and objective measures, including arm circumference and volumetric assessments, along with lymphoscintigraphy and ultrasonic measurements. Treatment primarily involves complex decongestive physical therapy, comprising manual lymphatic drainage, compression therapy, exercise, and meticulous skin care. These interventions aim to reduce swelling, alleviate discomfort, and prevent further complications. Additionally, lifestyle modifications such as avoiding extreme temperatures and maintaining proper hygiene are essential. Flavonoids can be used for drug therapy. Despite its prevalence, lymphedema often receives inadequate attention in clinical practice, emphasizing the importance of raising awareness and enhancing medical services for affected individuals. Clinicians play a pivotal role in educating patients about preventive measures and ensuring timely intervention. Overall, a comprehensive approach encompassing early diagnosis, multidisciplinary management, and patient education is essential to mitigate the burden of lymphedema in patients with breast cancer and improve their overall well-being.

Effects of Manual Lymphatic Drainage with Mobilization and Myofascial Release on Muscle Activities during Dynamic Balance in Adults with Calf Muscle Shortening

Mobilization with movement (MWM) and myofascial release (MFR) are treatment techniques that increase ankle dorsiflexion range of motion (DFROM). Manual lymphatic drainage (MLD) facilitates waste drainage and improves soft tissue tension in peripheral tissues. To date, no studies have investigated how the combination of MLD, MWM, and MFR influences the human body. The purpose of this study is to determine how the combination of MLD, MWM, and MFR affects DFROM and balance ability. We randomly assigned 16 individuals (26 feet) to one of three groups: MWM-MFR (MR), MWM-MLD (MD), or MWM-MFR-MLD (MRD) intervention. To confirm the intervention effect of each group, DFROM was assessed using a modified lunge test, and dynamic balance was measured using a modified star excursion balance test. In the results, differences were found between the MR and MRD groups in PL and mGCM activities in the 1 section (p = 0.008, p = 0.036) and between the MD and MRD groups in mGCM activity in the 4 and 5 sections (p = 0.049, p = 0.004). We suggest that the application of MRD is the most effective intervention for increasing muscle activation of the PL and mGCM during the modified star excursion balance test.

Demystifying vascularized lymph node transfers and lymphatico-venous anastomoses

Lymphedema continues to be a widely prevalent condition with no definitive cure. It affects a wide range of patients across different ages and backgrounds. The significant burden of this chronic and debilitating condition necessitates more research and comprehensive healthcare coverage for affected patients. In developed countries, cancer survivors are disproportionality affected by this condition. Risk factors including lymph node dissections and radiation render many cancer patients more susceptible to the development of lymphedema. Part of the challenge with lymphedema care, is that it exits on a broad spectrum with significant variability of symptoms. Advances and broader availability of various imaging modalities continue to foster progress in lymphedema surgery. The conservative management of lymphedema remains the primary initial management option. However, lymphedema surgeries can provide significant hope and may pave the way for significant improvements in the quality-of-life for many patients afflicted by this progressive and enfeebling condition. Reductive and physiologic procedures are becoming an important part of the armamentarium of the modern plastic and reconstructive surgeon. Recent advances in physiologic lymphedema surgeries are accelerating their transition from experimental surgeries to broadly adopted and widely accepted procedures that can lead to major successes in the fight against this condition. Prophylactic lymphedema surgery also presents a promising choice for many patients and can help prevent lymphedema development in high-risk patients.

Is the Absence of Manual Lymphatic Drainage-Based Treatment in Lymphedema after Breast Cancer Harmful? A Randomized Crossover Study

(1) Background: Manual lymphatic drainage (MLD), included within the complex decongestive therapy, as a therapy for the treatment of lymphedema has raised controversy about its benefits for lymphedema after breast cancer. The aim of this research is to test the effects of MLD on lymphedema after breast cancer during the treatment maintenance phase. (2) Methods: A randomized, single-blinded, controlled crossover trial was conducted to analyze the effects of a manual lymphatic drainage intervention compared to a control group without MLD intervention for the treatment of lymphedema. Arm volume measured by circumference measurement, subcutaneous tissue thickness measured by ultrasound, and the sensation of pain, heaviness, and swelling were evaluated as outcome measures. (3) Results: For the control group, an increase in volume was found in some of the circumference and subcutaneous tissue thickness measurements, in addition to a worsening of arm pain, swelling and heaviness. (4) Conclusion: The absence of treatment based on MLD in lymphedema after breast cancer worsens volume measurements, as well as arm heaviness. Therefore, it would be advisable to carry out this type of therapy as part of the maintenance treatment for lymphedema in breast cancer.

Effects of manual lymphatic drainage on total knee replacement: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Total knee joint replacement (TKR) is an effective method for the treatment of severe knee osteoarthritis. With an increasing number of surgeries, complications such as lower limb edema, pain, and limited mobility have caused a heavy burden. Manual lymphatic drainage (MLD) may be a solution to solve the problem. The study aims to evaluate the efficacy of MLD in reducing knee edema, pain, and improving range of motion (ROM) in patients after TKR.

METHODS

A search was conducted in PubMed, Embase, Cochrane Library, Web of Science, CNKI, VIPs, WanFang database, and Google Scholar from inception to June 2023. Only randomized controlled trials (RCTs) that compared the effects of MLD and non-MLD (or another physiotherapy) on improving knee edema, pain, and ROM after TKR were included. Stata 16.0 was used for meta-analysis. GRADE was used to assess the quality of evidence.

RESULTS

In total, 7 RCTs with 285 patients were identified. There were no significant differences found in the ROM of knee flexion (standardized mean difference (SMD) = 0.03, 95% confidence interval (CI): -0.22, 0.28, P = 0.812) and the ROM of knee extension (SMD= -0.30, 95%CI: -0.64, 0.04, P = 0.084). No differences were observed in the lower extremity circumference after TKR (SMD= -0.09, 95%CI: -0.27, 0.09, P = 0.324). For postoperative pain, there was no significant advantage between the MLD and non-MLD groups (SMD= -0.33, 95%CI: -0.71, 0.04, P = 0.083).

