Measurement Issues in Anthropometric Measures of Limb Volume Change in Persons at Risk for and Living with Lymphedema: A Reliability Study

Time trend of breast cancer-related lymphedema according to body mass index

PURPOSE

To clarify how body mass index (BMI) affects the development and temporal trend of breast cancer-related lymphedema (BCRL).

METHODS

This is a prospective study in which patients with operable breast cancer were registered in a single institute between November 2009 and July 2010. The incidence of lymphedema at 1, 3, and 5 years after surgery was assessed according to BMI, and the trend of newly developed BCRL was examined. Obesity was defined as BMI ≥25 in accordance with the Japan Society for the Study of Obesity.

RESULTS

A total of 368 patients were included in this study. The multivariate analysis of the whole population showed that high BMI, axillary dissection, and radiotherapy remained as risk factors for BCRL. Patients with high BMI showed a significantly higher incidence of new lymphedema than those with low BMI at 1 year (p < 00.001) regardless of axillary procedures (39.1 % vs 16.3 % for axillary dissection; 15.6 % vs 1.5 % for sentinel lymph node biopsy) but not at 3 and 5 years. Once BCRL developed, patients with high BMI showed slow recovery and 50.0 % of the patients retained edema at 5 years while patients with low BMI showed rapid recovery and 26.7 % retained after 3 years (p = 0.04).

CONCLUSION

The preoperative BMI affected the incidence and temporal trend of BCRL regardless of axillary procedures or radiotherapy. Patients with high BMI should be given appropriate information about BCRL before surgery with careful follow-up for BCRL after treatment.

Patient-reported outcomes: A primer for plastic surgeons

Surgical care today is no longer evaluated only on clinical outcomes but also on holistic patient wellbeing. Patient-reported outcomes (PROs) are a representation of the patient's perspective on their results and wellbeing. The aim of this review is to establish PROs as the center of healthcare and plastic surgery, to delineate important PROs in plastic surgery practice and research, to discuss the future of PROs within our discipline, and to encourage surgeons to incorporate PROs into their practice. PROs are an important parallel of clinical outcomes in that they can use the patient's perspective to 1) support clinical findings, 2) detect differences in care when there are no clear clinical differences, 3) track progress longitudinally, and 4) support systemic improvements in healthcare. Plastic surgery as a field is naturally aligned with PROs because, as a discipline, we focus on patient form and function. The emerging forefronts of plastic surgery such as lymphedema care, gender-affirming care, peripheral nerve surgery, migraine surgery, and breast implant illness are critically dependent on PROs. In the next decade, we predict that there will be a continued proliferation of robust PRO measures and integration into healthcare delivery. Outcomes research in surgery should continue to evolve as surgeons provide increasingly more benefits to improve patient wellbeing. Plastic surgeons must continue to play a prominent role in the future of PROs.

Managing the Morbidity: Individualizing Risk Assessment, Diagnosis, and Treatment Options for Upper Extremity Lymphedema

In the setting where breast cancer-related lymphedema (BCRL) remains a feared and common complication of breast cancer, here we review important factors for the development, diagnosis, prevention, and treatment of BCRL. We find that race/ethnicity affect BCRL development risk, that future studies should focus on understanding the biological reasons behind the increased susceptibility of certain racial minorities to BCRL, that surveillance, early detection, exercise programs, and arm compression can reduce the risk of BCRL, and that surgical techniques to preserve and restore lymphatic drainage being evaluated in randomized trials may become transformative in reducing BCRL risk for high-risk patients.

New Device to Measure Cross-Sectional Areas and Segmental Volumes of Objects and Limbs

Purpose

High accuracy volume measurements have important implications in different medical and non-medical situations. All methods used to date have challenges to achieve a usable clinical accuracy. Moreover, current methods have limitations to measure segmental volumes. We developed a new device that is able to measure a continuous profile of the cross-sectional areas along an object. Herewith the total volume of an object or any part of it are correspondingly determined.

Methods

The Peracutus Aqua Meth (PAM) generates continuous profiles of cross-sectional areas. Water is pumped in or out of a measuring unit at a nearly fixed flow rate and the speed of the water level (dh/dt) is measured continuously using a pressure sensor at the bottom. The change of the water level is a measure for the cross-sectional area of an object at any height. Signal processing is required to obtain valuable measurements. Three static objects and an arm of a test object were measured to demonstrate the accuracy and repeatability of the new device.

