Low Level Laser Therapy

Low Level Laser Therapy

PEP Topic 
Lymphedema
Description 

Low-level laser therapy (LLLT) involves the use of a hand-held infrared laser in an attempt to affect cells and physical symptoms often related to inflammation. The therapy has been approved by the Food and Drug Administration for treatment of post-mastectomy lymphedema. LLLT has also been evaluated for prevention and treatment of mucositis.

Effectiveness Not Established

Research Evidence Summaries

Ahmed Omar, M.T., Abd-El-Gayed Ebid, A., & El Morsy, A.M. (2011). Treatment of post-mastectomy lymphedema with laser therapy: Double blind placebo control randomized study. The Journal of Surgical Research, 165(1), 82–90.

doi: 10.1016/j.jss.2010.03.050
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Study Purpose:

To evaluate the effect of low-level laser therapy (LLLT) on limb volume, shoulder mobility, and grip strength

Intervention Characteristics/Basic Study Process:

Patients were randomized to treatment and placebo control groups. The treatment group received LLLT at an average dose of 1.5 J/cm2 for 20 minutes three times per week for 36 sessions. In the placebo group, the patients were set up with the same parameters of therapy but the machine was not turned on. All patients were advised to perform the same arm and shoulder exercises daily. Patients were evaluated every 4 weeks for 12 weeks.

Sample Characteristics:

  • The study sample (N = 50) was comprised of female patients with breast cancer.
  • Mean age of the sample was 54.06 years.
  • All patients had axillary node dissection and unilateral arm lymphedema.
  • Patients had arm circumference increases in the affected arm of 2–8 cm.
  • Patients with severe lymphedema were excluded.
  • Seventy-two percent of patients had modified radical mastectomy.
  • Lymphedema was in the dominant arm in 78% of patients.
  • Mean duration of lymphedema was 14 months and average time since surgery was 40 months.

Setting:

The study took place in an outpatient setting in Egypt.

Phase of Care and Clinical Applications:

The study has clinical applicability for late effects and survivorship.

Study Design:

The study used a randomized double-blind placebo-controlled design.

Measurement Instruments/Methods:

  • Arm circumference was measured.
  • Grip strength was measured with a dynamometer.
  • Goniometer measured shoulder range of motion.

Results:

The laser group had greater reduction in limb volume than controls. The difference was significant at 8 and 12 weeks (p < 0.01).  At 16 weeks, total limb circumference was 31 in the laser group and 23 in the control group. Shoulder mobility was better in the laser group and significantly better than controls at 12 weeks (p < 0.01).  Grip strength improved in both groups. At 8 and 12 weeks, grip strength improvement was significantly higher in the laser treatment group (p < 0.01).

Conclusions:

 LLLT reduces lymphedema arm volume and increased shoulder mobility and grip strength in women after mastectomy.

Limitations:

  • The study sample was small, with less than 100 participants.
  • Subject withdrawals were greater than or equal to 10%.
  • The study was of short duration, so long-term efficacy is not clear.

Nursing Implications:

Low-level laser therapy can reduce lymphedema volume and improve extremity strength and mobility. The study showed that 14% of patients did not adhere to receiving all treatments, which has also been shown in other studies of LLLT. The need for patients to make multiple visits for treatments may limit the practicality of the approach. Effects over the longer term are unclear.

Carati, C.J., Anderson, S.N., Gannon, B.J., & Piller, N.B. (2003). Treatment of post-mastectomy lymphedema with low-level laser therapy. Cancer, 98(6), 1114–1122.

doi: 10.1002/cncr.11641
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Study Purpose:

To study postmastectomy lymphedema using low-level laser therapy (LLLT).

Intervention Characteristics/Basic Study Process:

The control group received a placebo with one block of sham therapy followed by an eight-week period of rest and then one week of LLLT. The study group received two blocks of LLLT separated by an eight-week period of rest.