CONCLUSIONS

Based on the current evidence from RCTs, manual lymphatic drainage is not recommended for the rehabilitation of patients following total knee replacement.

Examining the efficacy of treatments for arm lymphedema in breast cancer survivors: an overview of systematic reviews with meta-analyses

Background

Lymphedema affects one in six breast cancer survivors making it a global healthcare challenge. There is considerable debate about the efficacy of different treatments for lymphedema. We aimed to summarize the current evidence for treatments for lymphedema in breast cancer survivors.

Methods

In this overview of systematic reviews with meta-analyses (SRMAs), five databases were searched for SRMAs of randomised controlled trials (RCTs) reporting effects of medications, surgery, exercise, laser therapy, acupuncture, kinesio taping, or complex decongestive physiotherapy (CDP) for breast cancer-related lymphedema published from database inception up to March 7, 2023. Data extraction was performed for the SRMAs and RCTs, and SRMAs were appraised with AMSTAR2. Random effects meta-analyses of the RCTs provided estimates of the pooled effects sizes (Hedges' g) for each treatment modality. This study is registered with PROSPERO, CRD42020184813.

Findings

1569 studies were identified by the search and eighteen SRMAs with 51 RCTs were included, investigating manual lymphatic drainage (MLD), compression pump, exercise, kinesio taping, laser, and acupuncture. Overall, the methodological quality of the SRMAs was low. SRMAs reached different conclusions for all treatment modalities, except for kinesio taping where the two SRMAs found no effect. The analysis of 40 RCTs with 1970 participants revealed a small effect across all interventions compared to any control (g = 0.20, p = 0.047, I2 = 0.79), corresponding to volume reductions of 119.7 ml (95% CI 135-104) and 88.0 ml (95% CI 99-77) in the intervention and control groups, respectively, and a small effect of exercise (g = 0.26, p = 0.022, I2 = 0.44). The between-group differences in volume reduction were small and did not reach statistical significance for any one treatment modality.

Interpretation

Based on the available data, there is no evidence of superiority of any one treatment on volume reduction nor any solid research refuting these treatments. Thus, definitive conclusions to inform clinical practice about the efficacy of these treatments cannot be drawn. Due to poor-quality evidence, more research is needed to untangle the efficacy of each treatment component for different stages of lymphedema.

Funding

Danish Cancer Society.

Level I of evidence does not support manual lymphatic drainage for total knee arthroplasty: a meta-analysis

It is unclear whether manual lymphatic drainage (MLD) following primary total knee arthroplasty (TKA) is effective in reducing pain and swelling and improving knee function. The present study investigated the efficacy of MLD after TKA. The outcomes of interest are the range of motion (ROM), pain (visual analogue scale, VAS), and circumference of the lower leg. This meta-analysis was conducted according to the 2020 PRISMA statement. In November 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase, with no time constraint. Only level I evidence studies, according to the Oxford Centre of Evidence-Based Medicine, were considered. All the randomised controlled trials (RCTs) comparing patients who have received MLD versus a group of patients who did not undergo MLD following primary TKA were accessed. Data from four RCTs (197 TKAs) were retrieved. 67% (132 of 197 patients) were women. The mean length of follow-up was 7.0 ± 5.8 weeks. The mean age of the patients was 69.6 ± 2.7 years, and the mean BMI was 28.7 ± 0.9 kg/m2. At baseline, between-group comparability was evidenced in the male:female ratio, mean age, mean BMI, knee flexion, and VAS. No difference was found in flexion (P = 0.7) and VAS (P = 0.3). No difference was found in the circumference of the thigh (P = 0.8), knee (P = 0.4), calf (P = 0.4), and ankle (P = 0.3). The current level I of evidence does not support the use of MLD in primary TKA.

Effectiveness of manual lymphatic drainage in intensive phase I therapy of breast cancer-related lymphedema-a retrospective analysis

BACKGROUND

The standard therapy for lymphedema of any origin is complex physical decongestive therapy (CDT). It comprises manual lymph drainage (MLD), compression therapy (CT), exercise therapy (ET), skincare, and patient education. Additionally, intermittent pneumatic compression (IPC) can be applied. However, the contribution of MLD to decongestion is repeatedly questioned.

PATIENTS AND METHODS

This study re-analyzes a previous study during a 3-week decongestion period, comparing two different types of compression bandaging at the weekend. Sixty-one patients with unilateral breast cancer-related lymphedema were included. The patients received the same therapy (CDT + IPC) except for the different weekend compression bandaging. MLD was performed twice a day on weekdays. The volume of the affected arm was measured on days 1, 5, 8, 12, 15, 19, and 22. For the analysis, the data of both study groups were pooled.

RESULTS

During the week, the patients showed a significant volume reduction (- 155.23 mL (week 1), - 101.02 mL (week 2), - 61.69 mL (week 3), respectively; p < 0.001 each) with a high effect size. On the weekends without MLD, they showed a slight, but also significant increase (12.08 mL (weekend 1), 8.36 mL (weekend 2), 4.33 mL (weekend 3), respectively; p < 0.001 each) with a medium effect size.

CONCLUSIONS

We showed a strong effect of MLD on volume reduction. Differences from other studies are the larger study population and the more intensive application of MLD. If applied intensively, MLD is strongly decongestive during a 3-week decongestion therapy for breast cancer-related lymphedema.

Comparative effects of lymphatic drainage and soft tissue mobilization on pain threshold, shoulder mobility and quality of life in patients with axillary web syndrome after mastectomy

PURPOSE

The purpose was to compare the effects of manual lymphatic drainage and soft tissue mobilization on pain threshold, shoulder mobility and quality of life in patients with axillary web syndrome.

