Manual lymphatic drainage therapy in patients with breast cancer related lymphoedema
TL;DR: The results of this study will provide information on the effectiveness of Manual Lymphatic Drainage and its impact on the quality of life and physical limitations of these patients, as well as the improvement of the concomitant symptomatology.
Abstract: Background
Lymphoedema is a common and troublesome condition that develops following breast cancer treatment. The aim of this study is to analyze the effectiveness of Manual Lymphatic Drainage in the treatment of postmastectomy lymphoedema in order to reduce the volume of lymphoedema and evaluate the improvement of the concomitant symptomatology.
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TL;DR: To assess the efficacy and safety of MLD in treating breast cancer-related lymphedema, six trials were included and it was found that participants with mild-to-moderate BCRL were better responders to MLD than were moderate- to-severe participants.
Abstract: Background More than one in five patients who undergo treatment for breast cancer will develop breast cancer-related lymphedema (BCRL). BCRL can occur as a result of breast cancer surgery and/or radiation therapy. BCRL can negatively impact comfort, function, and quality of life (QoL). Manual lymphatic drainage (MLD), a type of hands-on therapy, is frequently used for BCRL and often as part of complex decongestive therapy (CDT). CDT is a fourfold conservative treatment which includes MLD, compression therapy (consisting of compression bandages, compression sleeves, or other types of compression garments), skin care, and lymph-reducing exercises (LREs). Phase 1 of CDT is to reduce swelling; Phase 2 is to maintain the reduced swelling. Objectives To assess the efficacy and safety of MLD in treating BCRL. Search methods We searched Medline, EMBASE, CENTRAL, WHO ICTRP (World Health Organization's International Clinical Trial Registry Platform), and Cochrane Breast Cancer Group's Specialised Register from root to 24May 2013. No language restrictions were applied. Selection criteria We included randomized controlled trials (RCTs) or quasi-RCTs of women with BCRL. The intervention was MLD. The primary outcomes were (1) volumetric changes, (2) adverse events. Secondary outcomes were (1) function, (2) subjective sensations, (3) QoL, (4) cost of care. Data collection and analysis We collected data on three volumetric outcomes. (1) LE (lymphedema) volume was defined as the amount of excess fluid left in the arm after treatment, calculated as volume in mL of affected arm post-treatment minus unaffected arm post-treatment. (2) Volume reduction was defined as the amount of fluid reduction in mL from before to after treatment calculated as the pretreatment LE volume of the affected arm minus the post-treatment LE volume of the affected arm. (3) Per cent reduction was defined as the proportion of fluid reduced relative to the baseline excess volume, calculated as volume reduction divided by baseline LE volume multiplied by 100. We entered trial data into ReviewManger 5.2 (RevMan), pooled data using a fixed-effect model, and analyzed continuous data as mean differences (MDs) with 95% confidence intervals (CIs). We also explored subgroups to determine whether mild BCRL compared to moderate or severe BCRL, and BCRL less than a year compared to more than a year was associated with a better response to MLD. Main results Six trials were included. Based on similar designs, trials clustered in three categories. (1) MLD + standard physiotherapy versus standard physiotherapy (one trial) showed significant improvements in both groups from baseline but no significant between-groups differences for per cent reduction. (2) MLD + compression bandaging versus compression bandaging (two trials) showed significant per cent reductions of 30% to 38.6% for compression bandaging alone, and an additional 7.11% reduction forMLD (MD7.11%, 95% CI 1.75% to 12.47%; two RCTs; 83 participants). Volume reduction was borderline significant (P = 0.06). LE volume was not significant. Subgroup analyses was significant showing that participants with mild-to-moderate BCRL were better responders to MLD than were moderate-to-severe participants. (3) MLD+ compression therapy versus nonMLDtreatment + compression therapy (three trials) were too varied to pool. One of the trials compared compression sleeve plus MLD to compression sleeve plus pneumatic pump. Volume reduction was statistically significant favoringMLD (MD 47.00 mL, 95% CI 15.25 mL to 78.75 mL; 1 RCT; 24 participants), per cent reduction was borderline significant (P= 0.07), and LE volume was not significant. A second trial compared compression sleeve plus MLD to compression sleeve plus selfadministered simple lymphatic drainage (SLD), and was significant forMLD for LE volume (MD -230.00 mL, 95% CI -450.84 mL to -9.16 mL; 1 RCT; 31 participants) but not for volume reduction or per cent reduction. A third trial of MLD + compression bandaging versus SLD + compression bandaging