Different physical treatment modalities for lymphoedema developing after axillary lymph node dissection for breast cancer: A review

European Journal of Obstetrics & Gynecology and Reproductive Biology 149 (2010) 3–9

Review

Different physical treatment modalities for lymphoedema developing afteraxillary lymph node dissection for breast cancer: A review

Nele Devoogdt a,b,c,*, Marijke Van Kampen a,b, Inge Geraerts a,b, Tina Coremans c, Marie-Rose Christiaens d

a Department Physiotherapy, University Hospitals Leuven, Belgiumb Faculty of Kinesiology and Rehabilitation Sciences, Katholieke Universiteit Leuven, Belgiumc Department of Health Care Sciences, University College of Antwerp, Belgiumd Multidisciplinary Breast Center, University Hospitals Leuven, Belgium

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

2. Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

3.1. Combined Physical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

3.1.1. Skin care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

3.1.2. Manual Lymphatic Drainage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

3.1.3. Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

3.1.4. Multi-layer bandaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

3.1.5. Compression sleeve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

3.2. Intermittent Pneumatic Compression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

A R T I C L E I N F O

Article history:

Received 8 February 2009

Received in revised form 18 November 2009

Accepted 19 November 2009

Keywords:

Breast cancer

Lymphoedema

Combined Physical Therapy

Intermittent Pneumatic Compression

Elevation

A B S T R A C T

The purpose of this article is to provide a systematic review of Combined Physical Therapy, Intermittent

Pneumatic Compression and arm elevation for the treatment of lymphoedema secondary to an axillary

dissection for breast cancer. Combined Physical Therapy starts with an intensive phase consisting of skin

care, Manual Lymphatic Drainage, exercises and bandaging and continues with a maintenance phase

consisting of skin care, exercises, wearing a compression sleeve and Manual Lymphatic Drainage if

needed.

We have searched the following databases: PubMed/MEDLINE, CINAHL, EMBASE, PEDro and

Cochrane. Only (pseudo-) randomised controlled trials and non-randomised experimental trials

investigating the effectiveness of Combined Physical Therapy and its different parts, of Intermittent

Pneumatic Compression and of arm elevation were included. These physical treatments had to be

applied to patients with arm lymphoedema which developed after axillary dissection for breast cancer.

Ten randomised controlled trials, one pseudo-randomised controlled trial and four non-randomised

experimental trials were found and analysed. Combined Physical Therapy can be considered as an

effective treatment modality for lymphoedema. Bandaging the arm is effective, whether its effectiveness

is investigated on a heterogeneous group consisting of patients with upper and lower limb

lymphoedema from different causes. There is no consensus on the effectiveness of Manual Lymphatic

Drainage. The effectiveness of skin care, exercises, wearing a compression sleeve and arm elevation is not

investigated by a controlled trial. Intermittent Pneumatic Compression is effective, but once the

treatment is interrupted, the lymphoedema volume increases.

In conclusion, Combined Physical Therapy is an effective therapy for lymphoedema. However, the

effectiveness of its different components remains uncertain. Furthermore, high-quality studies are

warranted. The long-term effect of Intermittent Pneumatic Compression and the effect of elevation on

lymphoedema are not yet proven.

� 2009 Elsevier Ireland Ltd. All rights reserved.

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology andReproductive Biology

journal homepage: www.e lsev ier .com/ locate /e jogrb

* Corresponding author at: University Hospitals Leuven, Department Physiotherapy, Herestraat 49, 3000 Leuven, Belgium. Tel.: +32 16 348577; fax: +32 16 342186.

E-mail address: [email protected] (N. Devoogdt).

0301-2115/$ – see front matter � 2009 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/j.ejogrb.2009.11.016

N. Devoogdt et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 149 (2010) 3–94

3.3. Elevation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Fig. 1. Overview of the systematic literature search.

1. Introduction

Lymphoedema is an oedema caused by a reduced transportcapacity of the lymphatic system [1]. Patients with lymphoedemaexperience physical problems as well as psychosocial problems. Itis a phenomenon feared by many breast cancer patients [2,3]. Theincidence of lymphoedema after breast surgery is 26% on average[2]. Because of the reduced quality of life and the high incidence oflymphoedema after axillary dissection for breast cancer, aneffective, evidence-based treatment is necessary.

