Complex Decongestive Lymphatic Therapy With or Without Vodder II Manual Lymph Drainage in More Severe Chronic Postmastectomy Upper Limb Lymphedema: A Randomized Noninferiority Prospective Study
TL;DR: The results indicate that parallel (immediate and delayed) results may be obtained by CDT without the use of Vodder MLD and CB may be an essential part of lymphedema management.
About: This article is published in Journal of Pain and Symptom Management.The article was published on 2015-12-01 and is currently open access. It has received 56 citations till now. The article focuses on the topics: Lymphedema.
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TL;DR: The clinical importance of ependymal route-based targeted gene therapy and intranasal drug administration in the brain by taking advantage of the unique role played by brain lymphatic pathways in the regulation of CSF flow and ISF/CSF exchange is highlighted.
165 citations
28 Mar 2019
TL;DR: As a result of surgery or radiotherapy as treatment for cancer, functional components of the lymphatic system are partially removed or damaged, resulting in lymphoedema (accumulation of extracellular fluid in tissues).
Abstract: Lymphoedema is an oedematous condition with a specific and complex tissue biology. In the clinical context of cancer, the pathogenesis of lymphoedema ensues most typically from the modalities employed to stage and treat the cancer (in particular, surgery and radiotherapy). Despite advances in cancer treatment, lifelong lymphoedema (limb swelling and the accompanying chronic inflammatory processes) affects approximately one in seven individuals treated for cancer, although estimates of lymphoedema prevalence following cancer treatment vary widely depending upon the diagnostic criteria used and the duration of follow-up. The natural history of cancer-associated lymphoedema is defined by increasing limb girth, fibrosis, inflammation, abnormal fat deposition and eventual marked cutaneous pathology, which also increases the risk of recurrent skin infections. Lymphoedema can substantially affect the daily quality of life of patients, as, in addition to aesthetic concerns, it can cause discomfort and affect the ability to carry out daily tasks. Clinical diagnosis is dependent on comparison of the affected region with the equivalent region on the unaffected side and, if available, with pre-surgical measurements. Surveillance is indicated in this high-risk population to facilitate disease detection at the early stages, when therapeutic interventions are most effective. Treatment modalities include conservative physical strategies that feature complex decongestive therapy (including compression garments) and intermittent pneumatic compression, as well as an emerging spectrum of surgical interventions, including liposuction for late-stage disease. The future application of pharmacological and microsurgical therapeutics for cancer-associated lymphoedema holds great promise.
106 citations
TL;DR: A work group from the 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.
Abstract: 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
54 citations
TL;DR: There is some evidence that MLD in early stages following breast cancer surgery may help prevent progression to clinical lymphedema, but MLD may not provide additional benefit when combined with complex decongestive therapy.
Abstract: Manual lymphatic drainage (MLD) massage is widely accepted as a conservative treatment for lymphedema. This systematic review aims to examine the methodologies used in recent research and evaluate the effectiveness of MLD for those at-risk of or living with lymphedema. The electronic databases Embase, PubMed, CINAHL Complete and Cochrane Central Register of Controlled Trials were searched using relevant terms. Studies comparing MLD with another intervention or control in patients at-risk of or with lymphedema were included. Studies were critically appraised with the PEDro scale. Seventeen studies with a total of 867 female and two male participants were included. Only studies examining breast cancer-related lymphedema were identified. Some studies reported positive effects of MLD on volume reduction, quality of life and symptom-related outcomes compared with other treatments, while other studies reported no additional benefit of MLD as a component of complex decongestive therapy. In patients at-risk, MLD was reported to reduce incidence of lymphedema in some studies, while others reported no such benefits. The reviewed articles reported conflicting findings and were often limited by methodological issues. This review highlights the need for further experimental studies on the effectiveness of MLD in lymphedema. There is some evidence that MLD in early stages following breast cancer surgery may help prevent progression to clinical lymphedema. MLD may also provide additional benefits in volume reduction for mild lymphedema. However, in moderate to severe lymphedema, MLD may not provide additional benefit when combined with complex decongestive therapy.
44 citations
Cites background or methods or result from "Complex Decongestive Lymphatic Ther..."
...Follow-up beyond the post-intervention period was only reported by four studies at 6 months [22], 7 months [30], 12 months [33] and 60 months [34]....
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...…Significant volume and symptom reductions in both groups, no significant difference between groups, MLD did not increase therapeutic response in BCRL Gradalski et al. (2015) Poland [32] Patients with unilateral BCRL post-mastectomy, vol diff > 20% II 60 females, 0 males Age: 62.0 ± 12.2 and…...
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...the MLD technique used, six studies specifically mentioned massaging the contralateral axilla [22, 25, 29, 31, 33, 34]....
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...No additional benefit of MLD was also reported for improving oedema-related QOL and treatment satisfaction [22] or improving subjective symptoms related to lymphedema [19, 21]....