METHODS

This randomized clinical trial was conducted on 36 breast cancer patients with developed axillary web; participants were randomly divided into two groups. One group was treated with manual lymphatic drainage; the other group was treated with soft tissue mobilizations in addition to therapeutic exercises, i.e., stretching, strengthening and range of motion (ROM) exercises. The duration of treatment was four weeks (5 sessions/week), with therapeutic exercises as a common treatment protocol. Outcome measures were Breast-Cancer specific quality of life questionnaires, Disabilities of the Arm, Shoulder and Hand (DASH), Numeric Pain Rating Scale (NPRS), Patient Specific Functional Scale (PSFS), Dynamometer and Goniometer. All outcome measure readings were recorded at baseline and the end (4th week) of the treatment.

RESULTS

The compliance of the variable distribution with normal distribution was verified using the Shaphiro-Wilk test. Parametric tests were applied, and both groups showed significant effects (p < 0.05) in pairwise comparison (paired t-test). The comparison group analysis (independent t-test) showed that there was no significant difference in pain, upper limb strength, range of motions and fatigue component of quality of life questionnaire parameters (p > 0.05). Two parameters (DASH, PSFS) and one component of the quality of life questionnaire (global health) showed a significant difference (p < 0.05).

CONCLUSION

Manual lymphatic drainage showed more improvement in functional movements. It was concluded that both groups, manual lymphatic drainage and soft tissue mobilization groups were clinically equally effective.

TRIAL REGISTRATION NUMBER

This trial is registered at ClinicalTrial.gov PRS under trial number NCT05463185 on date 18/07/2022.

The Effect of Manual Lymph Drainage and Compression Bandaging for Stage 2 Breast Cancer-Related Lymphedema: A Randomized Controlled Trial

Aim: To explore the effect of manual lymph drainage (MLD), compression bandaging (CB), or combined decongestive therapy (CDT), including MLD and CB, on stage 2 breast cancer-related lymphedema (BCRL). Methods: Sixty women with stage 2 BCRL were enrolled. They were randomly divided into the MLD group, the CB group or the CDT group. Each group, respectively, received MLD alone, CB alone, or CDT composed of MLD and CB, for 2 weeks. The volume and the local tissue water (LTW) of affected arms were measured before and after treatment. Arm circumferences were measured at 4 cm interval starting from the wrist to the shoulder with a tape measure. LTW was detected using the (tissue dielectric constant, TDC) method and was expressed as TDC value in two sites on the ventral midpoint of upper arm and forearm. Results: The volume of affected arms in each group after 2-weeks' treatment was lower than their baseline and the difference was statistically significant (p < 0.05). But there was no significant difference in volume change among three groups. The TDC value of the upper arm and forearm in the group CB and the group CDT decreased distinctly compared with baseline (p < 0.05). But the TDC value of the upper arm and forearm after MLD did not change (p > 0.05). Compared with the group MLD and the group CDT, the reduction of the TDC value in the group CB was more significant (p < 0.05). Conclusions: MLD or CB alone could effectively reduce the volume of affected arms for patients with stage 2 BCRL, and CB also could reduce the LTW more significantly. CDT did not seem to show an extra advantage. Therefore, CB may be the first choice for stage 2 BCRL. But for patients who are unwilling or intolerant to CB, MLD can be selected.

Evaluation of Kinesio Taping for Edema, Ecchymosis, and Pain After Liposuction: A Prospective Pilot Study

BACKGROUND

Liposuction is a safe, simple, and effective method of body contouring. Pain, ecchymosis, and edema are often local complications at the removal site, especially in the first weeks after surgery. Several studies have shown that kinesiology (kinesio) taping improves blood and lymphatic flow, removing congestions of lymphatic fluid and alleviating hemorrhage. However, there are limited data on the effect of kinesio taping in mitigating local complications at fat grafting donor sites.

OBJECTIVES

The aim of this pilot study was to evaluate the impact of kinesio taping in reducing postoperative edema, pain, and ecchymosis in the liposuction area.

METHODS

Over a period of 18 months (January 2021-June 2022), 52 patients underwent liposuction of both flanks with subsequent breast fat grafting. Immediately after the surgery, kinesio taping was used on the right abdomen flank in all patients. Degree of edema as well as ecchymosis and pain were quantified at 7, 14, and 21 days after surgery.

RESULTS

There were statistically significant differences in the taping area for ecchymosis at 7 days after surgery, edema at 14 and 21 days after surgery, and in pain, rated on a visual analog scale, at 7, 14 and 21 days after surgery.

CONCLUSIONS

Kinesio taping, as used in this study, is beneficial in the reduction of edema and pain and the resolution of ecchymosis after liposuction.

LEVEL OF EVIDENCE: 3

Does the Academy of Breastfeeding Medicine's Clinical Protocol #36 'The Mastitis Spectrum' promote overtreatment and risk worsened outcomes for breastfeeding families? Commentary

BACKGROUND

In 2022 the Academy of Breastfeeding Medicine (ABM) published Clinical Protocol #36: The Mastitis Spectrum, which aims to update clinical approaches to management of benign lactation-related breast inflammation. The protocol has been timely because of the exponential increase in knowledge about the human milk microbiome over the past decade. This Commentary aims to continue respectful debate amongst clinicians and researchers within the Academy of Breastfeeding Medicine and more broadly, confident that we share a fundamental commitment to promote breastfeeding and support the well-being of lactating women, their infants and their families.