According to the International Society of Lymphology [3],lymphoedema has to be treated with Combined Physical Therapy.This is a two-stage treatment program. During the first orintensive phase, the lymphoedema has to be maximally reduced.This phase consists of skin care, Manual Lymphatic Drainage,exercises and multi-layer bandaging. The second or maintenancephase aims to conserve and optimize the result obtained in thefirst phase. It consists of skin care, exercises, compression by alow-stretch elastic sleeve and Manual Lymphatic Drainage whenneeded.

The aim of skin care in lymphoedema management is toimprove or maintain the condition and integrity of the skin, and toprevent skin injury, trauma and infection [4]. Manual LymphaticDrainage is a gentle massage technique and stimulates thelymphatic flow and the formation of lympholymphatic andaxilloaxillary anastomoses [5]. Long-term exercises can lead toimproved lymph flow by increased sympathetic outflow, increasedmuscular contractions and increased ventilation [6]. A multi-layerbandage counterbalances the elastic insufficiency of the connec-tive tissue of the subcutis and increases the tissue pressure toenhance lymph flow. A compression sleeve protects the armagainst wounds and bites and helps to maintain the lymphoedemareduction reached during the intensive phase [1].

Intermittent Pneumatic Compression is a multi-chamber devicethat inflates sequentially from distal to proximal, pushing theliquid ahead by its inflation [7].

The purpose of this manuscript is to review the availableliterature on different physical treatment modalities for lymphoe-dema, more specifically Combined Physical Therapy and itsdifferent parts, Intermittent Pneumatic Compression and armelevation, after axillary dissection for breast cancer and to offerrecommendations based on this literature.

2. Materials and methods

The literature search was limited to peer-reviewed articles inEnglish, French and Dutch, with the following databases searched:PubMed/MEDLINE, CINAHL, EMBASE, PEDro and Cochrane. Studiesof all dates were included and review articles were excluded.General keywords used for this search were ‘lymphoedema’,‘lymphedema’ or ‘lymphoedematous’. These keywords werecombined with: therapy/treatment/physiotherapy; skin care;drainage/massage; exercise; bandage/bandaging; stockings/gar-ment/sleeve/hosiery; pneumatic/compression/pressotherapy/pump; elevation.

The selection of articles was performed in three phases (seeFig. 1). In the first phase the selection was performed by analysingthe titles of the articles. In the second phase the abstracts and in thethird phase the articles were analysed.

Randomised and pseudo-randomised controlled trials (RCTs)and non-randomised experimental trials were included. The studypopulation was patients with arm lymphoedema, and this, for themajority of the patients, developed after axillary dissection forbreast cancer. Only studies investigating the effectiveness ofCombined Physical Therapy and its different parts, of IntermittentPneumatic Compression and of arm elevation were included.Outcome parameters were arm volume, shoulder mobility, musclestrength, subjective symptoms, tissue elasticity, skinfold thicknessand quality of life.

In Table 1 each study is described in detail, with an overview ofthe level of evidence and the Pedro score, the sample character-istics, a description of the treatment of lymphoedema, themeasurements and the results. The level of evidence is based onthe method outlined by the National Health and Medical ResearchCouncil. The Pedro score (see Table 2) is a score out of 10 and isdetermined by the staff of ‘the Physiotherapy Evidence Database’(or PEDro) and can be found on the website: http://www.pe-dro.fhs.usyd.edu.au. Only RCTs and pseudo-RCTs are analysed andscored.

3. Results

The search of the databases resulted in 317 articles, of which 15articles were included (see Fig. 1).

3.1. Combined Physical Therapy

No RCTs were found about the effectiveness of CombinedPhysical Therapy using a control group who did not receiveCombined Physical Therapy because, for ethical reasons, it is notpossible to refuse treatment to patients with lymphoedema.Didem et al. [8] have investigated the effectiveness by comparingCombined Physical Therapy performed by an experienced physical

Table 1Overview of randomised controlled trials (RCTs or level II), pseudo-RCTs (level III-1) and non-randomised experimental trials (level III-2) with sample characteristics, description of treatment, measurement and result.