Sample Characteristics:

  • The study sample (N = 61) was comprised of female patients who were randomized to the control group (n = 28) and the study group (n = 33). 
  • Patients were included in the study if they were aged 18 years or older, female, and had clinically manifested postmastectomy. 
  • Patients were excluded from the study if they had current metastases, a history of severe trauma to the arm, instability of condition, or cellulitis within past three months.
  • Lymphedema was defined as a greater than 200 ml difference between arms. 

Setting:

The study took place in Australia.

Study Design:

The study used a double-blind, randomized, placebo-controlled trial design, with 30 weeks of follow-up measurements.

Measurement Instruments/Methods:

  • Objective measurements were taken at the beginning and end of every session.
  • Perometry measured limb circumference.
  • Bioimpedence provided an objective measure of fluid distribution.
  • Tonometry provided indication of the compliance of the skin.
  • Data were analyzed using analysis of variance and multiple regressions; p < 0.05 was determined using t-tests.

Results:

There was no significant effect of placebo treatment or just one cycle of LLLT treatment on mean affected limb volume. There was no significant decrease in limb volume immediately after two treatments of LLLT. Limb volume at three months after two LLLT treatments were significantly less than after placebo treatment (p < 0.017). Limb extracellular fluid (ECF) was significantly decreased in placebo and with one treatment of LLLT; however, the mean ECF was most reduced after two LLLT cycles. Significant decreases in tonometry readings (indicating increased tissue hardness) were noted in patients treated with placebo or one LLLT. Participants receiving two LLLT cycles had an increased tonometry reading, which indicates softening of the tissues. There was no significant effect on range of motion.

Conclusions:

Two cycles of LLLT improved the condition of the lymphedema-affected limbs.

Limitations:

  • The study sample was small.
  • Special training is required.
  • Use of laser makes costs higher.

Dirican, A., Andacoglu, O., Johnson, R., McGuire, K., Mager, L., & Soran, A. (2010). The short-term effects of low-level laser therapy in the management of breast-cancer-related lymphedema. Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer, 19(5), 685–690.

doi: 10.1007/s00520-010-0888-8
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Study Purpose:

To evaluate the short-term benefits of low-level laser therapy (LLLT) when added to the conventional management of breast cancer-related lymphedema (BCRL)

Intervention Characteristics/Basic Study Process:

All patients had experienced at least one conventional treatment modality, such as complex physical therapy, manual lymphatic drainage, or pneumatic pump therapy. LLLT was added to patients' ongoing therapeutic regimen. All patients completed two cycles of LLLT. Assessment took place before and after the first and second cycle of LLLT sequentially.

Sample Characteristics:

  • The study sample (N = 17) was comprised of female patients with BCRL.
  • Mean age was 51.8 years, with a range of 44–64 years. 

Setting:

The study took place in an outpatient setting at the University of Pittsburgh Medical Center. 

Study Design:

The study used a quasi-experimental design.

Measurement Instruments/Methods:

  • Arm lymphedema was identified by measuring limb circumference.
  • Pain was measured using a typical pain diagram with a 0–10 subjective pain score.
  • Shoulder range of motion was measured using goniometric values.
  • The Patient and Observation Scar Assessment Scale (POSAS) was used in the study.

Results:

The difference between sums of the circumferences of the affected and unaffected arms decreased 54% and 73% after the first and second cycles of LLLT, respectively. Eighty-two percent of patients 14 out of 17 experienced decreased pain with motion by an average of 40% and 62.7% after the first and second cycle of LLLT, respectively. Scar mobility increased in 13 (76.4%) and shoulder range of motion improved in 14 (82.3%) patients after LLLT. One patient developed cellulitis during LLLT.

Conclusions:

Patients with BCRL received additional benefits from LLLT when used in conjunction with standard lymphedema treatment, including reduction in limb circumference, pain, increase in range of motion and scar mobility.

