A pilot, prospective evaluation of a novel alternative for maintenance therapy of breast cancer-associated lymphedema [ISRCTN76522412]

Etiology and treatment of cancer-related secondary lymphedema

Lymphedema and specifically cancer-related lymphedema is not the main focus for both patients and physicians dealing with cancer. Its etiology is an unfortunate complication of cancer treatment. Although lymphedema treatments have gained an appreciable consensus, many practitioners have developed and prefer their own specific protocols and this is especially true for conventional (manual) versus surgical treatments. This collection of presentations explores the incidence and genetics of cancer-related lymphedema, early detection and monitoring techniques, both conventional and operative treatment options, and the importance and role of exercise for patients with cancer-related lymphedema. These assembled presentations provide valuable insights into the challenges and opportunities presented by cancer-related lymphedema including the latest research, treatments, and exercises available to improve patient outcomes and quality of life.

Effect of Conservative Rehabilitation Interventions on Health-Related Quality of Life in Women with Upper Limb Lymphedema Secondary to Breast Cancer: A Systematic Review

Breast cancer-related lymphedema (BCRL) of the upper limb is a very common condition in women undergoing breast cancer treatment; it can cause considerable alterations in the daily life of patients and a decrease in their health-related quality of life (HRQoL). Currently, there are many conservative therapies that try to palliate the symptoms, but the results are still controversial and there are still no globally accepted treatments. The purpose of this article is to determine the effect, according to the current available evidence, on HRQoL of different conservative interventions in the rehabilitation of BCRL in the upper limb in women. Eighteen articles that compared the effects of standard treatments, such as manual lymphatic drainage-based decongestive therapy or compression measures, and other newer treatments, including new technologies and other types of treatment programs, were reviewed. According to the results of this review, the most recommended modality for the improvement of HRQoL would be a complex decongestive technique without manual lymphatic drainage. Although there are clinical trials that have demonstrated the effectiveness of various treatments, the results of the positive effects on HRQoL remain highly controversial. There is a need to continue to develop studies to help guide therapeutic decisions that can promote HRQoL in women affected by upper limb BCRL.

Pneumatic compression therapy using the EQ Press accelerates lymphatic flow in healthy equine forelimbs as determined by lymphoscintigraphy

OBJECTIVE

Limb lymphedema in horses can be debilitating and painful. Pneumatic compression therapy has shown significant benefits for people suffering from lymphedema. The objective of this study was to determine the effect of a novel, equine-specific pneumatic compression device on the lymphatic flow of healthy horse forelimbs as determined by Tc-99m sulfur colloid lymphoscintigraphy.

ANIMALS

6 healthy Thoroughbreds.

PROCEDURES

In a randomized crossover design, horses underwent bilateral forelimb lymphoscintigraphy following subcutaneous injection of Tc-99m sulfur colloid at the coronary band as untreated control or with pneumatic compression therapy using the EQ Press. Lateral, static images were obtained of the distal limb (time 0 to 60 minutes) and proximal limb (time 30 to 60 minutes) using a standard gamma camera. Lymphatic flow was determined by assigning a score to the time point at which Tc-99m sulfur colloid was first visualized at the level of the accessory carpal bone (1 to 7) in the distal limb and the cubital lymph node (1 to 4) in the proximal limb.

RESULTS

EQ Press treatment led to a significantly faster lymphatic flow of Tc-99m sulfur colloid to the predetermined anatomic locations of the accessory carpal bone (P = .002) in the distal limb and the cubital lymph node (P = .001) in the proximal limb.

CLINICAL RELEVANCE

Pneumatic compression therapy as provided by an equine-specific device encouraged lymphatic flow in healthy, nonedematous equine forelimbs. These data support further study of the EQ Press for pneumatic compression therapy in horses clinically affected by lymphedema and lymphatic drainage disorders.

Rehabilitation interventions for the management of breast cancer-related lymphedema: developing a patient-centered, evidence-based plan of care throughout survivorship

PURPOSE

A work group from the American Physical Therapy Association Academy of Oncologic Physical Therapy developed and published a clinical practice guideline (CPG) to aid clinicians in identifying interventions for individuals with breast cancer-related lymphedema (BCRL). This guideline reviewed the evidence for risk mitigation and volume reduction beginning at cancer diagnosis and continuing through survivorship. Application of CPGs can be challenging due to the variability of clinical settings, heterogeneous patient populations, and range of rehabilitation clinician expertise. The purpose of this paper is to assist these clinicians in implementing the recommendations from the CPG to develop a patient-centered, evidence-based plan of care.

METHODS/RESULTS

This publication presents important considerations for the implementation of recommended rehabilitation interventions across the trajectory of BCRL.

CONCLUSION

Current evidence supports specific interventions to treat or mitigate the risk for the various stages of BCRL. As clinicians implement these recommendations into practice, they also need to address other impairments that may exist in every individual. Continued collaboration between clinicians and researchers is necessary to further develop optimal treatment modalities and parameters.

IMPLICATIONS FOR CANCER SURVIVORS

By implementing evidence-based interventions as outlined in the CPG, clinicians can improve the quality of care for survivors of breast cancer.