ANALYSIS

Although Clinical Protocol #36 offers advances, it does not fulfil the principles of best practice implementation science for translation of evidence into clinical guidelines. Clinical Protocol #36 inaccurately represents studies; misrepresents theoretical models as proven aetiologies; does not consistently attribute sources; does not reliably apply the SORT taxonomy; and relies upon single case reports. As a result, various recommendations in Clinical Protocol #36 lack an evidence-base or credible underlying theoretical model. This includes recommendations to use 'lymphatic drainage' massage, therapeutic ultrasound, and oral lecithin. Similarly, based on a contestable theoretical model which is presented as fact, Clinical Protocol #36 makes the recommendation to either reduce frequency of milk removal or to maintain current frequency of milk removal during an episode of breast inflammation. Although Clinical Protocol #36 limits this advice to cases of 'hyperlactation', the diagnosis 'hyperlactation' itself is undefinable. As a result, this recommendation may put breastfeeding women who present with breast inflammation at risk of worsened inflammation and decreased breast milk production.

CONCLUSION

Clinical Protocol #36 offers some advances in the management of breast inflammation. However, Clinical Protocol #36 also exposes clinicians to two international trends in healthcare which undermine health system sustainability: overdiagnosis, including by over-definition, which increases risk of overtreatment; and antibiotic over-use, which worsens the crisis of global antimicrobial resistance. Clinical Protocol #36 also recommends unnecessary or ineffective interventions which may be accessed by affluent patients within advanced economies but are difficult to access for the global majority. The Academy of Breastfeeding Medicine may benefit from a review of processes for development of Clinical Protocols.

Effectiveness of physical exercise programmes in reducing complications associated with secondary lymphoedema to breast cancer: a protocol for an overview of systematic reviews

INTRODUCTION

Breast cancer-related lymphoedema (BCRL) is one of the most underestimated and debilitating complications associated with the treatment that women with breast cancer receive. Several systematic reviews (SRs) of different physical exercise programmes have been published, presenting disperse and contradictory clinical results. Therefore, there is a need for access to the best available and summarised evidence to capture and evaluate all the physical exercise programmes that focus on reducing BCRL.

OBJECTIVE

To evaluate the effectiveness of different physical exercise programmes in reducing the volume of lymphoedema, pain intensity and improving quality of life.

METHOD AND ANALYSIS

The protocol of this overview is reported following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols, and its methodology is based on Cochrane Handbook for Systematic Reviews of Interventions. Only those SRs involving physical exercise by patients with BCRL will be included, whether on its own or combined with other exercises or other physical therapy interventions.The outcomes of interest to be considered will be lymphoedema volume, quality of life, pain intensity, grip strength, range of motion, upper limb function and any adverse event. The MEDLINE/PubMed, Lilacs, Cochrane Library, PEDro and Embase databases will be searched for reports published from database inception to April 2023.Two researchers will perform study selection, data extraction and risk of bias assessment independently. Any discrepancy will be resolved by consensus, or ultimately, by a third-party reviewer. We will use Grading of Recommendations Assessment, Development and Evaluation System to assess the overall quality of the body of evidence.

ETHICS AND DISSEMINATION

The results of this overview will be published in peer-reviewed scholarly journals and the scientific dissemination will take place in national or international conferences. This study does not require approval from an ethics committee, as it does not directly collect information from patients.

PROSPERO REGISTRATION NUMBER

CRD42022334433.

Early Intervention with a Compression Sleeve in Mild Breast Cancer-Related Arm Lymphedema: A 12-Month Prospective Observational Study

BACKGROUND

In our previous randomized controlled trial (RCT), the progression/no progression of mild breast cancer-related arm lymphedema (BCRL) was examined among women randomized to a compression group (CG) with a compression sleeve (compression class (ccl) 1) or not (NCG) for 6 months. In the present prospective study, BCRL in the CG and NCG was followed for 12 months.

METHODS

At the end of the RCT, 33 women with mild BCRL were eligible in the CG and 37 in the NCG. The proportional differences in no progression/progression of BCRL were defined as a >2% increase from start of RCT or exceeding 10% in the lymphedema relative volume as measured by the water displacement method. In addition, changes in the lymphedema relative volume and tissue dielectric constant ratio, which measures local tissue water, were examined. At the end of the RCT (i.e., after 6 months), a one-month break of the compression treatment was made in the CG. If the lymphedema relative volume progressed by definition, the compression treatment was resumed and continued, with follow-up of all women at 9 and 12 months.

RESULTS

A larger proportion of women in the NCG showed progression (57%, 61%, 67%) compared to the CG (16%, 22%, 31%) at 6, 9, and 12 months (p < 0.001, 0.005, 0.012), respectively. Twelve (33%) women in the NCG did not progress at all. No changes of the lymphedema relative volume and local tissue water were found over time at any follow-ups, but were stable on a low level.

CONCLUSIONS

To avoid the progression of mild BCRL into a chronic issue in the long-term, compression sleeve ccl 1 may be applied immediately after early diagnosis of mild BCRL.

Low-intensity pulsed ultrasound reduces lymphedema by regulating macrophage polarization and enhancing microcirculation

Background: Conventional therapies reduce lymphedema but do not cure it because they cannot modulate the pathophysiology of secondary lymphedema. Lymphedema is characterized by inflammation. We hypothesized that low-intensity pulsed ultrasound (LIPUS) treatment could reduce lymphedema by enhancing anti-inflammatory macrophage polarization and microcirculation. Methods: The rat tail secondary lymphedema model was established through the surgical ligation of lymphatic vessels. The rats were randomly divided into the normal, lymphedema, and LIPUS treatment groups. The LIPUS treatment (3 min daily) was applied 3 days after establishing the model. The total treatment period was 28 days. Swelling, fibro adipose deposition, and inflammation of the rat tail were evaluated by HE staining and Masson's staining. The photoacoustic imaging system and laser Doppler flowmetry were used to monitor microcirculation changes in rat tails after LIPUS treatment. The cell inflammation model was activated with lipopolysaccharides. Flow cytometry and fluorescence staining were used to observe the dynamic process of macrophage polarization. Results: After 28 days of treatment, compared with the lymphedema group, the tail circumference and subcutaneous tissue thickness of rats in the LIPUS group were decreased by 30%, the proportion of collagen fibers and the lymphatic vessel cross-sectional area was decreased, and tail blood flow was increased significantly. Cellular experiments revealed a decrease in CD86⁺ macrophages (M1) after LIPUS treatment. Conclusion: The transition of M1 macrophage and the promotion of microcirculation could be responsible for the beneficial effect of LIPUS on lymphedema.