Author and evidence Sample characteristics Treatment Measurement Result

Combined Physical Therapy (CPT)

Didem et al. [8]

Level II

Pedro: 6

N = 53

Inclusion: unilateral oedema

after breast cancer, <5 cm difference,

duration >1 year

All patients: home program with bandage,

exercises, skin care, self-massage and walking

Group CPT

(N = 27): skin care, MLD, exercises,

bandage, 3�/week, 4 weeks

Group standard physiotherapy (N = 26): elevation,

head, neck and shoulder exercise, bandage

Before and after 4 weeks:

Arm volume: volumeter

Shoulder mobility

Oedema volume: �56% group CPT

versus �36% group standard

physiotherapy (p<0.050)

Shoulder mobility: shoulder flexion,

abduction and external rotation increased

in both groups equally (p>0.050)

Swedborg [9]

Level III-2

Pedro: /

N = 39

Inclusion: unilateral oedema after

breast cancer, >150 ml difference

Group A: massage (manual and vibrator, 15 min,

5�/week), grip exercises (20 min; 5�/week),

elastic sleeve (during day)

Group B: idem group A + warmth (20 min)

Group C: idem group A + elastic sleeve

(during day and night) 4 weeks

Before and after 4 weeks:

Arm volume: volumeter

Oedema volume: �21% group A versus

�28% group B versus �30% group C

Skin care (no RTC or pseudo-RCT)

Manual Lymphatic Drainage (MLD)

Andersen et al. [11]

Level II

Pedro: 6

N = 42

Inclusion: unilateral oedema after

breast cancer, >200 ml difference

or >2 cm difference

Exclusion: >30% difference

All patients: standard therapy with sleeve

(class II: 32–40 mmHg), information, exercises

Group standard therapy (N = 22): /

Group standard therapy/MLD (N = 20): MLD:

8 sessions in 2 weeks, 1 h/session,

education daily self-massage

Before and after 3 months:

Arm volume: circumferences

Shoulder mobility

Symptoms:

questionnaire

Compliance therapy

Oedema volume: �60% group standard

therapy versus �48%

group standard therapy/MLD (p>0.050)

Symptoms and compliance: difference (p>0.050)

Johansson et al. [13]

Level III-1

Pedro: 4

N = 35

Inclusion: unilateral oedema after

breast cancer, >10% difference

Exclusion: <6 months oedema

treatment

All patients: bandage, 3 weeks, day and night

Group B (N = 18): /

Group B/MLD (N = 17): MLD, 45 min/day, 5 days,

start after 2 weeks of bandage

Before and after 2 and 3 weeks:

Arm volume: volumeter

Symptoms: pain, heaviness,

tension

Oedema volume: first 2 weeks: �27% group

B versus �20%

group B/MLD (p>0.050); third week: �4%

group B versus �11% group B/MLD (p = 0.040)

Symptoms: no difference (p>0.050)

McNeely et al. [10]

Level II

Pedro: 7

N = 45

Inclusion: unilateral oedema after

breast cancer, >150 ml oedema

Exclusion: <6 months oedema treatment

All patients: skin care, bandage, 5�/week, 4 weeks

Group MLD/B (N = 24): MLD during 45 min

group B (N = 21): /

Before and after 4 weeks:

Arm volume: volumeter

Oedema volume: �46% group MLD/B

versus �39% group B (p = 0.217)

Williams et al. [12]

Level II

Pedro: 3

N = 31

Inclusion: unilateral oedema after

breast cancer, >3 months, >10% oedema,

clinically detectable trunk swelling

All patients: skin care, compression

sleeve, 5�/week, 3 weeks

Group MLD (N = 15): MLD by specialist, 45 min

(neck, anterior and posterior trunk, swollen arm)

Group SLD (N = 16): Simple Lymphatic Drainage

(SLD) by patient self, 20 min (neck, unaffected

axilla, anterior chest wall)