Results

Cross-sectional areas of a PVC pipe obtained with the PAM and with a caliper were compared. The differences between the two methods were less than 1.3%. Volume measurements of two mannequin arms show standard deviations of 0.37% and 0.34%, respectively, whereas the standard deviation of the volume measurement of a genuine arm was only 1.07%. These figures surpass reported clinical accuracy.

Conclusion

The new device demonstrates that determining the cross-section and its volumes of objects is possible in an accurate, reliable, and objective way. The results show that segmental volume measurements of human limbs are possible. Application in clinical and non-clinical situations seems meaningful.

Usability evaluation of a novel compact pneumatic compression device for the treatment of lymphoedema: Pilot study

Objective

To perform a preliminary usability evaluation of a novel, compact pneumatic compression device in patients with lymphoedema.

Methods

This open-label, single-arm trial had two phases: the first focused on the fitting of the pneumatic compression device (Aria Free^TM, Aria Health, San Diego CA, USA) and the second focused on evaluating the comfort of the entire system during a 45-min usage period. Both phases were conducted in a monitored clinical environment. Patients aged ≥18 years with a diagnosis of lower limb lymphoedema who had used a pneumatic compression device for ≥3 months were eligible. Patients rated subjective fit, comfort and usability on an 11-point Likert scale (where higher scores indicate better fit/comfort/usability). The truncated cone method was used to infer limb volume before and after therapy in phase 2.

Results

Twenty-four patients were screened, and 15 were enrolled (80% female; mean age 62 years); all completed both study phases. Patients rated the garment as easy to set up and fit (median score 6.5), and all reported that the therapy was comfortable (median score 10; p < 0.001 vs. reference score of 6). There was a 1.85% reduction in limb volume after device use for 45 min (p = 0.018 vs. before therapy). No safety issues were identified.

Conclusions

The new pneumatic compression device fitted well, was easy to use and reduced leg oedema.

Lymphaticovenular Anastomosis: Superficial Venous Anatomical Approach

Background  Lymphaticovenular anastomosis (LVA) is an effective, functional treatment for limb lymphedema. This study reports an alternative surgical approach to lymphedema treatment without the use of indocyanine green mapping.

Methods  A retrospective analysis was performed on 29 consecutive lymphedema patients who underwent LVAs from January 2015 to December 2020, whereby incisions were made along the anatomy of the superficial venous systems in both upper and lower extremities around the joint areas. The evaluation included qualitative assessments and quantitative volumetric analyses.

Result  The mean number of anastomoses was 3.07, and the operative time was 159.55 minutes. Symptom improvement was recorded in 86.21% of the patients, with a mean volume reduction of 32.39%. The lymphangitis episodes decreased from 55.17% before surgery to 13.79% after surgery, and the median number of lymphangitis episodes per year decreased from 1 before surgery to 0 after surgery.

Conclusions  The superficial venous anatomical approach is an easy way to start a lymphedema practice using LVA without other advanced surgical equipment. With this reliable technique, microsurgeons can perform LVA procedures and achieve good results.

A Software Suite for Limb Volume Analysis Applicable in Clinical Settings: Upper Limb Quantification

In medicine, tridimensional scanning devices produce digital surfaces that replicate the bodies of patients, facilitating anthropometric measurement and limb volume quantification in pathological conditions. Free programs that address this task are not commonly found, with doctors mainly relying on proprietary software. This aspect brings reduced reproducibility of studies and evaluation of alternative measures. A software package made up of three programs has been developed and released together with supporting materials to enhance reproducibility and comparisons between medical centers. In this article, the functions of the programs and steps for volume assessment were introduced together with a pilot study for upper limb volume quantification. This initial experiment aimed to also verify the performance of digital volumes derived from the convex-hull gift-wrapping algorithm and the alternative analysis methods enclosed in the software. Few of these digital volumes are parameter-dependent, requiring a value selection. The experiment was conducted on a small mixed-gender group of young adults without correction for factors like arm dominance or specific physical training. In the sample under investigation, the analysis confirmed the substantial agreement between the clinical and current configurations of digital volumes produced by the package (R ² interval from 0.93 to 0.97, r ranged from 0.965 to 0.984); in addition, as a general consideration, gender appears as a variable that could influence upper limb volume quantification if a single model is built.