Limitations:

  • The study sample was small, with less than 30 patients.
  • Results are potentially bias because there was no control group. 

Nursing Implications:

Further studies with appropriate sample size and control groups are necessary to assess the long-term effects of LLLT in combination with conventional treatments as well as the effect of the repetitive application.

Kaviani, A., Fateh, M., Yousefi Nooraie, R., Alinagi-Zadeh, M.R., & Ataie-Fashtami, L. (2006). Low-level laser therapy in management of postmastectomy lymphedema. Lasers in Medical Science, 21(2), 90-94.

doi: 10.1007%2Fs10103-006-0380-3
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Study Purpose:

To study the effects of low-level laser therapy (LLLT) in postmastectomy lymphedema

Intervention Characteristics/Basic Study Process:

Patients were randomly assigned to either a laser or sham group. Patients in the laser group were treated with GA-As laser device wavelength 890 nm over the arm and axillary areas. Therapy was administered three times a week for three weeks. Then, after an eight-week interval, the same treatment protocol was repeated. Patients received a total of 18 treatments.

Sample Characteristics:

  • The study involved 11 female patients; eight patients completed the therapy (four in each group).
  • The patients were all diagnosed with unilateral postmastectomy lymphedema.

Study Design:

This was a double blind controlled trial.

Measurement Instruments/Methods:

Investigators measured changes in patients’ limb circumferences, pain scores, range of motion (ROM), heaviness of the affected limb, and desire to continue the treatment. Measurements were taken before and during the treatment at 3, 9, 12, 18, and 22 weeks.

Results:

  • Eight patients completed the study.
  • Reduction in limb circumference occurred in both groups but was greatest in the treatment group.
  • Greater pain reduction occurred in the treatment group and desire to continue the therapy was greater in the treatment group. The other two parameters had no difference.

Conclusions:

The study reported that LLLT may be effective in reducing arm circumference and pain. Researchers encouraged further studies with larger samples and more therapy. The study used a good design and excellent blinding.

Limitations:

  • The study size was very small.
  • The design had some similarities to Carati et al. (2003) but did not use same means of objective assessment.

Kozanoglu, E., Basaran, S., Paydas, S., & Sarpel, T. (2009). Efficacy of pneumatic compression and low-level laser therapy in the treatment of postmastectomy lymphoedema: A randomized controlled trial. Clinical Rehabilitation, 23(2), 117–124.

doi: 10.1177/0269215508096173
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Study Purpose:

To compare the long-term efficacy of pneumatic compression and low-level laser therapies in the management of postmastectomy lymphoedema

Intervention Characteristics/Basic Study Process:

Sixty-four women who had undergone modified radical mastectomy with complete axillary dissection and radiotherapy were recruited for the study. All patients gave informed consent, and the hospital ethics committee had approved the study protocol. Patients who had a history of arm lymphedema of at least three months were recruited to the study. Fourteen patients were excluded from the study (three had current metastases, five had continuing radiotherapy, one had cellulitis, two had a history of receiving a physical therapy program in the previous six months, one was using diuretic agent for hypertension, and two refused the treatment and did not provide informed consent). Patients were randomized to the pneumatic compression therapy group (group I, n = 25) or the low-level laser therapy group (group II, n = 25) by consecutive alternate allocation according to the admittance to the study clinic. The physician who randomized the patients was blind to the treatment groups. Group I received two hours of therapy with an intermittent pneumatic compression therapy device. A pressure of 60 mmHg, which is generally recommended for the treatment of lymphedema, was used. Total treatment period was four weeks and consisted of 20 sessions. Group II received 20 minutes therapy (2800 Hz, 1.5 J/cm2) with a Ga-As 904 nm laser device three times a week. Total treatment period was four weeks and consisted of 12 sessions. Laser therapy was administered at three points on the antecubital fossa and at seven points on the axilla where the lymph nodes accumulated. All patients were advised to perform daily limb exercises (active range of motion, elevation and pumping exercises), hygiene, and skin care. In addition to pre- and post-treatment evaluation, follow-up measurements were performed at 3, 6 and 12 months by the same physician.