Before and after 3 weeks:

Arm volume: arm circumferences

Trunk oedema: calliper

Quality of Life: QLQ-C30

Symptoms

Oedema volume: �10% group MLD

versus �4% group

SLD (p = 0.053)

Trunk oedema and quality of life: no

difference (p>0.050)

Symptoms: group

MLD less pain (p = 0.010), discomfort (p = 0.002),

heaviness (p = 0.003), fullness (p<0.001), bursting

(p = 0.008) and hardness (p<0.001) than group SLD

Exercises

Moseley et al. [15]

Level III-2

Pedro: /

N = 52

Inclusion: unilateral oedema after breast

cancer, duration >0.5 year, >200 ml difference

Exclusion: <1 month oedema treatment

Experimental group (N = 24): exercise (inspire while

opening arms and expire while closing arms in

horizontal plane), 10 min, 2�/day, 1 month

Control group (N = 28): /

Before and after 1 month:

Arm volume: perometer

Trunk oedema: BIA

Tissue resistance: tonometer

Symptoms: pain, heaviness,

tightness, pins and needles,

burning sensations

and perceived arm size

Oedema volume: �101 ml experimental

group versus �7 ml control

group (p>0.050);

Trunk oedema: no difference

Tissue resistance: anterior thorax: +1.0mm

experimental group versus �0.4mm control group

(p = 0.005); forearm and upper arm: no difference

Symptoms: experimental group less heaviness (p = 0.044)

and perceived size (p = 0.016) than control group

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Table 1 (Continued )

Author and evidence Sample characteristics Treatment Measurement Result

McKenzie and Kalda [14]

Level II

Pedro: 2

N = 14

Inclusion: unilateral oedema after

breast cancer, 2–8 cm difference

All patients: compression sleeve (day)

Exercise group (N = 7): arm exercises

with elastic sleeve: 8 weeks, 3�/week

Control group (N = 7): /

Before and after 8 weeks:

Arm volume: volumeter

Quality of life: SF-36

Oedema volume: 0% exercise group versus

+6% control group (p>0.050)

Quality of life: no difference (p>0.050)

Bandage

Badger et al. [16]

Level II

Pedro: 6

N = 78

Inclusion: unilateral upper

(N = 54) or lower (N = 29)

limb oedema, >20% difference

All patients: elevation, exercises, skin

care, self-massage

Group B/H (N = 32): bandage

during 18 days, 24 h/day,

replaced each day, hosiery after 18 days

Group H (N = 46): immediately hosiery

Before and after 18 days and

24 weeks:

Arm volume: perometer

Oedema volume: after 19 days: �34%

group B/H versus �10% group H (p<0.050);

after 24 weeks: �33% group

B/H versus �20% group H (p<0.050)

Compression sleeve

Hornsby et al. [17]

Level II

Pedro: 3

N = 25

Inclusion: oedema

after breast cancer

All patients: exercise, information about

skin care, self-massage,4 weeks

Experimental group (N = 14):

compression sleeve day and night

Control group (N = 11): /

Before and after 4 weeks:

Arm volume: volumeter

Oedema volume: �23% experimental

group versus +1% control group (p = 0.150)

Intermittent Pneumatic Compression (IPC)

Berlin et al. [20]

Level III-2

Pedro: /

N = 55

Inclusion: unilateral or bilateral oedema

after breast cancer, >100 ml increase of

preoperative arm volume

All patients: elastic sleeve, 25–50 mmHg, 4 weeks

Group A (N = 28): /

Group B (N = 8): IPC with Flowtron, one chamber,

20 min, daily, 80 mmHg

Group C (N = 19): IPC with Lympha Press,

different overlapping chambers, 20–30 min,

twice daily, 90–120 mmHg

Before and after 4 weeks:

Arm volume: volumeter

Oedema volume: no difference

Dini et al. [18]

Level II

Pedro: 5

N = 80

Inclusion: unilateral

oedema, >10 cm difference

Exclusion: prior oedema treatment

All patients: guidelines about skin care

Experimental group (N = 40): IPC 2 weeks,

5 weeks rest, IPC 2 weeks, 2 h/day, 60 mmHg

Control group (N = 40): /

Before and after 9 weeks:

Arm circumference

Oedema circumference: �12%

experimental group versus �3%

control group (p = 0.084)

Johansson et al. [19]

Level II

Pedro: 4

N = 24

Inclusion: unilateral oedema after

breast cancer, >10% difference

All patients: elastic sleeve for 4 weeks

After 2 weeks: Group MLD (N = 12):

MLD, 45 min/session, 2 weeks, 5�/week

Group IPC (N = 12): IPC, 40–60 mmHg,

2 h/session, 2 weeks, 5�/week

Before, after 2 and 4 weeks:

Arm volume: volumeter

Shoulder mobility: goniometer

Muscle strength:

gripping force Symptoms

Oedema volume after 2 weeks:

�7%; after 4 weeks: �15% group MLD

versus �7% group IPC (p = 0.360)

Shoulder mobility, muscle strength,

subjective symptoms: no difference

Szuba et al. [7]

Level II

Pedro: 5

N = 23

Inclusion: unilateral oedema after

breast cancer, >20% difference

All patients: 10 days CPT and 30 days

compression sleeve and self-MLD

Group

CPT/IPC:

10 days IPC, 30 min, 40–50 mmHg Group CPT: /

Before and after 10 and 40 days:

Arm volume: volumeter

Tissue elasticity: tonometer

Joint mobility: goniometer

Oedema volume: after 10 days: �45%

group CPT/IPC versus �26% group CPT

(p<0.05); after 40 days: �30% group

CPT/IPC versus �27% group CPT

(p>0.05) Tissue elasticity and joint mobility:

no significant difference

Zanolla et al. [21]

Level III-2

Pedro: /

N = 60

Inclusion: oedema after breast cancer

All patients: elastic sleeve (during day)

and benzopyrones

Group 1 (N = 20): IPC with uniform

pressure, 90 mmHg, 6 h/day, 1 week

Group 2 (N = 20): IPC with different

pressure, 160 mmHg, 6 h/day, 1 week

Group 3 (N = 20): MLD, 1h, 3�/week, 4 weeks

Before and after 3 months:

Arm circumference

Mood: VAS

Oedema volume �21% group 1 versus �5%

group 2 versus �25% group 3 (p>0.050)

Mood: no significant difference

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Table 2Overview of PEDro score of the level II and III-1 studies.

Author Eligibility

criteriaa

Allocation Baseline

comparability

Blind

subject

Blind

therapist

Blind

assessor

Follow-

up

Intention-

to-treat

Between-group

comparison

Point estimates

and variability

Total

scoreRandom Concealed

Andersen et al. [11] + + � + � � � + + + + 6

Badger et al. [16] + + + + � � � + � + + 6

Didem et al. [8] + + + + � � � + � + + 6

Dini et al. [18] � + � + � � � � + + + 5

Hornsby [17] � + � � � � � + � � + 3

Johansson et al. [13] + � � + � � � + � + + 4

Johansson et al. [19] + + � � � � � + � + + 4

McKenzie and Kalda [14] � + � � � � � � � + � 2

McNeely et al. [10] + + + + � � + + � + + 7

Szuba et al. [7] + + � + � � � + � + + 5

Williams et al. [12] + + � + � � � � + � � 3

a Eligibility criteria does not contribute to the total score on 10.

N. Devoogdt et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 149 (2010) 3–9 7

therapist, to a standard physiotherapy program consisting ofelevation, exercises and bandaging, performed by the patientherself at home (PEDro score of 6, see Tables 1 and 2). The patientswho received Combined Physical Therapy had a significantlyhigher arm oedema reduction in comparison to the other patients(�56% versus �36%, p < 0.05).