The Effectiveness of Fluoroscopy-Guided Manual Lymph Drainage as Part of Decongestive Lymphatic Therapy on the Superficial Lymphatic Architecture in Patients with Breast Cancer-Related Lymphoedema: A Randomised Controlled Trial

The objective of this trial was to investigate the effectiveness of fluoroscopy-guided manual lymph drainage (MLD), as part of decongestive lymphatic therapy (DLT), on the superficial lymphatic architecture in patients with chronic mild to moderate breast cancer-related lymphoedema (BCRL). This trial was a multicentre, double-blind, randomised controlled trial involving 194 participants with BCRL. Participants were randomised into (1) DLT with fluoroscopy-guided MLD (intervention group), (2) DLT with traditional MLD (control group), or (3) DLT with placebo MLD (placebo group). Superficial lymphatic architecture was evaluated as a secondary outcome, visualised by ICG lymphofluoroscopy at the baseline (B0), post-intensive (P), and post-maintenance phases (P6). Variables were (1) number of efferent superficial lymphatic vessels leaving the dermal backflow region, (2) total dermal backflow score, and (3) number of superficial lymph nodes. The traditional MLD group showed a significant decrease in the number of efferent superficial lymphatic vessels at P (p = 0.026), and of the total dermal backflow score at P6 (p = 0.042). The fluoroscopy-guided MLD and placebo group showed significant decreases in the total dermal backflow score at P (p < 0.001 and p = 0.044, respectively) and at P6 (p < 0.001 and p = 0.007, respectively); the placebo MLD group showed a significant decrease in the total number of lymph nodes at P (p = 0.008). However, there were no significant between-group differences for the changes in these variables. In conclusion, based on lymphatic architecture outcomes, the added value of MLD, in addition to the other parts of DLT, could not be demonstrated in patients with chronic mild to moderate BCRL.

The effect of myofascial release in patients with breast cancer-related lymphedema: a cross-over randomized controlled trial

AIM

This study aimed to compare the effects of myofascial release (MFR) on upper extremity volume in patients with breast cancer-related lymphedema (BCRL).

DESIGN

A randomized, single-blinded, cross-over, controlled trial.

SETTING

An outpatient rehabilitation clinical setting.

POPULATION

Thirty patients with BCRL.

METHODS

Within a crossover design with randomized treatment sequences, fifteen subjects received MFR for 4 weeks, followed by 4 weeks of washout period, and then received placebo MFR and the other fifteen subjects received interventions in the reverse order. Each session had a 60 min process including either MFR or placebo MFR for 30 min, followed by complete decongestive therapy for 30 min twice a week. Upper limb volume as the primary outcome and subjective pain, shoulder range of motion (ROM), chest mobility, shoulder function, and quality of life as secondary outcomes were assessed before and at the end of each intervention period.

RESULTS

There were significant differences in upper limb volume after both MFR and placebo MFR (P<0.05) while no significant difference between MFR and placebo MFR treatments was found (P>0.05). MFR-based treatment also achieved a greater improvement than placebo MFR-based treatment in subjective pain and shoulder ROM (P<0.05), except for internal rotation, and shoulder function.

CONCLUSIONS

MFR-based treatment showed clinical improvement in shoulder function, induced by decreased edema volume and pain, and improved ROM and chest mobility. However, a further study with parallel randomized controlled trials to confirm what was achieved in the present study.

CLINICAL REHABILITATION IMPACT

MFR-based treatment is considered an important part of BCRL rehabilitation. Moreover, MFR-based treatment may be safe for patients with BCRL.

What do we know about treating breast-cancer-related lymphedema? Review of the current knowledge about therapeutic options

Breast-cancer-related lymphedema (BCRL) is a common consequence of oncological treatment. Its management is a complicated, chronic, and arduous process. Therapeutic options can be divided on non-surgical and surgical methods, although there is still no clear consensus about their effectiveness in preventing or stopping the disease. That brings problems in everyday practice, as there are no guidelines about proper time for starting therapy and no agreement about which management will be beneficial for each patient. The aim of this review is to summarize current knowledge about possible treatment choices, non-surgical so as surgical, indicate knowledge gaps, and try to direct pathways for future studies.

The effect of massage therapy on pain after surgery: A comprehensive meta-analysis

BACKGROUND

Findings on the usefulness of massage therapy (MT) in postoperative pain management are often inconsistent among studies.

OBJECTIVES

This study's aim is to conduct a meta-analysis of randomized controlled trials (RCT) to clarify the effects of massage therapy in the treatment of postoperative pain.

METHODS

Three databases (PubMed, Embase, and Cochrane Central Register of Controlled Trials) were searched for RCTs published from database inception through January 26, 2021. The primary outcome was pain relief. The quality of RCTs was appraised with the Cochrane Collaboration risk of bias tool. The random-effect model was used to calculate the effect sizes and standardized mean difference (SMD) with 95 % confidential intervals (CIs) as a summary effect. The heterogeneity test was conducted through I². Subgroup and sensitivity analyses were used to explore the source of heterogeneity. Possible publication bias was assessed using visual inspection of funnel plot asymmetry.