Lipedema: Insights into Morphology, Pathophysiology, and Challenges

Lipedema is an adipofascial disorder that almost exclusively affects women. Lipedema leads to chronic pain, swelling, and other discomforts due to the bilateral and asymmetrical expansion of subcutaneous adipose tissue. Although various distinctive morphological characteristics, such as the hyperproliferation of fat cells, fibrosis, and inflammation, have been characterized in the progression of lipedema, the mechanisms underlying these changes have not yet been fully investigated. In addition, it is challenging to reduce the excessive fat in lipedema patients using conventional weight-loss techniques, such as lifestyle (diet and exercise) changes, bariatric surgery, and pharmacological interventions. Therefore, lipedema patients also go through additional psychosocial distress in the absence of permanent treatment. Research to understand the pathology of lipedema is still in its infancy, but promising markers derived from exosome, cytokine, lipidomic, and metabolomic profiling studies suggest a condition distinct from obesity and lymphedema. Although genetics seems to be a substantial cause of lipedema, due to the small number of patients involved in such studies, the extrapolation of data at a broader scale is challenging. With the current lack of etiology-guided treatments for lipedema, the discovery of new promising biomarkers could provide potential solutions to combat this complex disease. This review aims to address the morphological phenotype of lipedema fat, as well as its unclear pathophysiology, with a primary emphasis on excessive interstitial fluid, extracellular matrix remodeling, and lymphatic and vasculature dysfunction. The potential mechanisms, genetic implications, and proposed biomarkers for lipedema are further discussed in detail. Finally, we mention the challenges related to lipedema and emphasize the prospects of technological interventions to benefit the lipedema community in the future.

Intermittent Pneumatic Compression for the Treatment of Lower Limb Lymphedema: A Pilot Trial of Sequencing to Mimic Manual Lymphatic Drainage Versus Traditional Graduated Sequential Compression

Background:

Recent advances in technology have allowed intermittent pneumatic compression (IPC) devices to develop so that their function mimics the process and principles of manual lymphatic drainage (MLD); however, research into the effectiveness of such devices is lacking. This study aimed to investigate the effectiveness of a patented IPC technique designed to mimic MLD (the LymphAssist), compared with a typical sequential IPC regimen.

Methods and Results:

Forty patients with a confirmed diagnosis of lower limb ISL (International Society of Lymphology) stage II or III lymphedema were recruited into this three-phased study. A bilateral leg volume assessment and quality-of-life assessment were completed at four clinic visits across the course of the study. The LymphAssist IPC regimen was significantly more effective in reducing distal leg volume than the sequential mode (mean volume reduction: 230 ± 135 mL vs. 140 ± 84 mL, respectively, p = 0.01). Improvements in leg volume were transient as both groups demonstrated a rebound or increase in volume during the washout period (LymphAssist: 238 ± 168 mL, sequential: 276 ± 158 mL, p = 0.3). Overall, IPC was effective in improving quality-of-life scores (mean reduction: 10 ± 11, p < 0.001).

Conclusion:

IPC is effective in reducing limb volume and improving quality of life for patients with lower limb lymphedema. IPC that mimics the MLD process has been shown to be more effective in reducing leg volume compared with traditional sequential IPC in the distal aspect of the leg. The increase in leg volume observed after discontinuation of IPC suggests that regular treatment is required to maintain its associated effects.

Clinical Trial Registration Number: NTC 03856281.

Clinical Evaluation of a Novel Wearable Compression Technology in the Treatment of Lymphedema, an Open-Label Controlled Study

A diagnosis of lymphedema comes with a lifetime requirement for careful self-care and treatment to control skin deterioration and the consequences of excessive fluid and protein buildup leading to abnormal limb volume and an increased risk of infection. The burden of care and psychosocial aspects of physical disfiguration and loss of function are associated with compromised quality of life (QoL). The current standard therapeutic intervention is complex decongestive therapy with manual lymph drainage and frequent wearing of compression garments. With insurance limitations on therapy visits and the time and travel required, additional home treatment options are needed. Pneumatic compression pumps that mimic the manual massage pressure and pattern are sometimes prescribed, but these are bulky, difficult to apply, and require immobility during treatment. An open-label pilot study in 40 subjects was performed to evaluate the QoL and limb volume maintenance efficacy of a novel wearable compression system (Dayspring™) that is low profile, easy to use, and allows for mobility during treatment. After 28 days of use, subjects had a statistically significant 18% (p < 0.001) improvement in overall QoL as measured by the Lymphedema Quality-of-Life Questionnaire compared with baseline. Individual QoL domains, and limb volume improved with therapy. Adherence was 98% over the course of the study. Results of the clinical evaluation suggest the Dayspring wearable compression device is safe and effective and improves QoL and limb volume. The novel, low-profile device is easy to use and allows for mobility during treatment, addressing a potential barrier to adherence with pneumatic compression devices.

Standard of care for lipedema in the United States

Background

Lipedema is a loose connective tissue disease predominantly in women identified by increased nodular and fibrotic adipose tissue on the buttocks, hips and limbs that develops at times of hormone, weight and shape change including puberty, pregnancy, and menopause. Lipedema tissue may be very painful and can severely impair mobility. Non-lipedema obesity, lymphedema, venous disease, and hypermobile joints are comorbidities. Lipedema tissue is difficult to reduce by diet, exercise, or bariatric surgery.