Manual Lymph Drainage With Progressive Arm Exercises for Axillary Web Syndrome After Breast Cancer Surgery: A Randomized Controlled Trial

OBJECTIVE

This study aimed to determine the effectiveness of a physical therapist-designed program tailored to axillary web syndrome (AWS) in women after breast cancer surgery.

METHODS

A prospective, single-center, assessor-blinded, randomized controlled trial was conducted at the Physiotherapy in Women's Health Research Unit of the Alcalá University (Madrid, Spain). Ninety-six women with AWS were assigned to the physical therapy group (manual lymph drainage [MLD] using resorption strokes and arm exercises as if performing median nerve neurodynamic glide exercises with no neural loading; n = 48) or the control group (standard arm exercises; n = 48), with both groups receiving treatment 3 times a week for 3 weeks. Both interventions included an educational component.

RESULTS

Compared with the control group, the physical therapy group showed significant and clinically relevant improvements in the primary outcome (self-reported pain intensity) at the primary and 3-month follow-ups. Significant and clinically relevant differences between groups were also found in the secondary outcomes (shoulder active range of motion, shoulder disability, and physical and functional aspects of health-related quality of life) at the primary follow-up and in the secondary outcomes as well as the trial outcome index at the 3-month follow-up. No significant differences were found at the 6-month follow-up in either primary or secondary outcomes.

CONCLUSION

The physical therapy program tailored to AWS was found to be effective for AWS symptoms in women after breast cancer surgery, both immediately after the program and after 3 months.

IMPACT

To our knowledge, this is the first appropriately designed study to demonstrate the effectiveness of MLD with progressive arm exercises for AWS. Clinicians and health service providers should consider how to provide survivors of breast cancer with AWS the opportunity to participate in physical therapy programs, including MLD with progressive arm exercises.

LAY SUMMARY

For axillary web syndrome following breast cancer surgery, a physical therapist can design a treatment program including manual lymph drainage and progressive arm exercises, which has been shown to result in reduced pain and improved motion compared with standard arm exercises.

Diagnostic Criteria for Breast Cancer-Related Lymphedema of the Upper Extremity: The Need for Universal Agreement

With advances in breast cancer treatments and resultant increased survival rates, emphasis has been placed on post-treatment complications such as breast cancer-related lymphedema (BCRL), a chronic, negative sequela of breast cancer treatment. Accurate BCRL diagnosis necessitates longitudinal screening beginning at preoperative baseline. Prospective screening programs incorporating symptoms, objective measurements and clinical examination allow for early detection, early intervention, and improved BCRL prognosis. Currently, varied diagnostic criteria for BCRL exist, and this lack of consensus leads to variation in diagnostic and screening practices across institutions. This review outlines current diagnostic tools, including subjective and objective measurement methods and clinical examination. The merits of different criteria are evaluated and recommendations are made regarding measurement tools and diagnostic criteria for BCRL. Ultimately, the BCRL diagnostic process should be universalized and combine objective measurements, clinical evaluation, and symptoms assessment, and adhere to the best practices of the measurement tools used.

Biology of Lymphedema

Simple Summary

Lymphedema is a chronic, debilitating disease of the lymphatic vasculature. Although several reviews focus on the anatomy and physiology of the lymphatic system, this review provides an overview of the lymphatic vasculature and, moreover, of lymphatic system dysfunction and lymphedema. Further, we aim at advancing the knowledge in the area of lymphatic system function and how dysfunction of the lymphatic system—as seen in lymphedema—affects physiological systems, such as the cardiovascular system, and how those might be modulated by lymphedema therapy.

Abstract

This narrative review portrays the lymphatic system, a poorly understood but important physiological system. While several reviews have been published that are related to the biology of the lymphatic system and lymphedema, the physiological alternations, which arise due to disturbances of this system, and during lymphedema therapy, are poorly understood and, consequently, not widely reported. We present an inclusive collection of evidence from the scientific literature reflecting important developments in lymphedema research over the last few decades. This review aims at advancing the knowledge on the area of lymphatic system function as well as how system dysfunction, as seen in lymphedema, affects physiological systems and how lymphedema therapy modulates these mechanisms. We propose that future studies should aim at investigating, in-detail, aspects that are related to fluid regulation, hemodynamic responses, and endothelial and/or vascular changes due to lymphedema and lymphedema therapy.