RESULTS

The analysis included 33 RCTs and showed that MT is effective in reducing postoperative pain (SMD, -1.32; 95 % CI, -2.01 to -0.63; p = 0.0002; I² = 98.67 %). A similar significant effect was found for both short (immediate assessment) and long terms (assessment performed 4-6 weeks after the MT). Remarkably, we found neither the duration per session nor the dose had an impact on the effect of MT and there seemed to be no difference in the effects of different MT types. In addition, MT seemed to be more effective for adults. Furthermore, MT had better analgesic effects on cesarean section and heart surgery than orthopedic surgery.

LIMITATIONS

Publication bias is possible due to the inclusion of studies in English only. Additionally, the included studies were extremely heterogeneous. Double-blind research on MT is difficult to implement, and none of the included studies is double-blind. There was some heterogeneity and publication bias in the included studies. In addition, there is no uniform evaluation standard for the operation level of massage practitioners, which may lead to research implementation bias.

CONCLUSIONS

MT is effective in reducing postoperative pain in both short and long terms.

Which physical therapy intervention is most effective in reducing secondary lymphoedema associated with breast cancer? Protocol for a systematic review and network meta-analysis

INTRODUCTION

Lymphoedema associated with breast cancer is caused by an interruption of the lymphatic system, together with factors such as total mastectomy, axillary dissection, positive lymph nodes, radiotherapy, use of taxanes and obesity. Physiotherapy treatment consists of complex decongestive therapy, manual lymphatic drainage and exercises, among other interventions. Currently, there are several systematic review and randomised controlled trials that evaluate the efficacy of these interventions. However, at present, there are no studies that compare the effectiveness of all these physical therapy interventions. The purpose of this study is to determine which physical therapy treatment is most effective in reducing breast cancer-related lymphoedema, improving quality of life and reducing pain.

METHODS AND ANALYSIS

MEDLINE, PEDro, CINAHL, EMBASE, LILACS and Cochrane Central Register of Controlled Trials will be searched for reports of randomised controlled trials published from database inception to June 2022. We will only include studies that are written in English, Spanish and Portuguese. We will also search grey literature, preprint servers and clinical trial registries. The primary outcomes are reduction of secondary lymphoedema associated with breast cancer, improvements in quality of life and pain reduction. The risk of bias of individual studies will be evaluated using the Cochrane Risk of Bias 2.0 Tool. A network meta-analysis will be performed using a random-effects model. First, pairs will be directly meta-analysed and indirect comparisons will be made between the different physical therapy treatments. The GRADE system will be used to assess the overall quality of the body of evidence associated with the main results.

ETHICS AND DISSEMINATION

This protocol does not require approval from an ethics committee. The results will be disseminated via peer-reviewed publications.

PROSPERO REGISTRATION NUMBER

CDR42022323541.

The effect of the combined use of complex decongestive therapy with electrotherapy modalities for the treatment of breast cancer-related lymphedema: a randomized clinical trial

Background

We evaluated the effects of combined complex decongestive therapy (CDT) with electrotherapy modalities (ultrasound and faradic currents) in patients with breast cancer-related lymphedema (BCRL), investigating upper extremity circumference, volume, pain, and functional disability.

Methods

Thirty-nine patients with unilateral BCRL were randomly allocated to three groups (n = 13) as the following: The control group received CDT, the ultrasound group received CDT and therapeutic ultrasound, and the faradic group received CDT and faradic current. All the participants underwent treatment for 10 sessions. The outcomes including volume, circumference (measured at five points), pain intensity, and functional disability of the affected upper extremity were evaluated at baseline and after the treatment.

Results

Following the treatment, an improvement was noted in lymphedema volume, pain, and functional disability in all the three groups and there was a significant difference between the groups (P < 0.05). However, changes in limb circumference at the end of the treatment were not significantly different among the three groups in any sites (P > 0.05).

Conclusion

The combination of electrotherapy modalities, faradic current or ultrasound, with CDT can result in a greater reduction in lymphedema volume, pain, and functional disability in patients with BCRL.

Trial registration

IRCT, IRCT201310292391N14, registered 03/01/2016.

Reduction of Arm Lymphedema Using Manual Lymphatic Therapy (Godoy Method)

Background: The manual lymphatic drainage (MLD) technique used during the early stages following surgical treatment of breast cancer can help prevent the progression of clinical lymphedema.

Objective: The objective of this study was to evaluate the effectiveness of manual lymphatic therapy (MLT) (Godoy method) in reducing the development of lymphedema immediately after breast cancer treatment.

Method: A randomized, blind, crossover, clinical trial was conducted involving 66 women with breast cancer-related lymphedema (BCRL), who underwent one hour of manual physical therapy and one hour of the control procedure. To evaluate the volume before and after the application of the MLT technique, volumetry, a water displacement technique was used. For statistical analysis, the paired t-test with 5% alpha error by Stats Direct 3(StatsDirect Ltd, Wirral, UK) was used.

Results: A significant reduction in the volume of the limb was found in all patients (p-value = 0.0001, paired t-test).

Conclusion: MLT is effective in reducing lymphedema after breast cancer treatment.

Significant Decrease in Glycated Hemoglobin, 2h-Post-Load Glucose and High-Sensitivity C-Reactive Protein Levels in Patients with Abnormal Body Mass Index after Therapy with Manual Lymphatic Drainage