Methods

This paper is a consensus guideline on lipedema written by a US committee following the Delphi Method. Consensus statements are rated for strength using the GRADE system.

Results

Eighty-five consensus statements outline lipedema pathophysiology, and medical, surgical, vascular, and other therapeutic recommendations. Future research topics are suggested.

Conclusion

These guidelines improve the understanding of the loose connective tissue disease, lipedema, to advance our understanding towards early diagnosis, treatments, and ultimately a cure for affected individuals.

Interventions for Breast Cancer-Related Lymphedema: Clinical Practice Guideline From the Academy of Oncologic Physical Therapy of APTA

A work group from the American Physical Therapy Association (APTA) Academy of Oncologic Physical Therapy developed a clinical practice guideline to aid clinicians in identifying interventions for people with breast cancer-related lymphedema, targeting volume reduction, beginning at breast cancer diagnosis and continuing through cancer treatments and survivorship. Following a systematic review of published studies and a structured appraisal process, recommendations were developed to guide physical therapists and other health care clinicians in their intervention selection. Overall, clinical practice recommendations were formulated based on the evidence for each intervention and were assigned a grade based on the strength of the evidence. The evidence for each specific intervention was synthesized and appraised by lymphedema stage, when the information was available. In an effort to make recommendations clinically applicable, they were presented by modality throughout the care trajectory. Methodology and research populations varied significantly across studies, and it will be important for future research to use standardized definitions for participant characteristics, diagnostic criteria, and interventions.

Bilateral Changes in Deep Tissue Environment After Manual Lymphatic Drainage in Patients with Breast Cancer Treatment-Related Lymphedema

BACKGROUND

Breast cancer treatment-related lymphedema (BCRL) arises from a mechanical insufficiency following cancer therapies. Early BCRL detection and personalized intervention require an improved understanding of the physiological processes that initiate lymphatic impairment. Here, internal magnetic resonance imaging (MRI) measures of the tissue microenvironment were paired with clinical measures of tissue structure to test fundamental hypotheses regarding structural tissue and muscle changes after the commonly used therapeutic intervention of manual lymphatic drainage (MLD).

METHODS AND RESULTS

Measurements to identify lymphatic dysfunction in healthy volunteers (n = 29) and patients with BCRL (n = 16) consisted of (1) limb volume, tissue dielectric constant, and bioelectrical impedance (i.e., non-MRI measures); (2) qualitative 3 Tesla diffusion-weighted, T₁-weighted and T₂-weighted MRI; and (3) quantitative multi-echo T₂ MRI of the axilla. Measurements were repeated in patients immediately following MLD. Normative control and BCRL T₂ values were quantified and a signed Wilcoxon Rank-Sum test was applied (significance: two-sided p < 0.05). Non-MRI measures yielded significant capacity for discriminating between arms with versus without clinical signs of BCRL, yet yielded no change in response to MLD. Alternatively, a significant increase in deep tissue T₂ on the involved (pre T₂ = 0.0371 ± 0.003 seconds; post T₂ = 0.0389 ± 0.003; p = 0.029) and contralateral (pre T₂ = 0.0365 ± 0.002; post T₂ = 0.0395 ± 0.002; p < 0.01) arms was observed. Trends for larger T₂ increases on the involved side after MLD in patients with stage 2 BCRL relative to earlier stages 0 and 1 BCRL were observed, consistent with tissue composition changes in later stages of BCRL manifesting as breakdown of fibrotic tissue after MLD in the involved arm. Contrast consistent with relocation of fluid to the contralateral quadrant was observed in all stages.

CONCLUSION

Quantitative deep tissue T₂ MRI values yielded significant changes following MLD treatment, whereas non-MRI measurements did not vary. These findings highlight that internal imaging measures of tissue composition may be useful for evaluating how current and emerging therapies impact tissue function.

Effect of pneumatic compression therapy on lymph movement in lymphedema-affected extremities, as assessed by near-infrared fluorescence lymphatic imaging

Previous studies have shown cost effectiveness and quality-of-life benefit of pneumatic compression therapy (PCT) for lymphedema. Insurers, such as the Centers for Medicare/Medicaid (CMS), however, desire visual proof that PCT moves lymph. Near-infrared fluorescence lymphatic imaging (NIRFLI) was used to visualize lymphatic anatomy and function in four subjects with primary and cancer treatment-related lymphedema (LE) of the lower extremities before, during, and after pneumatic compression therapy (PCT). Optically transparent and windowed PCT garments allowed visualization of lymph movement during single, one-hour PCT treatment sessions. Visualization revealed significant extravascular and lymphatic vascular movement of intradermally injected dye in all subjects. In one subject with sufficient patent lymphatic vessels to allow quantification of lymph pumping velocities and frequencies, these values were significantly increased during and after PCT as compared to pre-treatment values. Lymphatic contractile activity in patent lymphatic vessels occurred in concert with the sequential cycling of PCT. Direct visualization revealed increased lymphatic function, during and after PCT therapy, in all lymphedema-affected extremities. Further studies are warranted to assess the effects of PCT pressure and sequences on lymph uptake and movement.

Massage interventions and treatment-related side effects of breast cancer: a systematic review and meta-analysis

BACKGROUND

Massage as a complementary and alternative therapy has been associated with enhancing health and coping with treatment-related side effects in patients with breast cancer worldwide. This systematic review examined whether massage interventions provide any measurable benefit in breast cancer-related symptoms.