Another study (non-randomised experimental trial) examinedthe effect of a combined physical treatment, but not applied as theclassic form of Combined Physical Therapy [9]. They comparedthree groups and the treatment was applied for 4 weeks. The firstgroup received a manual massage and a massage with a vibrator 5times a week for 15 min, performed grip exercises 5 times a weekfor 20 min and wore an elastic sleeve every day during day-time.The second group had the same treatment but also receivedwarmth on the arm (55 8C) 5 times a week for 20 min. The thirdgroup had, in addition to the treatment of the first group, alsoworn an elastic sleeve day and night. The oedema reduction was21%, 28% and 30% respectively after 4 weeks of treatment. In theweekend the oedema often increased. In the first week, thetreatment was most effective, in the second week it was half aseffective and in the last 2 weeks the effect was the lowest.

3.1.1. Skin care

The effectiveness of skin care is not investigated by arandomised controlled trial.

3.1.2. Manual Lymphatic Drainage

Three level II studies and one level III-1 study have investigatedthe effectiveness of Manual Lymphatic Drainage (see Table 1). Thetwo studies of the highest quality could not show an additionaleffect of Manual Lymphatic Drainage, additional to bandaging andskin care [10] or to wearing a compression sleeve and to receivinginformation [11]. McNeely et al. [10] made subgroups of patientswith mild, moderate and severe lymphoedema and compared theeffect of Manual Lymphatic Drainage, bandaging and skin care tobandaging and skin care alone. They found that the reduction wassignificantly higher in the group with mild lymphoedema whoreceived Manual Lymphatic Drainage, skin care and bandagingthan in the group with mild lymphoedema who only received skincare and bandaging. This significant difference was not noticed inthe group with moderate or severe lymphoedema. Williams et al.[12] (PEDro score of 3) compared Manual Lymphatic Drainageperformed by a Vodder specialist to a simplified form of lymphaticdrainage performed by the patient herself. The Manual LymphaticDrainage group had a borderline significant higher reduction ofarm oedema than the group who had the simplified form (�10%versus �4%, p = 0.053). Patients with Manual Lymphatic Drainagehad also a significant improvement of emotional functioning,dyspnoea and sleep disturbances and had a significant improve-

ment of all arm symptoms (pain, discomfort, heaviness, fullness,bursting and hardness). In the study of Johansson et al. [13] (PEDroscore of 4) all patients wore a multi-layer bandage for 3 weeks andone of two groups received also Manual Lymphatic Drainage in thethird week. After 2 weeks, lymphoedema reduction was equal forboth groups. After the third week, the group with ManualLymphatic Drainage had a significant higher reduction oflymphoedema (�11%) than the group without Manual LymphaticDrainage (�4%) (p = 0.040). The reduction of subjective symptoms,such as pain, heaviness and tension was equal for both groups. Inall studies, Manual Lymphatic Drainage was performed by aspecialist and the duration of one session was between 45 min and1 h. In the four studies, the number of sessions varied from 5 [13] to8 [11] to 15 [12] and to 20 [10].

3.1.3. Exercises

One randomised controlled pilot study of low quality (PEDroscore 2) has examined the effectiveness of exercises for thetreatment of lymphoedema (see Table 1) [14]. Lymphoedemavolume did not change, neither in the exercises group, who worean elastic sleeve and performed resistance exercises 3 times a weekfor 8 weeks, nor in the control group, who only wore an elasticsleeve. In contrast, in the study of Moseley et al. [15], which is acontrolled but non-randomised study, the patients had after 1month performing exercises twice a day for 10 min (N = 24) more(non-significant) reduction of lymphoedema volume compared tothe patients who did not perform the exercises (N = 28) (9% versus0%, p = 0.211). They had significantly more impression of theanterior thorax with the tonometer (+1.0 versus �0.4; p = 0.005)and had less subjective symptoms as heaviness (p = 0.044) andperceived size (p = 0.016).

3.1.4. Multi-layer bandaging

One RCT exists about the effectiveness of multi-layer bandagingin comparison to hosiery (see Table 1) [16]. All patients receivedlimb elevation, exercises, skin care and self-massage. The firstgroup wore a bandage for 18 days. After 18 days they started towear a compression sleeve (upper limb) or garment (lower limb).The second group wore a compression sleeve or garment from thestart. Patients with bandages had a higher lymphoedema reductionimmediately after the treatment and at long-term follow-up. Thisstudy is of good quality (6 on PEDro scale) but the patient group isheterogeneous. Patients with lymphoedema of the upper andlower limb of different causes were included.