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...A further three of the 17 included studies also calculated volume using the truncated cone formula and circumferential measurements at 4-cm intervals [22, 29, 32]....
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TL;DR: CDT is an effective treatment modality for early stage BCRL and for more advanced BCRL, LNT has demonstrated efficacy, and a small number of studies suggest that liposuction may be an efficacious and safe treatment for moderate to severe BCRL.
Abstract: Objectives Breast cancer-related lymphedema (BCRL) represents a major complication of breast cancer treatment, impacting the quality of life for breast cancer survivors that develop it. The purpose of this review is to evaluate the literature surrounding BCRL treatment modalities to guide clinicians regarding risk-stratified treatment options. Methods A review of studies over a 10-year period (January 2006 to February 2016) was performed. Noninvasive strategies evaluated included compression therapy, manual lymphatic drainage, and complex decongestive therapy (CDT). Invasive modalities evaluated included liposuction and lymphatic bypass/lymph node transfer (LNT). Our search yielded 149 initial results with 45 studies included. Results A number of prospective studies have found that CDT is associated with volume reduction in the affected limb as well as improved quality of life, particularly in patients with early stage BCRL. With regards to invasive treatment options, data support that lymphatic bypass and LNT are associated with symptomatic and physiologic improvements, particularly in patients with more advanced BCRL. In addition, a small number of studies suggest that liposuction may be an efficacious and safe treatment for moderate to severe BCRL. Conclusions CDT is an effective treatment modality for early stage BCRL. For more advanced BCRL, LNT has demonstrated efficacy. Further study is required with respect to comparing BCRL treatment modalities.
44 citations
Cites background or methods from "Complex Decongestive Lymphatic Ther..."
...Another consideration of CDT is that the MLD component usually requires a skilled massage therapist.(33) Gradalski and colleagues randomized 51 patients to either CDT or compression bandage treatment with assessment of limb volume, edematous volume, volume change, and QoL after 26 weeks of therapy....
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...Although limited by the small number of patients and limited follow-up, the homogeneity of the patient population and adherence to treatment does strengthen the value of the data.(33) It should be noted that the 6 prospective CDT studies focused primarily on short-term outcomes rather than long-term outcomes with mean follow-up of <1 month....
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References
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TL;DR: Neither aerobic nor resistance exercise significantly improved cancer-specific QOL in breast cancer patients receiving chemotherapy, but they did improve self-esteem, physical fitness, body composition, and chemotherapy completion rate without causing lymphedema or significant adverse events.
Abstract: Purpose Breast cancer chemotherapy may cause unfavorable changes in physical functioning, body composition, psychosocial functioning, and quality of life (QOL). We evaluated the relative merits of aerobic and resistance exercise in blunting these effects. Patients and Methods We conducted a multicenter randomized controlled trial in Canada between 2003 and 2005 that randomly assigned 242 breast cancer patients initiating adjuvant chemotherapy to usual care (n = 82), supervised resistance exercise (n = 82), or supervised aerobic exercise (n = 78) for the duration of their chemotherapy (median, 17 weeks; 95% CI, 9 to 24 weeks). Our primary end point was cancer-specific QOL assessed by the Functional Assessment of Cancer Therapy–Anemia scale. Secondary end points were fatigue, psychosocial functioning, physical fitness, body composition, chemotherapy completion rate, and lymphedema. Results The follow-up assessment rate for our primary end point was 92.1%, and adherence to the supervised exercise was 70.2%. ...
970 citations
Journal Article•
TL;DR: This International Society of Lymphology (ISL) Consensus Document is the current revision of the 1995 Document for the evaluation and management of peripheral lymphedema, and presents a Consensus that embraces the entire ISL membership, rises above national standards, identifies and stimulates promising areas for future research and represents the best judgment of the ISL members on how to approach patients with peripheral lyMPhedema.