METHODS

Randomized controlled trials (RCTs) were searched for in PubMed, EMBASE.com and the Cochrane Library through June 2013. We evaluated the quality of the studies included by the Cochrane Handbook 5.2 standards and analyzed the data using the Cochrane Collaboration's RevMan 5.2 software.

RESULTS

Eighteen RCTs with a total of 950 participants were included. Compared with the control group, our meta-analysis showed that patients receiving regular use of massage had significantly greater reductions in anger and fatigue symptoms. However, there were no significant differences in depression, anxiety, pain, upper limb lymphedema, cortisol and health-related quality of life.

CONCLUSIONS

The current evidence demonstrates that there was mild evidence that massage may be a useful intervention in alleviating negative emotions and fatigue in patients with breast cancer. More trials with longer follow-up are needed to determine the exact long-term efficacy of this class of complementary and alternative medicine on breast cancer-related symptoms and quality of life.

A mechatronic system for quantitative application and assessment of massage-like actions in small animals

Massage therapy has a long history and has been widely believed effective in restoring tissue function, relieving pain and stress, and promoting overall well-being. However, the application of massage-like actions and the efficacy of massage are largely based on anecdotal experiences that are difficult to define and measure. This leads to a somewhat limited evidence-based interface of massage therapy with modern medicine. In this study, we introduce a mechatronic device that delivers highly reproducible massage-like mechanical loads to the hind limbs of small animals (rats and rabbits), where various massage-like actions are quantified by the loading parameters (magnitude, frequency and duration) of the compressive and transverse forces on the subject tissues. The effect of massage is measured by the difference in passive viscoelastic properties of the subject tissues before and after mechanical loading, both obtained by the same device. Results show that this device is useful in identifying the loading parameters that are most conducive to a change in tissue mechanical properties, and can determine the range of loading parameters that result in sustained changes in tissue mechanical properties and function. This device presents the first step in our effort for quantifying the application of massage-like actions used clinically and measurement of their efficacy that can readily be combined with various quantitative measures (e.g., active mechanical properties and physiological assays) for determining the therapeutic and mechanistic effects of massage therapies.

Lymphedema following treatment for breast cancer: a new approach to an old problem

Lymphedema following treatment for breast cancer can be an irreversible condition with a profound negative impact on quality of life. The lack of consensus regarding standard definitions of clinically significant lymphedema and optimal methods of measurement and quantification are unresolved problems. Inconsistencies persist regarding the appropriate timing of intervention and what forms of treatment should be the standard of care. There are reports that early detection and intervention can prevent progression, however,the Level 1 evidence to support this hypothesis has yet to be generated. To assess these controversies, we propose the implementation of a screening program to detect early lymphedema in conjunction with a randomized, prospective trial designed to generate Level 1 evidence regarding the efficacy of early intervention and appropriate treatment strategies. Collaboration among institutions that manage breast cancer patients is essential to establish a standardized approach to lymphedema and to establish guidelines for best practice.

Quality of life among breast cancer patients with lymphedema: a systematic review of patient-reported outcome instruments and outcomes

PURPOSE

Lymphedema following breast cancer surgery remains a common and feared treatment complication. Accurate information on health-related quality of life (HRQOL) outcomes among patients with lymphedema is critically needed to inform shared medical decision making and evidence-based practice in oncologic breast surgery. Our systematic review aimed to (1) identify studies describing HRQOL outcomes in breast cancer-related lymphedema (BCRL) patients, (2) assess the quality of these studies, and (3) assess the quality and appropriateness of the patient-reported outcome (PRO) instruments used.

METHODS

Using the PRISMA statement, we performed a systematic review including studies describing HRQOL outcomes among BCRL patients. Studies were classified by levels of evidence and fulfillment of the Efficace criteria. PRO instruments were assessed using the COSMIN criteria.

RESULTS

Thirty-nine studies met inclusion criteria, including 8 level I and 14 level II studies. Sixteen of 39 studies were compliant with the Efficace criteria. Seventeen HRQOL instruments were used, two specific to lymphedema patients. Exercise and complex decongestive therapy treatment interventions were associated with improved HRQOL.

CONCLUSIONS

High-quality data on HRQOL outcomes is required to inform surgical decisions for breast cancer management and survivors. Of the lymphedema-specific PRO instruments, the Upper Limb Lymphedema 27 (ULL-27) was found to have strong psychometric properties. Future studies should strive to use high-quality condition- specific PRO instruments, follow existing guidelines for HRQOL measurement and to consider economic burdens of BCRL.

IMPLICATIONS FOR CANCER SURVIVORS

As lymphedema may develop many years after breast cancer surgery, the ULL-27 may offer greater content validity for use in survivorship research.

Update on the biology and treatment of lymphedema

OPINION STATEMENT

The past decade has produced an explosion of insights into lymphatic vascular development and structural biology and, in parallel, into the function of the lymphatics in health and in disease. In lymphedema, there is a spectrum that extends from primary (heritable) to acquired causes of disease. The diagnosis of lymphatic edema implicates a very specific treatment approach that is predicated upon the favorable impact of physiotherapy upon lymph flow and protein clearance from the edematous zones of the body. The recognition of the unique biology that accompanies lymphatic causes of edema has stimulated new research directions that are likely to translate into exciting new pharmacologic and molecular approaches to diagnosis and treatment.