3.1.5. Compression sleeve

An RCT of Hornsby [17] investigated the effect of wearing acompression sleeve during the intensive phase (see Table 1, PEDroscore 3). All patients received information about lymphoedema

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and performed exercises, self-massage and skin care during 4weeks. One group also wore a compression sleeve. Lymphoedemareduction was (not significantly) higher in the patient group whowore a compression sleeve compared with the other group (�23%versus +1%, p = 0.150).

No RCT exists about the effectiveness of wearing a compressionsleeve during the maintenance phase.

3.2. Intermittent Pneumatic Compression

Three level II studies exist about the effectiveness of Intermit-tent Pneumatic Compression (see Table 1). In the study of Szubaet al. [7] (PEDro score of 5) all patients received Combined PhysicalTherapy for 10 days. One group also received IntermittentPneumatic Compression for 30 min a day. For the next 30 days,the reduction of lymphoedema was maintained by wearing acompression sleeve and self-drainage for both groups. After 10days, patients with Combined Physical Therapy and IntermittentPneumatic Compression had a significantly higher reduction oflymphoedema volume (�45%) compared to patients who had onlyCombined Physical Therapy (�26%) (p < 0.050). In the mainte-nance phase, the additional effect of Intermittent PneumaticCompression disappeared and after 30 days both groups had equalamount of lymphoedema reduction (�30% versus �27%,p > 0.050). Dini et al. [18] (PEDro score of 5) examined theadditional effect of 20 sessions Intermittent Pneumatic Compres-sion for 2 h a day on skin care. After 9 weeks, patients who hadIntermittent Pneumatic Compression and skin care had a border-line significantly higher lymphoedema reduction (�12%) com-pared to patients who only had skin care (�3%) (p = 0.084). Theydid not follow up their patients further. The third RCT (PEDro scoreof 4) compared the effectiveness of Manual Lymphatic Drainageand wearing a compression sleeve to Intermittent PneumaticCompression and wearing a compression sleeve [19]. After 2weeks, patients with Manual Lymphatic Drainage had anadditional reduction of lymphoedema volume of 15% and patientswith Intermittent Pneumatic Compression had an additionalreduction of 7% (p = 0.360). Furthermore, Berlin et al. [20]performed a non-randomised experimental trial. All patientsreceived a compression sleeve; one group received additionallyone-chamber Intermittent Pneumatic Compression, a secondgroup received multi-chamber Intermittent Pneumatic Compres-sion and these two groups were compared to a third group who didnot receive Intermittent Pneumatic Compression. There was nosignificant difference in lymphoedema reduction between thethree groups. Another non-randomised experimental trial wasperformed by Zanolla et al. [21]. The oedema circumference wassignificantly decreased by 21% in the group with uniformcompression therapy with lower pressure (90 mmHg) and non-significantly decreased by 5% in the group with differentcompression therapy with higher pressure (160 mmHg). Thetherapy was applied during 1 week for 6 h a day. Pressure ofIntermittent Pneumatic Compression ranged between 40 mmHgand 60 mmHg for the level II studies [7,18,19] and between80 mmHg and 160 mmHg for the other studies [20,21].

3.3. Elevation

No controlled study exists about the effectiveness of armelevation for the treatment of lymphoedema.

4. Discussion

This review article gives an overview of the effectiveness of thephysical treatment, i.e. Combined Physical Therapy and itsdifferent parts, Intermittent Pneumatic Compression and arm

elevation, of lymphoedema developing after axillary dissection forbreast cancer.

From 15 studies meeting the inclusion and exclusion criteria,only 11 studies were (pseudo-) randomised controlled trials(RCTs). Moreover, the quality of the major part of the (pseudo-)RCTs was poor. Only 4 of 11 studies had a score of 6 or 7 on thePEDro scale. In none of the studies was the subject or the therapistblinded to the type of treatment. In only one study was the assessorblinded. In addition, in only 3 of 11 studies was the allocation to thetreatment group concealed and in only 3 of 11 studies wereintention-to-treat analyses applied.