The objective of this study was to investigate the effect of manual lymphatic drainage (MLD) on the insulin resistance parameter (HOMA-IR), glycated hemoglobin (HbA1c), C-peptide, insulin, fasting plasma glucose (FPG), 2h-post-loadglucose (2h-PG) and the concentration of high-sensitivity C-reactive protein (hsCRP) in patients with abnormal body mass index. The study involved 30 patients, including patients with normal body weight (as a control group; group I; n = 14), overweight patients (group II; n = 9) and obese patients (group III; n = 7). Each patient underwent 10 sessions of MLD therapy, 3 times a week for 30 min. In addition, we measured body mass index (BMI) and waist-to-hip ratio (WHR) and performed body composition analysis as well as biochemical tests before MLD therapy (stage 0′) and after MLD therapy (stage 1′). A statistically significant correlation was demonstrated between the concentration of C-peptide, BMI, the amount of visceral adipose tissue (r = 0.87, p = 0.003; r = 0.76, p = 0.003, respectively), and the HOMA-IR index, BMI and the amount of visceral adipose tissue (r = 0.86, p = 0.005; r = 0.84, p = 0.042, respectively), before and after MLD therapy. In overweight patients (group II), a statistically significant (p = 0.041) decrease in the hsCRP level by 2.9 mg/L and a significant (p = 0.050) decrease in the 2h-PG level by 12 mg/dL after the MLD therapy was detected. Moreover, in the group of obese patients (group III), a statistically significant (p = 0.013) decrease in HbA1c level by 0.2% after MLD therapy was demonstrated. Our results indicate that MLD may have a positive effect on selected biochemical parameters, with the most favorable changes in overweight patients. Further studies in a larger number of patients are warranted to confirm our findings, to test in-depth their mechanism, and to investigate clinical benefits of this alternative therapy in patients with abnormal body mass index.

Emerging Anti-Inflammatory Pharmacotherapy and Cell-Based Therapy for Lymphedema

Secondary lymphedema is a common complication of lymph node dissection or radiation therapy for cancer treatment. Conventional therapies such as compression sleeve therapy, complete decongestive physiotherapy, and surgical therapies decrease edema; however, they are not curative because they cannot modulate the pathophysiology of lymphedema. Recent advances reveal that the activation and accumulation of CD4+ T cells are key in the development of lymphedema. Based on this pathophysiology, the efficacy of pharmacotherapy (tacrolimus, anti-IL-4/IL-13 antibody, or fingolimod) and cell-based therapy for lymphedema has been demonstrated in animal models and pilot studies. In addition, mesenchymal stem/stromal cells (MSCs) have attracted attention as candidates for cell-based lymphedema therapy because they improve symptoms and decrease edema volume in the long term with no serious adverse effects in pilot studies. Furthermore, MSC transplantation promotes functional lymphatic regeneration and improves the microenvironment in animal models. In this review, we focus on inflammatory cells involved in the pathogenesis of lymphedema and discuss the efficacy and challenges of pharmacotherapy and cell-based therapies for lymphedema.

Re-thinking benign inflammation of the lactating breast: Classification, prevention, and management

Despite the known benefits of breastfeeding for both infant and mother, clinical support for problems such as benign inflammation of the lactating breast remain a research frontier. Breast pain associated with inflammation is a common reason for premature weaning. Multiple diagnoses are used for benign inflammatory conditions of the lactating breast which lack agreed or evidence-based aetiology, definitions, and treatment. This article is the second in a three-part series. This second review analyses the heterogeneous research literature concerning benign lactation-related breast inflammation from the perspectives of the mechanobiological model and complexity science, to re-think classification, prevention, and management of lactation-related breast inflammation. Benign lactation-related breast inflammation is a spectrum condition, either localized or generalized. Acute benign lactation-related breast inflammation includes engorgement and the commonly used but poorly defined diagnoses of blocked ducts, phlegmon, mammary candidiasis, subacute mastitis, and mastitis. End-stage (non-malignant) lactation-related breast inflammation presents as the active inflammations of abscess, fistula, and septicaemia, and the inactive condition of a galactocoele. The first preventive or management principle of breast inflammation is avoidance of excessively high intra-alveolar and intra-ductal pressures, which prevents strain and rupture of a critical mass of lactocyte tight junctions. This is achieved by frequent and flexible milk removal. The second preventive or management principle is elimination of the mechanical forces which result in high intra-alveolar pressures. This requires elimination of conflicting vectors of force upon the nipple and breast tissue during milk removal; avoidance of focussed external pressure applied to the breast, including avoidance of lump massage or vibration; and avoidance of other prolonged external pressures upon the breast. Three other key preventive or management principles are discussed. Conservative management is expected to be effective for most, once recommendations to massage or vibrate out lumps, which worsen micro-vascular trauma and inflammation, are ceased.

Web Axillary Pain Syndrome-Literature Evidence and Novel Rehabilitative Suggestions: A Narrative Review

Axillary web syndrome (AWS) is defined as a visible and palpable network of cords in the skin of the axillary cavity that are tensed by shoulder abduction following surgery for breast cancer, causing significant functional limits of the ipsilateral upper limb (UL) and pain. The purpose of this narrative review is to discuss rehabilitation approaches for greater efficacy with respect to pain and novel suggestions. AWS is a frequent complication of axillary lymphadenectomy that necessitates a thorough follow-up in the medium to long term. Physiotherapy is effective in the treatment of functional limb deficits, the management of pain, and the treatment of upper limb disability. The best management approach involves the use of soft tissue techniques to slow the natural course of the syndrome, in association with therapeutic exercises for functional recovery and muscle strengthening. AWS is linked secondary lymphedema, requiring integration with manual lymphatic drainage. The physiotherapy management of AWS is currently fragmented, and insufficient information is available on the nature of the disease. Thus, randomized and controlled studies that compare rehabilitation approaches in AWS are desirable, including the possibility of using mesotherapy in the treatment of axillary and upper limb pain.

Intensive Treatment for Upper Limb Lymphedema

Introduction Breast cancer-related lymphedema (BCRL) is a complication of treatment for breast cancer. The aim of the present study is to report a form of intensive treatment for BCRL. Method A crossover study was conducted involving the evaluation of the change in the volume of the upper limbs of 45 women with BCRL who underwent the intensive Godoy Method® (eight hours/day for five days). Volumetric analyses were performed before and after treatment and differences were analyzed using the paired t-test. Reductions in volume were found in all patients. Results The average reduction was 45.38%. The reduction was between 15% and 20% in 6.67% of the women (n = 3); 20% to 30% in 13.33% (n = 6); 30% to 40% in 20% (n = 9); 40% to 50% in 40% (n = 18); and more than 50% in 20% of the women (n = 9). Conclusion The intensive form of treatment for lymphedema is highly effective in a short period of time, with a 40% to 50% reduction in volume in five days, but requires specialized centers adapted to this form of therapy. This is an option for reference centers in the treatment of lymphedema and the formation of human resources.