Sample Characteristics:

  • The study sample (N = 50) was comprised of two groups receiving either pneumatic compression therapy (group I, n = 25) or low-level laser therapy (group II, n = 25). 
  • Mean age for group I was 51.2 years and group II was 45.4 years. 
  • All patients had breast cancer-related lymphedema. 
  • Patients were included in the study if they had a history of arm lymphedema of at least three months. 
  • Patients were excluded from the study if they
    • Had current metastases, continuing radiotherapy, cellulitis, venous thrombosis, chronic inflammatory diseases, a history of severe trauma, or photosensitivity
    • Were using any medications that affect body fluid and electrolyte balance
    • Had limitation of the upper-extremity joints
    • Had a history of physical therapy other than skin care and home exercises directed to lymphedema within the previous six months.

 

 

Setting:

The study took place at the Department of Physical Medicine and Rehabilitation of Cukurova University in Turkey.

Phase of Care and Clinical Applications:

Patients were undergoing long-term follow-up care. The study has clinical applicability for late effects and survivorship. 

Study Design:

The study used a randomized controlled trial design.

Measurement Instruments/Methods:

  • The affected and unaffected upper limbs of the patients were measured by tape at seven anatomic sites, including the axilla, 10 cm proximal and distal to the antecubital fossa, elbow, 5 cm proximal to the wrist, wrist, and mid-palm. Lymphedema was defined as a difference of more than 2 cm at least three of the seven points. The sum of the circumferences of the affected and unaffected limbs was calculated and the difference between these two values was recorded as delta circumference.
  • Pain with motion was measured by a visual analog scale of 0–100 mm, ranging from no pain to very severe pain.
  • Range of motion of the upper-extremity joints was measured using a conventional goniometer when patients were lying in the supine position.
  • Grip strength was measured by portable hydraulic hand dynamometer. The measurements were performed when patients were seated in straight position, with the shoulder adducted, elbow flexed at 90°, and forearm in neutral rotation. A mean of three attempts was calculated, with a 15-second rest in between each of three contractions.

Results:

Delta circumference decreased significantly at one, three, and six months within both groups, and the decrease was still significant at month 12 only in group II (p = 0.004). Improvement of group II was greater than that of group I post-treatment (p = 0.04) and at month 12 after 12 months (p = 0.02). Pain was significantly reduced in group I only at post-treatment evaluation, whereas in group II it was significant post-treatment and at follow-up visits. No significant difference was detected in pain scores between the two groups. Grip strength was improved in both groups, but the differences between groups were not significant.

Conclusions:

Patients in both groups improved after the interventions. Group II had better long-term results than group I. Low-level laser might be a useful modality in the treatment of post-mastectomy lymphedema.

Limitations:

  • The study sample was small, with less than 30 participants for each group and less than 100 participants in total. 
  • The study lacked a sham or control group because of ethical issues.
  • Patients were not blinded because of the different types of treatment. 

Nursing Implications:

Prospective randomized controlled studies with a larger sample size are needed to better understand the efficacy of low-level laser therapy and pneumatic compression in the treatment of postmastectomy lymphedema. In addition to these suggested treatment modalities, patients are recommended to perform daily limb exercises and follow skin care instructions throughout their lives.

Lau, R.W., & Cheing, G.L. (2009). Managing postmastectomy lymphedema with low-level laser therapy. Photomedicine and Laser Surgery, 27(5), 763–769.

doi: 10.1089/pho.2008.2330
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Study Purpose:

To investigate effects of low-level laser therapy in managing lymphedema

Intervention Characteristics/Basic Study Process:

Women were randomly assigned to laser treatment or usual care. Subjects in the laser group received low-level laser therapy (LLLT) three times a week for four weeks to the axillary region. Outcome measures were assessed at baseline, after four weeks of treatment and again at a four-week follow-up.