A randomized controlled trial comparing two types of pneumatic compression for breast cancer-related lymphedema treatment in the home

Purpose

Pneumatic compression devices (PCDs) are used in the home setting as adjunctive treatment for lymphedema after acute treatment in a clinical setting. PCDs range in complexity from simple to technologically advanced. The objective of this prospective, randomized study was to determine whether an advanced PCD (APCD) provides better outcomes as measured by arm edema and tissue water reductions compared to a standard PCD (SPCD) in patients with arm lymphedema after breast cancer treatment.

Methods

Subjects were randomized to an APCD (Flexitouch system, HCPCS E0652) or SPCD (Bio Compression 2004, HCPCS E0651) used for home treatment 1 h/day for 12 weeks. Pressure settings were 30 mmHg for the SPCD and upper extremity treatment program (UE01) with standard pressure for the APCD. Thirty-six subjects (18 per group) with unilateral upper extremity lymphedema with at least 5% arm edema volume at the time of enrollment, completed treatments over the 12-week period. Arm volumes were determined from arm girth measurements and suitable model calculations, and tissue water was determined based on measurements of the arm tissue dielectric constant (TDC).

Results

The APCD-treated group experienced an average of 29% reduction in edema compared to a 16% increase in the SPCD group. Mean changes in TDC values were a 5.8% reduction for the APCD group and a 1.9% increase for the SPCD group.

Conclusion

This study suggests that for the home maintenance phase of treatment of arm lymphedema secondary to breast cancer therapy, the adjuvant treatment with an APCD provides better outcomes than with a SPCD.

Systematic review: conservative treatments for secondary lymphedema

Background

Several conservative (i.e., nonpharmacologic, nonsurgical) treatments exist for secondary lymphedema. The optimal treatment is unknown. We examined the effectiveness of conservative treatments for secondary lymphedema, as well as harms related to these treatments.

Methods

We searched MEDLINE^®, EMBASE^®, Cochrane Central Register of Controlled Trials^®, AMED, and CINAHL from 1990 to January 19, 2010. We obtained English- and non-English-language randomized controlled trials or observational studies (with comparison groups) that reported primary effectiveness data on conservative treatments for secondary lymphedema. For English-language studies, we extracted data in tabular form and summarized the tables descriptively. For non-English-language studies, we summarized the results descriptively and discussed similarities with the English-language studies.

Results

Thirty-six English-language and eight non-English-language studies were included in the review. Most of these studies involved upper-limb lymphedema secondary to breast cancer. Despite lymphedema's chronicity, lengths of follow-up in most studies were under 6 months. Many trial reports contained inadequate descriptions of randomization, blinding, and methods to assess harms. Most observational studies did not control for confounding. Many studies showed that active treatments reduced the size of lymphatic limbs, although extensive between-study heterogeneity in areas such as treatment comparisons and protocols, and outcome measures, prevented us from assessing whether any one treatment was superior. This heterogeneity also precluded us from statistically pooling results. Harms were rare (< 1% incidence) and mostly minor (e.g., headache, arm pain).

Conclusions

The literature contains no evidence to suggest the most effective treatment for secondary lymphedema. Harms are few and unlikely to cause major clinical problems.

Advanced pneumatic therapy in self-care of chronic lymphedema of the trunk

BACKGROUND

The purpose of this study was to conduct a preliminary, post-market, home study of the Flexitouch(®) system to examine the potential efficacy of the device as a component of self-care in breast cancer survivors with truncal lymphedema.

METHODS AND RESULTS

A quasi-experimental, pre-treatment, post-treatment design was used. Twelve participants received a total of ten self-administered, consecutive, one hour per day treatments. Treatments one and two were observed by study staff and the remaining eight were unobserved. Assessments were conducted at baseline, after the first two treatments, mid-way through therapy, and at the end-of-study. Logs revealed 100% compliance with the eight prescribed unobserved home treatments. Symptoms were assessed by self-report symptom surveys. Signs, objectively observed physical phenomenon, were assessed by staff-initiated skin examination and circumferential truncal measurements. Statistically significant improvement in truncal symptoms and sleep were found. Changes in function and girth were not statistically significant in this initial study.

CONCLUSIONS

Breast cancer survivors with truncal lymphedema may benefit from using an advanced pneumatic compression devices with truncal treatment as part of their self-care program. Participants were highly compliant in device use. Further research of this intervention is warranted. To facilitate future research, clinically meaningful reductions in truncal girth should be defined.

Tissue fluid pressure and flow during pneumatic compression in lymphedema of lower limbs

BACKGROUND

Physiotherapy of edema in cases with obstructed main lymphatics of lower limbs requires knowledge of how high external pressures should be applied manually or set in compression devices in order to generate tissue pressures high enough to move tissue fluid to nonswollen regions and to measure its flow rate.

METHODS

We measured tissue fluid pressure and flow in subcutaneous tissue of lymphedematous limbs stages II to IV at rest and during pneumatic compression under various pressures and inflation timing. An 8-chamber sequential compression device inflated to pressures 50-120 mmHg, for 50 sec each chamber, with no distal deflation, was used. Pressures were measured using a wick-in-needle and electronic manometer. Fluid flow was calculated from continuously recorded changes in limb circumference using strain gauge plethysmography.