Physical therapies in the decongestive treatment of lymphedema: A randomized, non-inferiority controlled study

OBJECTIVE

To assess whether the treatment with intermittent pneumatic compression plus multilayer bandages is not inferior to classical trimodal therapy with manual lymphatic drainage in the decongestive lymphedema treatment.

STUDY DESIGN

Randomized, non-inferiority, controlled study to compare the efficacy of three physical therapies' regimens in the Decongestive Lymphatic Therapy.

PARTICIPANTS

194 lymphedema patients, stage II-III with excess volume > 10% were stratified within upper and lower limb and then randomized to one of the three treatment groups. Baseline characteristics were comparable between the groups.

INTERVENTION

all patients were prescribed 20 sessions of the following regimens: Group A (control group): manual lymphatic drainage + Intermittent Pneumatic Compression + Bandages; Group B: pneumatic lymphatic drainage + Intermittent Pneumatic Compression + Bandages; and Group C: only Intermittent Pneumatic Compression + Bandages.

END-POINT

Percentage reduction in excess volume (PREV).

RESULTS

All patients improved after treatment. Global mean of PREV was 63.9%, without significant differences between the groups. The lower confidence interval of the mean difference in PREV between group B and group A, and between group C and group A were below 15%, thus meeting the non-inferiority criterion. Most frequent adverse events were discomfort and lymphangitis, without differences between groups. A greater baseline edema, an upper-limb lymphedema and a history of dermatolymphangitis were independent predictive factors of worse response in the multivariate analysis.

CONCLUSIONS

Decongestive lymphatic therapy performed only with intermittent pneumatic compression plus bandages is not inferior to the traditional trimodal therapy with manual lymphatic drainage. This approach did not increase adverse events.

An important tool in lymphedema management: validation of Turkish version of the lymphedema breast cancer questionnaire

PURPOSE

This study aimed to perform the psychometric evaluation of the Turkish version of the Lymphedema and Breast Cancer Questionnaire (LBCQ).

METHODS

Patients with BCRL (n = 50) received a Turkish version of the following measurement tools: Lymphedema Functioning, Disability, and Health Questionnaire (Lymph-ICF), Disabilities of the Arm, Shoulder and Hand questionnaire (Quick DASH), LBCQ and Upper Extremity Functional Index (UEFI-20). Patients without BCRL (n = 50) completed only the Turkish LBCQ. Psychometric properties were analyzed with internal consistency, test-retest reliability, ROC analysis, criterion, and discriminant validity.

RESULTS

The internal consistency of the Turkish LBCQ was strong (Cronbach's α coefficient >0.60). Test-retest reliability was also very strong (intraclass correlation coefficients from 0.79 to 1; p < 0.001). Criterion validity was supported by a moderate correlation of LBCQ with volumetric measurement, skinfold thickness, and questionnaires (Lymph-ICF, UEFI, and Quick DASH) (p < 0.05) via the ROC analysis, the cut-off point was found as "6" in distinguishing individuals with lymphedema and those without. There were significant differences in LBCQ total and subscale scores between participants with and without BCRL (p < 0.05).

CONCLUSIONS

This study clinically confirmed the validity, reliability, and applicability of the Turkish LBCQ in the Turkish population. LBCQ will enable the early detection of lymphedema and will save the country financially with early diagnosis.IMPLICATIONS FOR REHABILITATIONThe LBCQ was successfully translated, adapted, and validated into the Turkish language.Turkish version of the LBCQ was found to be reliable and valid to evaluate the signs and symptoms of lymphedema in Turkish women with breast cancer.By using LBCQ, rehabilitation professionals can detect lymphedema at an early stage, reduce the cost of lymphedema treatment and prevent the development of advanced lymphedema in their clinics.

It was just mind blowing to be honest: a qualitative phenomenological study exploring cancer survivor's experiences of indocyanine green lymphography used to inform lymphedema therapy management

PURPOSE

A diagnosis of secondary lymphedema following cancer treatment can necessitate lifelong therapy. Indocyanine green (ICG) lymphography is a technique for visualising lymphatics to enable individualised lymphedema diagnosis, staging and therapy prescription. The participant experience of undergoing the procedure and the impact of imaging findings on lymphedema management is unknown. This study aimed to explore participant's experiences of ICG lymphography to inform cancer-related lymphedema therapy.

METHODS

A qualitative phenomenological study was conducted using semi-structured interviews with 17 adult participants who had undergone ICG lymphography for stage 0 to 2 upper or lower limb secondary cancer-related lymphedema (International Society of Lymphology, Lymphology 53(1):3-10, 2020).

RESULTS

Seventeen participants were included in the study ranging in age from 36 to 78 years (M = 53.8 years), the majority had a primary diagnosis of breast cancer (N = 7) or melanoma (N = 7). Three overarching themes emerged. Firstly, describing the experience of the ICG lymphography procedure. Secondly, the new knowledge explained symptoms and tailored treatment. Participants reflected on how seeing their lymphatic system helped in understanding about their lymphedema symptoms and guided changes towards more individualised lymphedema management. The final theme described the internal impact of self-knowledge, which included impacts of the new information on empowerment and motivation to self-manage participant's condition as well as their feelings.

CONCLUSIONS

ICG lymphography had beneficial impacts on participant's understanding of their lymphedema symptoms and often led to changes in management, positive outcomes in response to management changes and peace of mind about management plans, leading to feeling more empowered to self-manage their condition.