Effect of Nonelastic Compression With an Adjustable Wrap After Total Knee Arthroplasty

Swelling is a common phenomenon after total knee arthroplasty, with potential for negative impact on the rehabilitation process and final outcome. The aim of this study was to investigate the effectiveness of a new compression protocol with a self-adjustable, nonelastic compression wrap for the knee region. This study was conducted as a prospective comparative study. Total leg volume and the circumference of the knee at three levels were compared between groups. The results of our study suggest that the application of the new compression protocol has no effect on swelling in the acute postoperative phase (0-2 days) but reduces swelling at Day 14 within the subacute phase. The observed positive effect of the compression protocol could be of clinical importance in the subacute phase as well as for a subgroup of patients suffering from aberrant quadriceps weakness concomitant with knee swelling.

Lymphoedema, a significant health problem in Israel: A descriptive community-based study

Lymphoedema (LE) is recognised as a chronic disabling disease. Knowledge on patient characteristics, treatments, and outcomes in Israel is lacking. The aim of the study was to (a) describe demographic and health characteristics, treatments, utilisation, and functional outcomes of patients receiving physical therapy due to LE in a large nationwide healthcare provider in Israel; and (b) assess the feasibility of conducting a future practice-based evidence (PBE) study. This is a retrospective observational cohort study. Descriptive analyses of an electronic medical record database were performed. Data from 6013 patient episodes were analysed. A high proportion of patients had two or more comorbidities (80%) and chronic medication use (85%) with increasing rates over the 8-year period. The most frequent LE classification was stage 2 (45%). A majority of LE was in the lower limbs (51%) with increasing rates over the years. The most frequent treatment-related activity was measuring limb circumference and the most frequent intervention was educating for self-management. This study provides a first comprehensive description of patient characteristics receiving physical therapy for LE in Israel. The available database offers an opportunity for PBE studies. Recommendations for improvements in specific data collection processes were identified.

Determination of the Minimum Detectable Change in the Total and Segmental Volumes of the Upper Limb, Evaluated by Perimeter Measurements

Among female breast cancer survivors, there is a high prevalence of lymphedema subsequent to axillary lymph node dissection and axillary radiation therapy. There are many methodologies available for the screening, diagnosis and follow-up of breast cancer survivors with or without lymphedema, the most common of which is the measurement of patients’ arm circumference. The purpose of this study was to determine the intra-rater minimal detectable change (MDC) in the volume of the upper limb, both segmentally and globally, using circumference measurements for the evaluation of upper limb volume. In this study, 25 women who had received a unilateral mastectomy for breast cancer stage II or III participated. On two occasions separated by 15 min, the same researcher determined 11 perimeters for each arm at 4 cm intervals from the distal crease of the wrist in the direction of the armpit. The MDC at the segmental level ranged from 3.37% to 7.57% (2.7 to 14.6 mL, respectively) and was 2.39% (42.9 mL) at the global level of the arm; thus, minor changes in this value result in a high level of uncertainty in the interpretation of the results associated with the diagnosis of lymphedema and follow-up for presenting patients.

Volumetric Differences in the Suprafascial and Subfascial Compartments of Patients with Secondary Unilateral Lower Limb Lymphedema

BACKGROUND

The subfascial compartment (deep to the deep fascia) in extremity lymphedema has not been evaluated. This study investigated the volumetric differences between the suprafascial and subfascial compartments of patients with unilateral lower extremity lymphedema.

METHODS

Thirty-two female patients with unilateral lower extremity lymphedema were enrolled, with eight patients in each of Cheng lymphedema grades I to IV. The volumes of the suprafascial and subfascial compartments were calculated after manually drawing the region of interest on computed tomographic images. The volumetric differences and their ratios in the suprafascial and subfascial compartments between each patient's bilateral limbs were compared.

RESULTS

The volume of the lymphedematous limbs (9647 ml) was significantly greater than the volume of unaffected limbs (6906 ml), with a median volumetric difference of 2097 ml (30.6 percent) (p < 0.01). The median suprafascial compartment volumetric difference was 1887 ml (56.6 percent) and the subfascial compartment volumetric difference was 208 ml (4.7 percent) (p < 0.01). The median volumetric difference ratio of the thigh and lower leg was 24.6 percent and 40.6 percent, respectively. The median volumetric differences in Cheng lymphedema grades I to IV were 1012, 1787, 2434, and 4107 ml, respectively, which were statistically significant among the four Cheng lymphedema grades using the Kruskal-Wallis test (p < 0.01).