RESULTS

Before massage, in all stages of lymphedema, stagnant tissue fluid pressures in subcutaneous tissue ranged between -1 and +10 mmHg and did not differ from those measured in normal subjects. Pressures generated in tissue fluid by pneumatic compression reached 40-100 mmHg and were lower than those in inflated chambers. High pressure gradient through the skin was caused by its rigidity (fibrosis) and dissipation of applied compression force to proximal noncompressed limb regions. The calculated volumes of displaced tissue fluid ranged from 10 to 30 ml per compression cycle, to reach in some cases 100 ml in the groin region.

CONCLUSIONS

Tissue fluid pressures generated by a pneumatic device were found lower than in the compression chambers. The obtained results point to the necessity of applying high pressures and longer compression times to generate effective tissue fluid pressures and to provide enough time for moving the stagnant fluid.

Management of secondary lymphedema related to breast cancer

AbstractOBJECTIVE To review recent literature on the management of secondary lymphedema following breast cancer.QUALITY OF EVIDENCE MEDLINE, EMBASE, AMED, PubMed,and the Internet were searched for articles published between 2005 and 2009. Articles were evaluated using Sackett's levels of evidence. The literature search focused on primary research and systematic reviews.MAIN MESSAGE Secondary lymphedema related to breast cancer is an ongoing challenge. Evidence suggests that there are several safe and beneficial treatments, including complex decongestive therapy, physiotherapy, and exercise. Furthermore, resistive exercises,previously contraindicated on the affected side, have been found to be both beneficial and safe with careful progression and monitoring. Exercise guidelines and patient education topics are presented with a comprehensive reference list for further reading.CONCLUSION Advances in cancer treatment, cancer and exercise research, and lymphedema management require that physicians have a basic understanding of the current evidence to provide appropriate patient education and referral.

Direct evidence of lymphatic function improvement after advanced pneumatic compression device treatment of lymphedema

Lymphedema affects up to 50% of all breast cancer survivors. Management with pneumatic compression devices (PCDs) is controversial, owing to the lack of methods to directly assess benefit. This pilot study employed an investigational, near-infrared (NIR) fluorescence imaging technique to evaluate lymphatic response to PCD therapy in normal control and breast cancer-related lymphedema (BCRL) subjects. Lymphatic propulsion rate, apparent lymph velocity, and lymphatic vessel recruitment were measured before, during, and after advanced PCD therapy. Lymphatic function improved in all control subjects and all asymptomatic arms of BCRL subjects. Lymphatic function improved in 4 of 6 BCRL affected arms, improvement defined as proximal movement of dye after therapy. NIR fluorescence lymphatic imaging may be useful to directly evaluate lymphatic response to therapy. These results suggest that PCDs can stimulate lymphatic function and may be an effective method to manage BCRL, warranting future clinical trials.

Current concepts and future directions in the diagnosis and management of lymphatic vascular disease

Despite the central, complex role for the lymphatic system in the maintenance of human health, the biology of this important and complex vasculature has been relatively under-investigated. However, the last decade has witnessed a substantial growth in the elucidation of lymphatic structural biology and the function of this system in health and in disease. These newly gained insights can be used to formulate our evolving concepts about the diagnostic and therapeutic approaches to patients with lymphatic vascular disorders. In lymphedema, there is a spectrum of disease that extends from primary (heritable) to secondary (acquired) causes. Once detected, the presence of lymphatic edema mandates very specific modalities of intervention, predominated by physiotherapeutic techniques. In addition, a physiological basis for adjunctive, intermittent pneumatic compression has been established, and these modalities may be indicated in selected patient populations. The acknowledgement of a unique biology in lymphatic edemas is, increasingly, guiding research efforts within this field. Increasing investigative attention is being directed toward animal models of lymphatic vascular disease. As insight into the complex biology of the lymphatic vasculature continues to expand through focused biomedical investigation, the translation of these mechanistic insights into targeted, rationally conceived therapeutics will become increasingly feasible.

Lymphoedema therapy in breast cancer patients: a systematic review on effectiveness and a survey of current practices and costs in Finland

BACKGROUND

This study systematically evaluates the effects and harms of physiotherapy methods and explores current treatment practices and costs in relation to lymphoedema in breast cancer patients in Finland.

MATERIAL AND METHODS

A systematic review of randomized controlled trials (RCTs) on physiotherapy interventions for breast cancer patients with lymphoedema. A postal survey to lymph therapists, a telephone and register survey for therapy costs.

RESULTS

We identified 14 RCTs, of which two had moderate and the others high risk of bias. There was moderate evidence that compression bandages decreased lymphoedema, and that pneumatic pumps had no effect on lymphoedema. In Finland lymph therapy practice is a combination of manual lymph drainage (MLD), compression bandages, therapeutic exercises and guidance for self-treatment, with an annual average cost of EUR 799 per patient.

CONCLUSIONS

Compression bandages are likely to reduce upper limb lymphoedema in breast cancer patients. Evidence on other physiotherapy methods and their combinations is limited due to the poor quality of the trials. No evidence was found on any outcomes other than upper limb volume. We call for well-designed trials with patient-related outcomes on the effectiveness of MLD, guidance and therapeutic exercises.