Abstract: This International Society of Lymphology(ISL) Consensus Document is the currentrevision of the 1995 Document for theevaluation and management of peripherallymphedema (1) for discussion at the XXIVInternational Congress of Lymphology. It isbased upon modifications: [A] suggested andpublished following the 1997 XVI InternationalCongress of Lymphology (ICL) inMadrid, Spain (2) discussed at the 1999 XVIIICL in Chennai, India (3) and considered/confirmed at the 2000 (ISL) ExecutiveCommittee meeting in Hinterzarten, Germany(4); [B] derived from integration ofdiscussions and written comments obtainedduring and following the 2001 XVIII ICL inGenoa, Italy as modified at the 2003 ISLExecutive Committee meeting in Cordoba,Argentina (5); [C] suggested from comments,criticisms, and rebuttals as published in theDecember 2004 issue of Lymphology (6);[D] discussed in both the 2005 XX ICL inSalvador, Brazil and the 2007 XXI ICL inShanghai, China and modified at the 2008Executive Committee Meeting in Naples, Italy(7,8); and [E] modified from discussions andwritten comments from the 2009 XXII ICLin Sydney, Australia, the 2011 XXIII ICL inMalmo, Sweden and 2012 ExecutiveCommittee Meetings.The document attempts to amalgamatethe broad spectrum of protocols advocatedworldwide for the diagnosis and treatment ofperipheral lymphedema into a coordinatedproclamation representing a “Consensus” ofthe international community. The document is not meant to override individual clinicalconsiderations for problematic patients nor tostifle progress. It is also not meant to be alegal formulation from which variations definemedical malpractice. The Society understandsthat in some clinics the method of treatmentderives from national standards while inothers access to medical equipment andsupplies is limited, and therefore the suggestedtreatments are impractical. Adaptability andinclusiveness does come at the price thatmembers can rightly be critical of what theysee as vagueness or imprecision in definitions,qualifiers in the choice of words (e.g., the useof “may... perhaps... unclear”, etc.) andmention (albeit without endorsement) oftreatment options supported by limited harddata. Most members are frustrated by thereality that NO treatment method has reallyundergone a satisfactory meta-analysis(let alone rigorous, randomized, stratified,long-term, controlled study). With this understanding,the absence of definitive answersand optimally conducted clinical trials, andwith emerging technologies and newapproaches and discoveries on the horizon,some degree of uncertainty, ambiguity, andflexibility along with dissatisfaction withcurrent lymphedema evaluation and managementis appropriate and to be expected.We continue to struggle to keep the documentconcise while balancing the need for depthand details. With these considerations inmind, we believe that this latest versionpresents a Consensus that embraces the entireISL membership, rises above national standards, identifies and stimulates promisingareas for future research and represents the best judgment of the ISL membership on how to approach patients with peripheral lymphedema as of 2013. Therefore the document has been, and should continue to be, challenged and debated in the pages of Lymphology (e.g., as Letters to the Editor), and ideally will remain a continued focal point for robust discussion at local, national and international conferences in lymphology and related disciplines. We further anticipate as experience evolves and new ideas and technologies emerge that this “living document” will undergo further periodic revision and refinement as the practiceand theories of medicine and specificallylymphology change and advance.
603 citations
TL;DR: Slow progressive weight lifting had no significant effect on limb swelling and resulted in a decreased incidence of exacerbations of lymphedema, reduced symptoms, and increased strength in breast-cancer survivors with stable lyMPhedema.
Abstract: The proportion of women who had an increase of 5% or more in limb swelling was similar in the weight-lifting group (11%) and the control group (12%) (cumulative incidence ratio, 1.00; 95% confidence interval, 0.88 to 1.13). As compared with the control group, the weight-lifting group had greater improvements in self-reported severity of lymphedema symptoms (P = 0.03) and upper- and lower-body strength (P<0.001 for both comparisons) and a lower incidence of lymphedema exacerbations as assessed by a certified lymphedema specialist (14% vs. 29%, P = 0.04). There were no serious adverse events related to the intervention. Conclusions In breast-cancer survivors with lymphedema, slowly progressive weight lifting had no significant effect on limb swelling and resulted in a decreased incidence of exacerbations of lymphedema, reduced symptoms, and increased strength. (ClinicalTrials.gov number, NCT00194363.)
487 citations
TL;DR: The authors demonstrated the effectiveness of a surveillance program that included preoperative limb volume measurement and interval postoperative follow-up to detect and treat subclinical LE.
Abstract: BACKGROUND. The incidence of breast cancer (BC)-related lymphedema (LE) ranges from 7% to 47%. Successful management of LE relies on early diagnosis using sensitive measurement techniques. In the current study, the authors demonstrated the effectiveness of a surveillance program that included preoperative limb volume measurement and interval postoperative follow-up to detect and treat subclinical LE. METHODS. LE was identified in 43 of 196 women who participated in a prospective BC morbidity trial. Limb volume was measured preoperatively and at 3month intervals after surgery. If an increase >3% in upper limb (UL) volume developed compared with the preoperative volume, then a diagnosis of LE was made, and a compression garment intervention was prescribed for 4 weeks. Upon reduction of LE, garment wear was continued only during strenuous activity, with symptoms of heaviness, or with visible swelling. Women returned to the 3-month interval surveillance pathway. Statistical analysis was a repeated-measures analysis of variance by time and limb (P � .001) comparing the LE cohort with an age-matched control group. RESULTS. The time to onset of LE averaged 6.9 months postoperatively. The mean (� standard deviation) affected limb volume increase was 83 mL (� 119 mL;
416 citations
TL;DR: It was found that the more intensive and health professional based therapies generally yielded the greater volume reductions, whilst self instigated therapies such as compression garment wear, exercises and limb elevation yielded smaller reductions.
269 citations