CONCLUSIONS

The volumetric differences in the lymphedematous limb were statistically significantly greater than in the unaffected limb, including both suprafascial and subfascial compartments. The volumetric differences are consistent with the Cheng lymphedema grading system as a reliable indicator of unilateral extremity lymphedema.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, IV.

Comparisons of Manual Tape Measurement and Morphomics Measurement of Patients with Upper Extremity Lymphedema

Lymphedema is a debilitating condition characterized by swelling from lymph fluid exceeding transport capacity. A gold standard for arm measurement is not established, and measurement methods vary. This study evaluates the comparability of the tape measure and Analytic Morphomics in deriving limb circumference measurements in patients with upper extremity lymphedema.

Test-Retest Reliability of Volume and Local Tissue Water Measurements in Lower Limbs of Healthy Women and Men

Background: Measurements of lower limb (LL) volume and local tissue water by tissue dielectric constant (TDC) are common in lymphedema management. Knowledge of normal variability in health subjects is important and can serve as a base for early lymphedema diagnosis but is currently lacking. The aim of this study was to evaluate test-retest reliability of LL volume and TDC values in healthy women and men. Methods and Results: Thirty-three women and 28 men were measured twice, 2 weeks apart. Volume was calculated from circumferential measurements every 4 cm and TDC in 14 points. Test-retest reliability was evaluated using intraclass correlation coefficient (ICC), changes in the mean, standard error of measurement in percentage (SEM%), and smallest real difference in percentage (SRD%). For volume, reliability was high (ICC 0.99) and measurement errors were low in both women and men (SEM%: 1.1%-1.3%; SRD%: 3.1%-3.6%). For TDC, reliability was fair to excellent in women (ICC 0.63-0.93) and poor to excellent in men (ICC 0.21-0.89). Measurement errors were acceptable in all points in women (SEM%: 3.9%-10.2%; SRD% 10.8%-28.2%), but only in 11 points in men (SEM%: 3.9%-14.5%; SRD%: 10.9%-40.1%). The points close to bone and tendons in men had lower reliability and higher measurement errors. Conclusion: Measurements of LL volume and TDC are reliable in healthy women and men; both methods can be recommended. However, TDC points close to bone and tendons in men should be used with caution.

Clinical Outcomes After Physical Therapy Treatment for Secondary Lymphedema After Breast Cancer

Breast cancer is the most commonly diagnosed cancer in women and approximately 33% of survivors will develop lymphedema. Untreated lymphedema may be limb threatening or cause substantial functional limitations. The purpose of this case report is to detail the physical therapy (PT) management and outcomes for a patient with right upper extremity and breast lymphedema. The goal of this case report is to provide rehabilitation clinicians with an example of effective treatment management and the underlying treatment rationale. A 64-year-old female with stage 2A breast cancer underwent neoadjuvant chemotherapy, a lumpectomy with 18 lymph nodes removed, and radiation therapy. She subsequently developed secondary lymphedema of the right breast and upper extremity. Physical therapy interventions included instruction on a complete decongestive therapy program, which consists of manual lymphatic drainage and compression bandaging and exercises to improve shoulder range of motion (ROM), posture, and strength. As a result of PT, her right shoulder ROM and anthropometric measurements improved and the patient achieved independence with self-lymphatic massage and compression bandaging techniques to maintain these gains. This case report is unique as it details the clinical decision making required during a complex course of cancer care that necessitated adjustments to the PT plan of care for sustainable outcomes.

Perometry versus simulated circumferential tape measurement for the detection of breast cancer-related lymphedema

PURPOSE

Despite increasing emphasis on screening and early intervention for breast cancer-related lymphedema (BCRL), there is marked heterogeneity in diagnostic methodology, including for volumetric measures. This retrospective study compared two volumetric modalities, perometry and simulated circumferential tape measurement (anatomic- and interval-based), for BCRL detection.