Sample Characteristics:

  • The study sample (N = 21) was comprised of female patients. 
  • Mean age range was 50.9–51.3 years.
  • Patients had undergone unilateral mastectomy for breast cancer and clinically manifested lymphedema of the arm. 
  • Patients were not receiving any concurrent cancer treatment.

 

Setting:

The study took place in an outpatient setting in China.

Study Design:

The study used a single-blind, randomized controlled trial design.

Measurement Instruments/Methods:

  • Arm volume was measured using a tank volumeter.
  • Tissue pressure resistance was measured using a tonometer.
  • Patients took the Disability of Arm Shoulder and Hand (DASH) questionnaire.

Results:

In the laser group, arm volume decreased significantly (p = 0.000), whereas those in the control group had a significant increase at the four-week follow-up. Group differences were significant (p = 0.044) at the four-week follow-up time point. For the first month, there were no significant differences between groups. Over time, the laser group showed a significant increase in tonomety readings at some sites (p = 0.000), indicating less tissue hardness, while there were no changes in the control group. Mean DASH scorers decreased significantly from baseline in the laser group (p = 0.04). There were no significant changes in DASH scores in the control group.

Conclusions:

Low-level laser treatment in the study appeared to improve subjective pain and disability, improve tissue tone, and reduce lymphedema.

Limitations:

  • The study sample was small, with less than 30 participants.
  • Although authors state the study was single blinded, patients would have known if they were or were not receiving laser treatment because no sham control was used.
  • No information was obtained or reported about other patient activities and behaviors that are known to potentially affect lymphedema development

Nursing Implications:

Low-level laser therapy is promising for management of lymphedema postmastectomy.

Ridner, S.H., Poage-Hooper, E., Kanar, C., Doersam, J.K., Bond, S.M., & Dietrich, M.S. (2013). A pilot randomized trial evaluating low-level laser therapy as an alternative treatment to manual lymphatic drainage for breast cancer-related lymphedema. Oncology Nursing Forum, 40, 383–393. 

doi: 10.1188/13.ONF.383-393
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Study Purpose:

To examine the impact of advanced practice nurse (APN)-administered low-level laser therapy (LLLT) as a stand-alone and complementary treatment for arm volume, symptoms, and quality of life (QOL) in women with breast cancer–related lymphedema

Intervention Characteristics/Basic Study Process:

Three interventions were used, including LLLT alone, manual lympatic drainage (MLD) alone, and combined MLD and LLLT. LLLT alone used a RianCorp LTU 904, FAD-approved, class I laser. Grids for the areas to be treated were identified. The laser was applied, and exposure was limited to 20–30 seconds per point in each grid. Time for each session using this procedure was about 20 minutes. MLD alone included treatment that followed international standards. A standard number of strokes was used at each anatomical location. Each MLD session took about 40 minutes. Combined MLD and LLLT included participants receiving 20 minutes of LLLT, followed by 20 minutes of MLD. In addition, compression bandaging was applied after each treatment regardless of group assignment. Baseline and outcome data were collected pretreatment and on the last day of treatment after therapy was concluded.

Sample Characteristics:

  • N =  46   
  • MEAN AGE = 66.6 years (SD = 10.4 years)
  • MALES: 0%, FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: Breast cancer survivors with treatment-related lymphedema
  • OTHER KEY SAMPLE CHARACTERISTICS:  95.7% Caucasian

Setting:

  • SITE:  Single site 
  • SETTING TYPE:  Other 
  • LOCATION:  Private medical practice in Florida

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Late effects and survivorship

Study Design:

  • A pilot, randomized clinical trial

Measurement Instruments/Methods:

  • Extracellular fluid with bioelectrical impedance
  • Arm volume with circumferential measurement
  • Height and weight
  • Skin assessment checklist
  • Lymphedema Symptom Intensity and Distress Scale-Arm (LSIDS-A)
  • Brief Fatigue Inventory (BFI)
  • Profile of Mood States-Short Form (POMS)
  • Center for Epidemiologic Studies-Depression (CES-D)
  • Upper Limb Lymphedema-27 (ULL27)
  • Functional Assessment of Cancer Therapy-Breast (FACT-B)

Results:

All groups had clinically and statistically significant reduction in volume (p < 0.05); however, no statistically significant between-group differences were found in volume reduction. Treatment-related improvements were noted in symptom burden within all groups; however, no group differences were noted in psychological and physical symptoms or QOL. Skin improvement was noted in each group that received LLLT.

Conclusions:

LLLT with compression bandaging may offer a time-saving therapeutic option to conventional MLD.

Limitations:

  • Small sample (< 100)
  • Risk of bias (no blinding)
  • Other limitations/explanation: The dose of each intervention varied by individual patient because current reimbursement does not cover lymphedema therapy once reduction has slowed or stopped.

Nursing Implications:

The study demonstrates that a trained APN could implement lymphedema therapy in clinical practice. LLLT with bandaging may offer a time-saving therapeutic option to conventional MLD. Studies with a larger sample size are needed to compare MLD and LLLT.

Systematic Review/Meta-Analysis

Moseley, A.L., Carati, C.J., & Piller, N.B. (2007). A systematic review of common conservative therapies for arm lymphoedema secondary to breast cancer treatment. Annals of Oncology, 18(4), 639–646. 

doi: 10.1093/annonc/mdl182
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Purpose:

STUDY PURPOSE: To review the common conservative therapies for arm lymphedema secondary to breast cancer treatment

  • Complex physical therapy 
  • Manual lymphatic drainage 
  • Pneumatic pump therapy 
  • Oral pharmaceuticals 
  • Low-level laser 
  • Limb exercise
  • Limb elevations
  • Self-massage 

Search Strategy:

DATABASES USED: Search of English literature using the search engines CINAHL, PubMed, MEDLINE, CancerLit, PEDro, and Cochrane Evidence-Based Medicine Database; proceedings from the International Society of Lymphology and the Australian Lymphoedema Association; and contact with primary authors when publications were difficult to source. 

 

 

Literature Evaluated:

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Data were extracted using EndNote 7® (Thomson Reuters), and a quality scale assessment tool was used. Review included randomized, controlled, parallel, crossover format, and case-controlled and cohort studies. Case reports and anecdotal evidence were not reviewed. Because of treatment and data heterogeneity, authors were not able to perform a meta-analysis.

Results:

Magnitude of reduction in arm volume based on average volume change
 
Recommended for Practice
  • Manual lymphatic drainage and compression: 43%
  • CPT: 28%
  • Compression: 12% (not rated as stand-alone therapy)
 
Likely to Be Effective
  • Low-level laser: 12% therapy 
  • Manual lymphatic drainage alone: 24%
 
Benefits Balanced With Harm
  • Exercise: 5%
 
Effectiveness not Established
  • Pneumatic pump: 27%
  • Self-massage: 3%
 
Not Recommended for Practice
  • Drugs (benzopyrones): 16%
  • Elevation: 3% (not rated as stand-alone therapy)
 

Limitations:

  • Limited sample size in many studies and few randomized, controlled trials

Omar, M.T., Shaheen, A.A., & Zafar, H. (2012). A systematic review of the effect of low-level laser therapy in the management of breast cancer-related lymphedema. Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer, 20(11), 2977–2984.

doi: 10.1007/s00520-012-1546-0
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Purpose:

To review the effect of low-level laser therapy (LLLT) in the management of breast cancer-related lymphedema

Search Strategy:

Databases searched were MEDLINE, EMBASE, CINAHL, Center for Reviews and Dissemination, PEDro, and Cochrane Database of Systematic Reviews. Search keywords were breast cancer, lymphedema, and low level laser therapy. Studies were included in the review if they

  • Were randomized controlled and uncontrolled trials. 
  • Had a sample of women with unilateral lymphedema secondary to breast cancer surgery
  • Had a sample that experienced a limb volume increase greater than or equal to 100 ml compared to the contralateral limb. 
  • Compared LLLT  to no treatment, placebo, or another therapy.