Development of a framework for pneumatic device selection for lymphedema treatment

The results of three patients with difficult to manage leg and trunk lymphedema are reported. Patients were treated with the current standard of care: combined decongestive therapy. All three patients met obstacles in achieving independent self-care, which impeded their discharge to home care. The use of two currently available programmable pneumatic compression devices (PCDs) was investigated to determine if these devices could enable these difficult-to-manage patients to meet their discharge goals. Results indicate that programmable PCDs can be effective in managing complicated cases of leg and trunk lymphedema, and that differences may exist between devices. In this trial, the device with lower applied pressures and smaller pneumatic chambers provided better tolerated treatment and overall better patient outcomes. These three case reports show that in-home use of an appropriate PCD can help patients with stage 3 and advanced stage 2 lymphedema achieve stable limb volumes with no exacerbation of lymphedema-related symptoms. Results also demonstrate the ability of patients to consistently use programmable PCDs in a home environment. The results are presented in a structured decision-making framework to aid the therapist and physician in selecting appropriate patients for home PCD lymphedema therapy, and in the selection of an appropriate PCD.

The unique biology of lymphatic edema

Sadly, the subject of lymphatic vascular insufficiency continues to engender relative neglect by health care professionals, which represents a source of frustration and fear among patients. A re-consideration of the unique, complex biology of lymphatic vascular disorders has the capacity both to reinvigorate interest and facilitate the implementation of the correct, existing treatment interventions for individuals affected by these disease states. While most of this complex lymphatic biology remains somewhat elusive, growing insights into the molecular mechanisms of lymphatic development and repair have been instructive. Present and future considerations in lymphedema diagnosis and management must acknowledge the unique tissue biology of this disorder. Many changes are unique to the lymphatic mechanisms of chronic edema. The profound stimulus to collagen deposition in the integument seems to be unique to chronic lymphatic edema, although this biology remains largely unexplicated. Several lines of evidence also suggest that lymphatic function has a unique and important influence upon adipose biology. Molecular investigation of murine models of human acquired lymphedema are beginning to shed light on these processes. Such focused mechanistic, approaches to the study of lymphedema and other lymphatic diseases are vital, as we attempt to expand our insights into the complex biology of lymphedema and its potential responsiveness to pharmacologic control and molecular intervention, prevention, and reversal.

Lymphedema

Lymphedema is increasingly being seen in patients receiving home health care and throughout the general population. Substantial risks of complications are associated with failure to recognize its presence, worsening of the condition and the use of inadequate or incomplete therapy. Therapeutic truncal clearance as a component of therapy is universally accepted by professional therapists as being essential, but often rejected by third-party payers. This therapeutic component is based on sound physiological principles, but there has not been, nor will there likely be, peer-reviewed testing because it is deemed unethical to subject patients to therapy without its use. We believe that if the physiological basis for this therapy were more widely understood, its absolute need would be better recognized. Thus, our goal is to describe those lymphatic system features that directly impact lymphedema development and complications emphasizing the role of and scientific basis for truncal clearance as an essential treatment component.

The efficacy of manual lymphatic drainage therapy in the management of limb edema secondary to reflex sympathetic dystrophy

The objective of this study is to investigate the efficacy of manual lymphatic drainage (MLD) therapy in edema secondary to the reflex sympathetic dystrophy (RSD). A total of 34 patients were allocated randomly into two groups. All of the patients undertook nonstreoidal anti-inflammatory drug, physical therapy and therapeutic exercise program for 3 weeks. Patients in study group undertook MLD therapy additionally. Then the patients continued 2-month maintenance period with recommended home programs. Volumetric measurements pain scores and functional measurements were assessed at baseline, after treatment and 2 months after the treatment. After treatment, improvement in edema was statistically significant in the study group but not in the control group. At follow-up, with respect to baseline, improvements were not significant in both of the groups. Between the groups, difference of the percentage improvements in edema was statistically significant with superiority of MLD group after treatment, but not significant at follow-up. In this pilot study, MLD therapy was found to be beneficial in the management of edema resulted from RSD. Although the long-term results showed tendency towards improvement, the difference was not significant.

Interface pressures produced by two different types of lymphedema therapy devices

BACKGROUND AND PURPOSE

Sequential compression is used to manage lymphedema, but little is known about pressures delivered to the therapeutic targets. This study characterized actual pressures delivered by a traditional compression pump (Lympha Press [LP]) and one using an alternate compression pattern (Flexitouch [FT]).

SUBJECTS

Ten adults who were healthy volunteered to participate in the study.

METHODS

Pressure-time along the forearm was measured using a 256-pressure sensor array during the pressure cycling of each device. Device assessments were separated by at least 48 hours.

RESULTS

Pressure patterns and magnitudes produced by the 2 devices differed considerably. The FT pressure pattern displayed a rapid rise and fall, progressing from the wrist toward the elbow. The LP pressure rose slower and was sustained at a higher level during its inflation cycle. Pressures delivered with the LP were significantly greater than those delivered with the FT.

DISCUSSION AND CONCLUSION

The pressure patterns and magnitudes on treated limbs depend on the device. These differences should be considered before selecting a device for a specific patient.