was not significant (P = 0.10) for per cent reduction, the only outcome measured (MD 11.80%, 95% CI -2.47% to 26.07%, 28 participants). MLD was well tolerated and safe in all trials. Two trials measured function as range of motion with conflicting results. One trial reported significant within-groups gains for both groups, but no between-groups differences. The other trial reported there were no significant within-groups gains and did not report between-groups results. One trial measured strength and reported no significant changes in either group. Two trials measured QoL, but results were not usable because one trial did not report any results, and the other trial did not report between-groups results. Four trials measured sensations such as pain and heaviness. Overall, the sensations were significantly reduced in both groups over baseline, but with no between-groups differences. No trials reported cost of care. Trials were small ranging from 24 to 45 participants. Most trials appeared to randomize participants adequately. However, in four trials the person measuring the swelling knew what treatment the participants were receiving, and this could have biased results. Authors' conclusions MLD is safe and may offer additional benefit to compression bandaging for swelling reduction. Compared to individuals with moderate to-severe BCRL, those with mild-to-moderate BCRL may be the ones who benefit from adding MLD to an intensive course of treatment with compression bandaging. This finding, however, needs to be confirmed by randomized data. In trials where MLD and sleeve were compared with a nonMLD treatment and sleeve, volumetric outcomes were inconsistent within the same trial. Research is needed to identify themost clinically meaningful volumetric measurement, to incorporate newer technologies in LE assessment, and to assess other clinically relevant outcomes such as fibrotic tissue formation. Findings were contradictory for function (range of motion), and inconclusive for quality of life. For symptoms such as pain and heaviness, 60% to 80% of participants reported feeling better regardless of which treatment they received. One-year follow-up suggests that once swelling had been reduced, participants were likely to keep their swelling down if they continued to use a custom-made sleeve. (Less)
205 citations
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
TL;DR: The current evidence from RCTs does not support the use of MLD in preventing or treating lymphedema, and clinical and statistical inconsistencies between the various studies confounded the evaluation of the effect ofMLD on breast-cancer-related lyMPhedema.
Abstract: Lymphedema is a common complication of axillary dissection for breast cancer. We investigated whether manual lymphatic drainage (MLD) could prevent or manage limb edema in women after breast-cancer surgery. We performed a systematic review and meta-analysis of published randomized controlled trials (RCTs) to evaluate the effectiveness of MLD in the prevention and treatment of breast-cancer-related lymphedema. The PubMed, EMBASE, CINAHL, Physiotherapy Evidence Database (PEDro), SCOPUS, and Cochrane Central Register of Controlled Trials electronic databases were searched for articles on MLD published before December 2012, with no language restrictions. The primary outcome for prevention was the incidence of postoperative lymphedema. The outcome for management of lymphedema was a reduction in edema volume. In total, 10 RCTs with 566 patients were identified. Two studies evaluating the preventive outcome of MLD found no significant difference in the incidence of lymphedema between the MLD and standard treatment groups, with a risk ratio of 0.63 and a 95% confidence interval (CI) of 0.14 to 2.82. Seven studies assessed the reduction in arm volume, and found no significant difference between the MLD and standard treatment groups, with a weighted mean difference of 75.12 (95% CI, −9.34 to 159.58). The current evidence from RCTs does not support the use of MLD in preventing or treating lymphedema. However, clinical and statistical inconsistencies between the various studies confounded our evaluation of the effect of MLD on breast-cancer-related lymphedema.
157 citations
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.
56 citations
TL;DR: There was mild evidence that massage may be a useful intervention in alleviating negative emotions and fatigue in patients with breast cancer, and more trials with longer follow-up are needed to determine the exact long-term efficacy.
Abstract: 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. 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. 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. 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.
54 citations
References
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Journal Article•
TL;DR: Low stretch compression bandaging is an effective treatment giving volume reduction of slight or moderate arm lymphedema in women treated for breast cancer.