 

Literature Evaluated:

The total references retrieved was 10. Literature was evaluated using Sackett''s levels of evidence. The PEDro Scale was used to rate the methodological quality of trials.

Sample Characteristics:

  • The final number of studies included was eight. 
  • The total sample across studies was 210 patients, with a range of 10–64.

Phase of Care and Clinical Applications:

The study has clinical applicability for late effects and survivorship. 

Results:

A variety of doses and laser wavelengths were studied with different definitions for lymphedema.  3b dual wavelength scanning was used in three studies with favorable results. Hand-held 3b lasers were used in five studies where the laser was applied directly over fibrotic or congested areas. All doses were within the therapeutic window. In most studies, treatment was three times weekly with up to 18 total sessions over three to four months. Various methods were used to measure outcomes and reliability of measures was not discussed. Sometimes laser was used in combination with other co-interventions that could have influenced results.

Conclusions:

There is moderate to strong evidence for effectiveness of LLLT for the management of breast cancer-related lymphedema.

Limitations:

  • The review had a limited number of studies. 
  • The variation of methods of outcome measurement and variability of LLLT treatment regimens makes comparison across studies difficult. 
  • Co-interventions used in studies could intervene to affect results. 
  • There were substantial baseline differences in study sample groups (the duration and severity of lymphedema varied greatly).

Nursing Implications:

Findings suggest moderate to strong support for use of LLLT to manage lymphedema among patients with breast cancer. Research in this area needs to incorporate reliability of lymphedema measurement and common definitions of lymphedema

Oremus, M., Dayes, I., Walker, K., & Raina, P. (2012). Systematic review: Conservative treatments for secondary lymphedema. BMC Cancer, 12, 6.

doi: 10.1186/1471-2407-12-6
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Purpose:

STUDY PURPOSE: To examine the effectiveness of conservative treatments for lymphedema


TYPE OF STUDY: Systematic review

Search Strategy:

DATABASES USED: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, AMED, and CINAHL 1990–January 2010


KEYWORDS: Search terms provided in online file


INCLUSION CRITERIA: RCT or observational study with comparison group, pediatric and adult patients with secondary lymphedema for any reason except filariasis infection


EXCLUSION CRITERIA: Pharmacologic or surgical treatment for lymphedema

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: 6,814 articles were evaluated.


EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Jadad scale used for RCTs; Newcastle-Ottawa Scale used  for observational studies

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED = 44 (32 with cancer)
  • SAMPLE RANGE ACROSS STUDIES: 21–150
  • KEY SAMPLE CHARACTERISTICS: Cancer evidence was in patients with breast cancer.

Phase of Care and Clinical Applications:

PHASE OF CARE: Not provided

Results:

Six RCTs involving intermittent pneumatic compression (IPC) were used. Two showed IPC had benefit over CDT or self-massage, and three did not show IPC to be any better than massage, skin care, or elastic sleeve; one compared different IPC devices. Six RCTs using massage-based treatments were used, and five showed no benefit. Four studies of low-level laser were used. Three showed low-level laser was superior to exercise, sham laser, or usual care, and one shows that low-level laser was better than sham laser at some time points in the study. Dieting yielded conflicting findings. Equivocal results were seen for ultrasound, modified manual lymph drainage, and compression stockings.

Conclusions:

This review provides limited evidence of effects of conservative treatments for lymphedema, and no conclusions about the most effective conservative approach are possible from this review.