Upper extremity lymphatic function at rest and during exercise in breast cancer survivors with and without lymphedema compared with healthy controls

Lymphoscintigraphy was used to measure lymphatic function at rest and during exercise in breast cancer survivors with lymphedema (BCRL, n = 10), breast cancer survivors (BC, n = 10), and controls (Cont, n = 10). After injection of 99mTc-antimony colloid to the hands, subjects rested or performed 12 repeated sets of arm cranking for 2.5 min at 0.6 W/kg followed by 2.5 min of rest. One-minute spot views were taken with a gamma-radiation camera immediately postinjection and every 10 min over 60 min to calculate clearance rate. As well, an upper body scan was taken at 65 min postinjection to measure radiopharmaceutical uptake in the axilla (Ax) and forearm (Fore). All groups displayed similar increases in clearance rate with exercise ( P = 0.000). Ax significantly increased with exercise in Cont only [Cont: (mean ± SD) 4.9 ± 2.6 vs. 7.9 ± 4.2%, P = 0.000; BCRL: 1.4 ± 1.2 vs. 1.7 ± 2.1%, P = 0.531; BC: 3.9 ± 3.4 vs. 5.2 ± 3.2%, P = 0.130], whereas Fore, indicating dermal backflow, significantly increased in BCRL only (BCRL: 2.4 ± 0.87 vs. 4.4 ± 2.0%, P = 0.004; BC: 1.1 ± 0.25 vs. 1.1 ± 0.31%, P = 0.784; Cont: 0.93 ± 0.26 vs. 1.0 ± 0.20%, P = 0.296). The results indicate that, in women with BCRL, exercise causes radiopharmaceuticals to clear from the hand at the same rate as BC and Cont, but, instead of reaching the axilla, a greater amount of activity gets trapped in the dermis of the forearm. BC, meanwhile, have similar lymphatic function as Cont; however, there is a highly variable response that may suggest that some BC subjects may be at risk for developing lymphedema.

A Simple and Innovative Device to Measure Arm Volume at Home for Patients With Lymphedema After Breast Cancer

Purpose

We designed an arm volumeter specifically for home use based on the water displacement method. The objective of this study was to determine its accuracy and precision, and compare it with a standard volumeter used in lymphedema clinics worldwide.

Patients and Methods

Using a standard model hospital volumeter and our own device, we took three consecutive measurements of 11 specially cast cylinders, which had known volumes ranging from 10mL to 4 L, and measurements of both arms of 15 volunteers.

Results

Measurements with both volumeters were highly accurate (R2= 0.9999) when compared with the known volumes of the cast cylinders, and were strongly correlated (R2= 0.9974) when each arm volume was compared between volumeters. Measurements with our volumeter were more precise both with the cylinders (average standard deviation [SD], 3.2 v 8 mL; P = .0553) and with the arms (average SD, 11.1 v 19 mL; P = .0034). Whereas the standard volumeter is expensive, fragile (acrylic), and prone to leaks, our volumeter is inexpensive, virtually indestructible, leak proof, and suitable for home use.

Conclusion

Arm volumes can be measured quickly and accurately at home using a simple, inexpensive, and robust device based on water displacement. Readily accessible arm volumetry at home may have widespread influence on the management of lymphedema after breast cancer.

Physical therapies for reducing and controlling lymphoedema of the limbs

BACKGROUND

Lymphoedema is the accumulation of excess fluid in the body caused by obstruction of the lymphatic drainage mechanisms. Management involves decongesting the reduced lymphatic pathways in order to reduce the size of the limb. There is a great deal of debate as to which components of a physical treatment programme are the most crucial.

OBJECTIVES

To assess the effect of physical treatment programmes on: volume, shape, condition and long-term control of oedema in lymphoedematous limbs; psycho-social benefits.

SEARCH STRATEGY

We searched the Cochrane Breast Cancer Group trials register (September 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4,2003), MEDLINE, EMBASE, CINAHL, UnCover, PASCAL, SIGLE, reference lists produced by The British Lymphology Society, the National Research Register (NRR) and The International Society of Lymphology congress proceedings.

SELECTION CRITERIA

Randomised controlled clinical trials that tested physical therapies with a follow-up period of at least six months.

DATA COLLECTION AND ANALYSIS

Two blinded reviewers independently assessed trial quality and extracted data . Meta-analysis was not performed due to the poor quality of the trials.

MAIN RESULTS

Only three studies involving 150 randomised patients were included. Since none studied the same intervention it was not possible to combine the data. One crossover study of manual lymph drainage (MLD) followed by self-administered massage versus no treatment, concluded that improvements seen in both groups were attributable to the use of compression sleeves and that MLD provided no extra benefit at any point during the trial. Another trial looked at hosiery versus no treatment and had a very high dropout rate, with only 3 out of 14 participants in the intervention group finishing the trial and only 1 out of 11 in the control group. The authors concluded that wearing a compression sleeve is beneficial. The bandage plus hosiery versus hosiery alone trial, concluded that in this mixed group of participants bandage plus hosiery resulted in a greater reduction in excess limb volume than hosiery alone and this difference in reduction was maintained long-term.

REVIEWERS' CONCLUSIONS

All three trials have their limitations and have yet to be replicated, so their results must be viewed with caution. There is a clear need for well-designed, randomised trials of the whole range of physical therapies if the best approach to managing lymphoedema is to be determined.