It can be supposed that Combined Physical Therapy is aneffective treatment modality for arm lymphoedema developingafter axillary dissection. Patients with Combined Physical Therapyperformed by a specialist had 20% higher reduction of lymphoe-dema volume compared to a placebo Combined Physical Therapyperformed by the patient herself [8]. The quality of this study wasacceptable. According to Swedborg [9] Combined Physical Therapywas most effective the first week and the oedema volumedecreased less towards the end of the fourth week of the intensivetreatment. They also concluded that the treatment sessions shouldpreferably be given daily and breaks at weekends should beavoided. These are findings from only one older study and have tobe confirmed by other studies.

The effectiveness of the different parts of Combined PhysicalTherapy will be successively discussed. The effectiveness of skincare has not been examined by controlled studies. The effect ofexercise on the lymphoedema volume is not obvious. Firstly, a highqualitative RCT is missing. Secondly, the results of two studies withlow quality are conflicting. The effectiveness of Manual LymphaticDrainage is well investigated but there is conflicting evidence. TwoRCTs [10,11] of moderate to high quality do not show an effect ofManual Lymphatic Drainage, whereas results from one RCT [12]and one pseudo-RCT [13], both of low quality, show an additionalbeneficial effect from Manual Lymphatic Drainage on lymphoe-dema volume reduction. McNeely et al. [10], although finding nooverall beneficial effect from Manual Lymphatic Drainage,analysed subgroups of patients and found that patients with mildlymphoedema in the group with Manual Lymphatic Drainage had alarger reduction than patients with mild lymphoedema in thegroup without Manual Lymphatic Drainage. So, based on theconflicting findings among these studies, further study iswarranted to determine the relative benefit of Manual LymphaticDrainage. Hornsby [17] could not statistically prove the effective-ness of a compression sleeve for the treatment of lymphoedema.The study was of low quality and they included a limited number ofpatients (N = 25). Badger et al. [16] have proven in a moderatequality study the effectiveness of bandaging and this in compari-son with hosiery. This study included patients with all differentcauses of lymphoedema of both the lower and the upper limb. So,the exact effect of bandaging on lymphoedema developing afteraxillary dissection for breast cancer is not known. There exists noscientific evidence to support or refute the use of a compressionsleeve during the maintenance phase of Combined PhysicalTherapy.

The effectiveness of Intermittent Pneumatic Compression iswell investigated. Two RCTs, both of moderate quality, showed asignificant short-term effect of Intermittent Pneumatic Compres-sion on lymphoedema reduction [7,18] but in the long term, theeffect could not be maintained [7]. Another study concluded thatIntermittent Pneumatic Compression is as effective as ManualLymphatic Drainage [19].

Due to a lack of high-quality studies it is difficult to makeconclusions and offer recommendations about the differentphysical treatment modalities discussed in this review. Oneplacebo-controlled study of moderate quality has proven that

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Combined Physical Therapy is effective for the treatment oflymphoedema after axillary dissection for breast cancer. This hasto be further confirmed by other high-quality studies. Scientificevidence on bandaging exists, although the study was of moderatequality and the study group consisted of patients with upper andlower lymphoedema. The effect of bandaging has to be furtherexamined on only breast cancer patients with arm lymphoedema.Further research on the effectiveness of skin care, exercises andwearing an elastic sleeve is necessary. Two studies with acceptablequality could not prove the effectiveness of Manual LymphaticDrainage, so this treatment modality also has to be furtherinvestigated. Intermittent Pneumatic Compression is an effectivetreatment modality for lymphoedema at short term. These studieswere of moderate quality. High-quality studies with long-termapplication of Intermittent Pneumatic Compression at lowerpressures are needed.

Requirements for new studies are high-quality randomisedcontrolled trials in which enough patients are included, in which apower analysis is performed, in which besides the lymphoedemavolume the arm symptoms and quality of life are also analysed andin which subgroups of patients with lymphoedema are analysed.

Acknowledgements

None.

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