Limitations:

Most studies had “fair” quality. Follow-up time frames in studies varied considerably. The majority of studies were among breast cancer patients only. It is surprising that this review did not include any studies involving CDT.

Nursing Implications:

Findings from this review showed that most interventions reduced limb volume and were not associated with any significant patient harms. Dieting alone does not appear to be particularly effective for limb volume reduction. Patients may benefit from a variety of conservative approaches to manage lymphedema. Ongoing research is needed to determine comparative effects of various approaches.

Rodrick, J. R., Poage, E., Wanchai, A., Stewart, B. R., Cormier, J. N., & Armer, J. M. (2013). Complementary, alternative, and other non-complete decongestive therapy (CDT) treatment methods in the management of lymphedema: A systematic search and review. PM&R, 6, 250–274.

doi: 10.1016/j.pmrj.2013.09.008
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Purpose:

STUDY PURPOSE: To provide a critical analysis of the contemporary published research that pertains to complementary, alternative, and other noncomplete decongestive therapies for treatment of lymphedema (LE) and to provide practical applications of that evidence to improve care of patients with or at risk for LE


TYPE OF STUDY: Systematic review

Search Strategy:

DATABASES USED: PubMed, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, PapersFirst, Proceedings-First, Worldcat, PEDro, National Guideline Clearing House, ACP Journal Club, DARE, and the authors' archives


KEYWORDS: Best practice for the management of lymphoedema, plus expanded terms for all literature related to lymphedema (2004–2012)


INCLUSION CRITERIA: No specific inclusion criteria identified


EXCLUSION CRITERIA: No gray literature was included; nonrefereed articles, abstracts, and dissertations were excluded. Exclusion of 574 articles took place due to duplication, inability to obtain the English translation, inadequate sample size, insufficient level of evidence due to study design, and failure to meet inclusion criteria. Another 47 articles were rejected because they fell outside the systematic review inclusion criteria by definition of four categories (i.e.,botanical, pharmaceutical, physical agent modalities, and modalities of contemporary value), by design, or for lack of an English translation. The categories of pharmaceuticals and botanicals were excluded as well.

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: 659 articles were reviewed.

 

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: The authors used first screening, second screening, and third screening to determine final body of reviewed articles. The level of evidence for each study assessed by using the research grading system from the Putting Evidence into Practice (PEP) level of evidence guidelines.

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED = 22
  • SAMPLE RANGE ACROSS STUDIES/TOTAL PATIENTS INCLUDED IN REVIEW: Not applicable; included several singles and several review articles
  • KEY SAMPLE CHARACTERISTICS: Human being with lymphedema and animal model with lymphedema (i.e., a rabbit ear model with “created” secondary lymphedema and rat tail model with “created” secondary lymphedema)

Phase of Care and Clinical Applications:

PHASE OF CARE:  Mutliple phases of care

Results:

Limited high-level evidence was available for all categories. Well-constructed randomized, controlled trials related specifically to lymphedema were limited. Objective outcome measures over time were absent from several studies. The rationale for the use and benefits of the specific modality, as related to lymphedema, was often anecdotal. Participant numbers were fewer than 50 for most studies.

Conclusions:

No interventions were ranked as "recommended for practice." Two treatment modalities (low-level laser therapy and Kinesio taping combined with decongestive lymphatic therapy and pneumatic compression, with Kinesio taping compared with compression bandaging) in three studies were ranked as "likely to be effective." The literature review indicated that many of the physical agent modalities demonstrated long-standing support within the literature, with broad parameters for therapeutic application and benefit for secondary conditions associated with lymphedema. However, additional investigation regarding the individual contributory value and the factors that contribute to their efficacy specific to lymphedema is critically needed.

Limitations:

Inclusion criteria were not clearly stated. Sample range across studies and total patients included in review were not specified.

Nursing Implications:

More rigorous human research in complementary and alternative modalities is needed to optimize patient outcomes.


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