METHODS

Between 2005 and 2017, 287 female patients with unilateral breast cancer were prospectively screened for BCRL by perometry and the relative volume change (RVC) formula. Circumferential measurement was performed by sampling at five anatomic landmark-based points or 4-cm intervals from pairs of perometer arm diameter measurements. Volumetric conversion was by a frustum model. The Bland-Altman method was used to compare segmental volume differences. Confusion matrix analysis was performed for each circumferential measurement technique against perometry.

RESULTS

Median follow-up was 34.7 months over 4 postoperative visits. There was no difference in total arm volume comparing any of the circumferential measurement techniques to perometry. Landmark-based methods significantly underestimated upper arm volume (mean difference - 207 mL [- 336, - 78 mL]) and overestimated forearm volume (mean difference + 170 mL [+ 105, + 237 mL]). Landmark-based methods had greater sensitivity and specificity compared to 4-cm interval methods for detection of both RVC ≥ 10 and 5-10%. Landmark-based methods were comparable to perometry for detection of RVC ≥ 10%, but sensitivity was only 63.2-66.7% for RVC 5-10%.

CONCLUSIONS

This hypothesis-generating study suggested the superiority of anatomic landmark-based circumferential tape measurement compared to interval-based methods, while generating questions about the underestimation of upper arm volume and overestimation of forearm volume of circumferential tape measurement compared to perometry.

Diagnostic Methods, Risk Factors, Prevention, and Management of Breast Cancer-Related Lymphedema: Past, Present, and Future Directions

PURPOSE OF REVIEW

Breast cancer-related lymphedema (BCRL) is a chronic, adverse, and much feared complication of breast cancer treatment, which affects approximately 20% of patients following breast cancer treatment. BCRL has a tremendous impact on breast cancer survivors, including physical impairments and significant psychological consequences. The intent of this review is to discuss recent studies and analyses regarding the risk factors, diagnosis, prevention through early screening and intervention, and management of BCRL.

RECENT FINDINGS

Highly-evidenced risk factors for BCRL include axillary lymph node dissection, lack of reconstruction, radiation to the lymph nodes, high BMI at diagnosis, weight fluctuations during and after treatment, subclinical edema within and beyond 3 months after surgery, and cellulitis in the at-risk arm. Avoidance of potential risk factors can serve as a method of prevention. Through establishing a screening program by which breast cancer patients are measured pre-operatively and at follow-ups, are objectively assessed through a weight-adjusted analysis, and are clinically assessed for signs and symptoms, BCRL can be tracked accurately and treated effectively. Management of BCRL is done by a trained professional, with research mounting towards the use of compression bandaging as a first line intervention against BCRL. Finally, exercise is safe for breast cancer patients with and without BCRL and does not incite or exacerbate symptoms of BCRL.

SUMMARY

Recent research has shed light on BCRL risk factors, diagnosis, prevention, and management. We hope that education on these aspects of BCRL will promote an informed, consistent approach and encourage additional research in this field to improve patient outcomes and quality of life in breast cancer survivors.

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.

Intra-observer and inter-observer reliability of leg circumference measurement among six observers: a single blinded randomized trial

Hypothesis: Circumference measurement of extremities that was reported to be a reliable method as long as being standardized is commonly used both in clinical and home settings by clinicians or caregivers due to its cheapness and easy use. Objectives: The aims of this study were to determine the inter-observer and intra-observer reliability of manual circumference measurement among different observers and various measurement points. Methods and Results: A total of 58 lower limbs were included in the study. Both lower limbs of each subject were assessed by 6 observers randomly using circumference measurement method from 9 reference points specified with a Leg-O-Meter. All observers performed the measurements and they were blind to each other's measurements. Results: Measurement results from reference points were statistically significant between good to perfect (ICC 0.65-0.99, p<0.001). Interrater reliability of all observers' first and second measurements showed perfect reliability for both measurements (ICC: 0.92-0.99, p<0.001). Conclusions: This study demonstrated that the lower extremity manual circumference measurement is a reliable method for clinical practice. Abbreviations: BMI = Body Mass Index, ICC = Intraclass Correlation Coefficient, Metatarsal heads (cA), Ankle-heel (cY), Ankle (cB), Distal beginning point of gastrocnemius (cB1), The widest point for gastrocnemius (cC), Head of fibula (cD), Midline of knee (cE), Midline of thigh (cF), Groin level (cG).