Abstract: We examined the effects of low stretch compression bandaging (CB) alone or in combination with manual lymph drainage (MLD) in 38 female patients with arm lymphedema after treatment for breast cancer. After CB therapy for 2 weeks (Part I), the patients were allocated to either CB or CB + MLD for 1 week (Part II). Arm volume and subjective assessments of pain, heaviness and tension were measured. The mean lymphedema volume reduction for the total group during Part I was 188 ml (p < 0.001), a mean reduction of 26% (p < 0.001). During Part II the volume reduction in the CB + MLD group was 47 ml (p < 0.001) and in CB group 20 ml. These differences were not significant (p = 0.07). A percentage reduction of 11% (p < 0.001) in the CB + MLD group and 4% in the CB group was significantly different (p = 0.04). In both the CB and the CB + MLD group, a decrease of feeling of heaviness (p < 0.006 and p < 0.001, respectively) and tension (p < 0.001 for both) in the arm was found, but only the CB + MLD group showed decreased pain (p < 0.03). Low stretch compression bandaging is an effective treatment giving volume reduction of slight or moderate arm lymphedema in women treated for breast cancer. Manual lymph drainage adds a positive effect.
141 citations
TL;DR: A large clinical experience suggests that outcome is best with a multidisciplinary team approach that is based in an outpatient setting and combines gradient compression garments, sequential pneumatic pumps, and ancillary support services.
122 citations
"Manual lymphatic drainage therapy i..." refers background in this paper
...It is marked by an abnormal increase of tissue proteins, oedema, chronic inflammation and fibrosis [2]....
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TL;DR: The key to predicting successful lymphedema treatment is the initial volume of edema in the tissues regardless of whether the intervention is early or late.
Abstract: Background: There are currently between 1 and 2 million breast cancer survivors in the United States. Is the advocated, early intervention the key to successful treatment, or are there other, more important factors? Methods: Responses to combined decongestive therapy (CDT) for 69 women were analyzed with regard to duration of lymphedema, differences in arm circumference, percent differences in arm volumes, volume of edema, reduction of edema volumes, and duration of treatment. Results: Two- and three-dimensional (2D and 3D) analyses showed little correlation between duration and volume of edema or between duration and response and treatment. However, they did show a correlation between initial volumes of fluid in the tissues and responses. Patients with initial volumes of 250 mL or less had a mean reduction of 78% with CDT, whereas those with initial volumes between 250 and 500 mL had a mean reduction of 56%. Conclusion: The key to predicting successful lymphedema treatment is the initial volume of edema in the tissues regardless of whether the intervention is early or late.
109 citations
"Manual lymphatic drainage therapy i..." refers background in this paper
...On the other hand, the fact that CPT implies several techniques (manual lymph drainage, skin care and multilayer compression bandaging followed by a compression garment to reduce oedema and therapeutic exercises) makes it difficult to recognize which of them is the truly effective one in the treatment of lymphoedema [12-14]....
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TL;DR: It is suggested that lymphoedema is a unique and complex experience for the patient which influences many spheres of life and adjustment to the condition is impeded by higher limb volume and facilitated by appropriate treatment to reduce limb volume.
Abstract: This article describes a study which was designed to explore patients' perceptions of breast-cancer-related arm lymphoedema and the factors that may be associated with these perceptions. The findings of the study suggest that lymphoedema is a unique and complex experience for the patient which influences many spheres of life. Adjustment to the condition is impeded by higher limb volume and facilitated by appropriate treatment to reduce limb volume.
66 citations
"Manual lymphatic drainage therapy i..." refers background in this paper
...Problems associated with lymphoedema include: pain, altered sensations such as discomfort and heaviness, difficulties with physical mobility, physiological distress, recurrent infections and social isolation [3,4]....
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TL;DR: The study showed that both groups obtained a significant reduction in edema and that MLD did not contribute significantly to reduce edema volume.
50 citations
"Manual lymphatic drainage therapy i..." refers background in this paper
...However, no significant differences in objective measures regarding change in arm volume or subjective measures of symptoms related to lymphoedema were found between the 2 groups [18]....
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